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A TEXT-BOOK OF 

MINOR SURGERY 



A TEXT-BOOK OF 

MINOR SURGERY 



BY 

EDWARD MILTON FOOTE, A.M., M.D. 

INSTRUCTOR IN SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS (COLUMBIA 

UNIVERSITY) ; LECTURER ON SURGERY, NEW YORK POLYCLINIC MEDICAL 

SCHOOL ; VISITING SURGEON, NEW YORK CITY HOSPITAL ; VISITING * 

SURGEON, ST. JOSEPH'S HOSPITAL; CONSULTING PURGEON, 

RANDALL'S ISLAND HOSPITALS AND SCHOOLS 

FORMERLY CHIEF IN SURGERY AT THE VANDERBILT CLINIC 



ILLUSTRATED BY FOUR HUNDRED AND SEVEN ENGRAVINGS 
FROM ORIG4NAL DRAWINGS AND PHOTOGRAPHS 





D. APPLETON AND COMPANY 

NEW YORK AND LONDON 

1909 



COPYRIGHT, 1907, BY 
D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



THIS BOOK IS DEDICATED TO 

THE MAN AT THE POINT OF THE KNIFE 

FOR HIS GRIT AND PATIENCE, AND ESPECIALLY FOR 

HIS WILLINGNESS TO BE PHOTOGRAPHED 

THAT OTHERS MAY PROFIT BY 

HIS MISFORTUNE 



PREFACE 



IN preparing this "Minor Surgery," it has been my purpose to 
apply to the less serious, cvery-day problems of surgical practise the 
new knowledge which the discoveries of the last twenty-five years 
have revealed. During this period the advances in diagnosis and 
treatment have rendered necessary a new surgical literature, and many 
excellent text-books have appeared, in one, two, and four volumes. 
In these the more serious surgical conditions are exhaustively dis- 
cussed, while the treatment of the lesser ailments the minor surgery 
Avhich forms the bulk of surgical practise is condensed into a chapter 
or two, in which methods of treatment long since outgrown still find 
their place. Nor is the importance of minor surgery recognized in 
the curriculum of our medical schools. 

And yet this neglected field of minor surgery is the only one into 
which the average practitioner will ever enter, and is also the one 
in which most surgeons will find the majority of their patients. What 
wonder then that the physician, untaught and unread in minor sur- 
gery, fails to achieve good results, and that more bad surgery is per- 
formed upon the hand than upon the organs of the abdomen ? 

Impressed by the need of a text-book which describes in detail 
the manifold lesser accidents and surgical diseases which the general 
practitioner is called upon to treat, I commenced eight years ago 
the preparation of such a book. It has been rewritten several times, 
until hardly a page of the original manuscript remains; and it ap- 
pears now in its development, somewhat larger, but the same in pur- 
pose as when it was first conceived. 

If this " Minor Surgery " fails to meet the expectations of the 
reader, this fault, does not lie in the author's lack of experience; for T 
had the richest opportunity for the preparation of just such a book in 
a ten years' almost daily service in the Surgical Department of the 



viii PREFACE 

Vanderbilt Clinic, with an average annual attendance of about four 
thousand new patients. Besides this I have enjoyed the advantages 
which come from teaching both niinor surgery and general surgery 
in the College of Physicians and Surgeons, and from surgical at- 
tendance in the Randall's Island Hospitals, the New York City Hos- 
pital, and the New York Polyclinic Hospital. 

I have striven to present in compact form the results of this ex- 
perience and the best that has been written in books, magazines, and 
journals, taking with free hand from every available source. A mere 
list of the articles consulted would fill several pages. Very few au- 
thors' names are mentioned because such simple procedures as are 
herein described must often suggest themselves to many minds. We 
all owe so much to our predecessors. 

The aim has been to illustrate by photographs as far as possible. 
Too often medical illustrations show what might be, rather than 
what is; for the difficulties of making clinical photographs sufficiently 
clear for good reproduction are tremendous. Mr. IT. C. Lehrnaim 
has aided me very much in this part of the work, and has also fur- 
nished all of the drawings. My thanks are also due to Dr. E. J. 
McKenzie for many good photographs made while he was a student 
in my clinic; and to Mr. B. F. Puffer, who took for me the photo- 
graphs to illustrate the chapter on bandaging. 

EDWARD MILTON FOOTE. 

136 WEST FORTY-EIGHTH STREET, 
NEW YORK. 



CONTENTS 



SECTION I 
AFFECTIONS OF THE HEAD 

PAGE 

CHAPTER I. INJURIES OF THE HEAD 

General considerations 1 

Contusions: Subconjunctival ecchymosis Hematoma of the new- 
born; of the ear. 

Hemorrhage: From the nose ......... 2 

Abrasions: Removal of powder grains ....... 7 

Foreign bodies 8 

Foreign body in the eye; ear and nose; mouth and throat. 

Wounds 13 

Wounds of the eye; mouth; Steno's duct; periosteum. 

Fractures 17 

Fracture of skull; into frontal sinus; of malar; of nasal; of superior 
maxilla; of inferior maxilla; complications. 

Dislocation of the jaw: Subluxation 24 

CHAPTER II. INFLAMMATIONS OF THE HEAD 

Effects of heat and cold 25 

Burns Sunburn; of lip X-ray burn Frost-bite Dermatitis. 
Acute inflammations 31 

Urticaria Herpes Impetigo Acne Cellulitis Erysipelas 

Boil Stye Boils of the nose and ear Abscess Alveolar 

Abscess. 
Inflammations of the eye 47 

Acute conjunctivitis Purulent conjunctivitis Granular lids 

Trachoma Ingrowing lashes. 

Inflammation of the ear: Otitis media 51 

Inflammations of the nose 53 

Acute rhinitis Chronic rhinitis Suppuration in frontal sinus; 

in antrum of Highmore. 
Inflammations of the mouth and throat ....... 55 

Stomatitis and gingivitis Peritonsillar abscess Retropharyn- 

geal abscess. 
Inflammations of the skin 57 

Eczema Ringworm Ulcer Anthrax Noma. 
Chronic inflammations 59 

Syphilis: Secondary lesions; tertiary lesions Tuberculosis of 

nose and mouth Actinomycosis. 

ix 



X CONTENTS 

PAGE 

CHAPTER III. TUMORS AND DEFORMITIES op THE HEAD 

Cystic tumors 66 

Milium Comedo Sebaceous cyst -Mucous cyst Salivary cysts 

Dental cyst Dermoid cyst Congenital sinus. 
Benign solid tumors 70 

Papilloma Mole Lipoma Fibrolipoma Angioma Nevus 

Acne hypertrophica Hypertrophy of tonsil Adenoids Epulis 

Otoli t hs Osteoma Spu r . 
Malignant tumors 92 

Epithelioma of scalp; of face; of lip; of tongue Sarcoma Angio- 

sarcoma -Parotid tumors Cancer of tonsil. 
Acquired deformities 10S 

Cicatrices Nasal deformities Deviation of septum Elongation 

of uvula. 
Congenital deformities 112 

Harelip Cleft palate Cleft lower lip Thick lips Tongue tie 

Deformities of ear. 



SECTION II 

AFFECTIONS OF THE NECK 

CHAPTER IV. INJURIES AND INFLAMMATIONS OF THE NECK 

Contusions 117 

Foreign bodies 117 

Foreign bodies: of larynx; of trachea; of esophagus. 

Wounds 118 

Wounds of vessels; of trachea; of esophagus Tracheotomy 
Intubation 

Sprain of cervical spine 122 

Fractures 123 

Fracture of hyoid; of larynx; of trachea; of vertebra. 

Dislocation of vertebra 125 

Inflammations 125 

Burn Cellulitis Erysipelas Boil Carbuncle Abscess An- 
gina ludovici Anthrax Tuberculosis of vertebra. 

CHAPTER V. TUMORS AND DEFORMITIES OF THE NECK 

Tumors 135 

Sebaceous cysts Thyroid cyst Thyreoglossal cyst Branchio- 
genic cyst Lipoma: Simple, diffuse, intermuscular Fibroma 
Lymphadenitis: Acute; tuberculous; syphilitic; in leukemia; in 
pseudoleukemia; in sarcoma; in carcinoma Goiter. 

Acquired deformities 147 

Cicatrices Wryneck. 



CONTENTS XI 

SECTION III 
AFFECTIONS OF THE TRUNK 

PAGE 

CHAPTER VI. INJURIES AND INFLAMMATIONS OF THE TRUNK 

Contusions 153 

Contusion of breast; of back and ribs; of abdomen. 

Wounds .156 

Hemorrhage from umbilicus -Gunshot wound of back Pene- 
trating wound of pleural cavity; of pericardial cavity; of abdomen. 

Sprains 158 

Sprain of back Railroad spine. 

Fractures 163 

Fracture of clavicle; of scapula; of sternum; of ribs; of vertebra. 

Dislocations 169 

Dislocation of clavicle; of costal cartilage; of vertebra. 

Acute inflammations 170 

Burns Insect bites Scabies Herpes zoster Cellulitis Derma- 
titis Erysipelas Abscess of breast; of umbilicus Bed-sore 
Empyema. 

Chronic inflammations 177 

Syphilis Tuberculosis of sternoclavicular joint; of ribs; of verte- 
bra; of sacroiliac joint; of mammary gland. 

CHAPTER VII. TUMORS AND DEFORMITIES OF THE TRUNK 

Cystic tumors 181 

Sebaceous cyst Umbilical cyst Coccygeal cyst Dermoid cyst 

Cysts of mammary gland. 
Solid benign tumors of trunk 183 

Granuloma Keloid Papilloma Fibrolipoma Lipoma. 
Solid tumors of breast 187 

Hypertrophy -Adenoma Early diagnosis of malignant tumors 

Tumors of male breast. 

Malignant tumors of trunk : Carcinoma and sarcoma of skin . . 191 
Acquired deformities 192 

Coccygodynia Hernia: Umbilical; inguinal; femoral; strangulated 

Ascites Paracentesis. 
Congenital deformity: Spina bifida 201 



SECTION IV 
AFFECTIONS OF THE GENITO-URINARY ORGANS 

CHAPTER VIII. INJURIES AND INFLAMMATIONS OF THE MALE GENITO- 
URINARY ORGANS 

Subcutaneous injuries 203 

Contusion of penis and testicle Hematoma Hematocele 
Fracture of penis Paraphimosis Neuralgia of testicle. 



xii CONTENTS 

PAGE 

Foreign bodies 206 

Foreign bodies of penis; of urethra; of bladder. 

Wounds: Rupture of urethra; of bladder . 208 

Acute inflammations 210 

Burns Balanitis Herpes Urethritis Abscess Gonorrhea 
Cystitis Epididymitis Posterior urethritis Stricture Reten- 
tion of urine Incontinence Catheterization Eczema Chan- 
croid Inguinal adenitis. 

Chronic inflammations 225 

Syphilis Mixed infection Syphilitic orchitis Tuberculosis of 
testicle. 

CHAPTER IX. TUMORS AND DEFORMITIES OF THE MALE GENITO-URINAKY 
ORGANS 

Tumors . . . . . .231 

Cysts of skin; of testicle Warts Epithclioma Carcinoma 
Sarcoma Castration Tumors of bladder and prostate. 

Acquired deformities 236 

Hydrocele Hydrocele of the cord Varicocele. 

Congenital deformities 244 

Phimosis Circumcision Short frenum Narrow meatus Hypo- 
spadias Epispadias Exstrophy of bladder Undescended testi- 
cle. 

CHAPTER X. AFFECTIONS OF THE FEMALE GENITO-URINARY GROANS 

Injuries 255 

Contusions Rupture of hymen; of vagina- Hernatoma Acute 
laceration of perineum Hemorrhage Rape. 

Foreign bodies . 258 

Foreign bodies of vagina; of urethra; of bladder. 

Acute inflammations 2f>0 

Pruritus Eczema Simple vulvitis and vaginitis Acute gonor- 
rhea; of vulva; of urethra; of Bartholin's glands Simple suppu- 
ration. 

Chronic inflammations 264 

Chronic gonorrhea Endocervicitis Endometritis Dilatation 
Currettage Chancroid Syphilis Chancre Condyloma. 

Tumors 270 

Cyst of Bartholin's gland Urethral caruncleCervical polyp 
Carcinoma; of vulva; of cervix. 

Acquired deformities -72 

Relaxation of sphincter of bladder Incontinence of childhood 
Retention of urine Catheterization Prolapse of urethra Old 
laceration of perineum Prolapse of uterus Fistula of vagina; of 
urethra. 

Congenital deformities 277 

Adhesions of clitoris Imperforate hymen Stenosis of cervix, 



CONTENTS xiii 

SECTION V 

.l/'7<7<:r'/7n.V,S' OF THE ANLJH AND ItKCTt M 

I'M, I 

CHAPTKU XI. INJURIES AND INFLAMMATIONS OK 1111: AM s AND KKCTUM 

Injuries 280 

Examination of patient Stretching of sphincter ani Wounds 

Hemorrhage. 

Foreign bodies: Impacted feces 286 

Acute inflammations . 286 

Intertrigo Pruritus Proctitis Fissure Abscess- Fistula 

Gonorrhea Chancroid. 
Chronic inflammations . 300 

Syphilis Tuberculosis Ulcer of Rectum Stricture. 
CHAPTER XII. TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

Tumors 307 

Venereal warts Polyp Hemorrhoids: Acute; chronic Carcinoma 

Sarcoma. 
Acquired deformities 318 

Prolapse: Acute; chronic Rectal hernia Incontinence of sphinc- 
ter ani. 

Congenital deformities 322 

Imperforate anus Stricture. 



SECTION VI 
AFFECTIONS OF THE ARM AND HAND 

CHAPTER XIII. INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

Subcutaneous injuries 324 

Contusion Blister Hematoma Rupture of muscle. 
Wounds 328 

Minute wounds Ligation of vessels Suture of tendons; of 

nerves Wounds of joints. 

Foreign bodies . 336 

Sprains 338 

Sprain of shoulder Neuritis Acute tenosynovitis: Serous syno- 

vitis Bursitis. 

CHAPTER XIV. DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

Dislocations 347 

I Dislocation of shoulder; of elbow; of radius; of ulna Subluxation 
of radius Dislocation of wrist; of thumb Overextension of 
thumb Dislocation of finger Drop-finger. 

Fractures 363 

Separation of epiphysis Green-stick fracture Fracture of 
humerus; of olecranon; of head of radius; of shaft of ulna or 
radius PVacture. Colles's; of carpus; of metacarpals; of phalanges 
Compound fractures Crushed fingers Amputation of fingers. 



xiv CONTENTS 

PAGE 

CHAPTER XV. INFLAMMATIONS OF THE ARM AND HAND 

Effects of heat and cold 393 

Burns Mangle injury Frost-bite Chilblains Gangrene: Car- 
bolic, etc.; with cellulitis; diabetic. 

Acute inflammations 399 

Infection in wounds Anatomical tuberclt Dermatitis Erysipe- 
las Erysipeloid Cellulitis Boil Paronychia: Acute; chronic - 
Thecitis Suppurating synovitis Arthritis Bursitis Lymphan- 
gitis -Lymphadenitis Eczema Ulcer from vaccination. 

Arthritic and chronic inflammations 433 

Rheumatism Gonorrheal arthritis Deforming arthritis Gout 
Syphilis Tuberculosis of tendon sheaths; of joints Osteo- 
myelitis. 

CHAPTER XVI. TUMORS AND DEFORMITIES OF THE ARM AND HAND 

Tumors 445 

Ganglion Aneurism Varix Inclusion cyst Lipoma Fibroma 

Papilloma Neurofibroma Osteoma - Granuloma Wart 

Epithelioma Sarcoma. 
Acquired deformities 463 

Cicatricial contractions Dupuytren's contraction. 
Congenital deformities 467 

Web-finger Supernumerary finger Hypertrophy of finger 

Deficiency of finger Too many accessory tendons. 



SECTION VII 
AFFECTIONS OF THE LEG AND FOOT 

CHAPTER XVII. INJURIES OF THE LEG AND FOOT 

Injuries 471 

Contusions Abrasions Blister Hematoma: Subungual; sub- 
periosteal Rupture of vein; of tendon. 

Wounds 475 

Wounds of joint; of tendon; of nerve. 

Bursitis .476 

Bursitis: Prepatellar; subgluteal; back of knee; under tendo 
Achillis; metatarsophalangeal Serous synovitis -Floating cartil- 
age. 

Sprain 486 

Sprain of hip; of knee; of ankle Chronic synovitis Rupture of 
ligament. 

Dislocation 497 

Fractures 497 

Fracture of femur; of patella; of tibia (non-union); of fibula; of 
lower end of tibia and fibula; of astragalus; of os calcis; of meta- 
tarsals; of phalanges. 

Amputation . , 509 



CONTENTS XV 

PAGE 

CHAPTER XVIII. INFLAMMATIONS OP THE LEG AND FOOT 

Effects of heat and cold 511 

Frost-bite Burns Gangrene. 

Acute inflammation .514 

Cellulitis Lymphangitis Phlebitis Thrombosis Lymphadeni- 
tis Abscess Pediculosis. 

Chronic and arthritic inflammations 519 

Eczema Ulcer Perforating ulcer Suppurating synovitis 
Rheumatism Gonorrheal arthritis Gout Syphilis Tuberculo- 
sis. 

CHAPTER XIX. TUMORS AND DEFORMITIES OF THE LEG AND FOOT 

Tumors 537 

Callus Corn Varicose veins -Aneurism Ganglion Sebaceous 
cyst Lipoma Fibroma Osteoma Sarcoma Carcinoma. 

Acquired deformities 543 

Twisted nail Ingrown nail Hallux valgus Hallux rigidus 
Hammer-toe Flatfoot Transverse flatfoot Painful heel. 
Congenital deformities: Hypertrophy Supernumerary toes . . . 561 

SECTION VIII 

MINOR SURGICAL TECHNIQUE 

CHAPTER XX. OPERATIVE TECHNIQUE 

Conditions of operation 563 

Asepsis Operating room Preparation of patient Hands of the 
operator Instruments Solutions Local anesthesia. 

Treatment of the wound 568 

Control of hemorrhage Tying a ligature Drainage Sutures 
Dressings: Dry gauze; cotton-collodion; wet. 

Some typical operations 575 

Opening an abscess Removal of a tumor Skin-grafting: Thiersch 
method; Wolfe method Plastic operations Lumbar puncture 
Transfusion Infusion Venesection Cupping Leeching Vacci- 
nation. 

CHAPTER XXI. THE ROLLER BANDAGE 

General principles 589 

Preparation of a bandage Application: Anchoring; spiral reverse; 
overlapping of turns; figure of eight; the spica; amount of pressure; 
completion. 

Bandages of head 595 

1. Horizontal circular 2. Oblique circular 3. Double oblique circu- 
lar 4. Crossed circular 5. Knotted 6. Figure of eight 7. Single 
roller 8. Double roller 9. Partial recurrent 10. Figure of eight 
of one eye -11. Figure of eight of both eyes 12. Four-tailed of 
jaw 13. Barton's of jaw 14. Gibson's of jaw 15. Figure of 
eight of forehead and chin. 

Bandages of the neck and axilla, alone and in combination . . . 613 
16. Circular 17. Posterior figure of eight of head and neck 18. 
2 



Xvi CONTENTS 

PAGE 

Anterior figure of eight of head and neck 19. Figure of eight of 
neck and axilla 20. Figure of eight of both axillae 21. Oblique 
circular of neck and axilla 22. Complete, of neck 23. Complete, 
of axilla 24. Anterior figure of eight of neck and chest. 

Bandages of the trunk 626 

25. Anterior figure of eight of chest 26. Posterior figure of eight of 
chest 27. Spiral of the chest 28. Spica of one breast 29. Spica 
of both breasts 30. Velpeau's figure of eight of chest and shoulder 
31. Desault's of chest and shoulder 32. Descending spiral of 
abdomen 33. Many-tailed of abdomen. 

Bandages of the upper extremity 643 

34. Ascending spica of shoulder 35. Descending spica of shoulder 
36. Spiral of arm 37. Concentric figure of eight of elbow 38. 
Eccentric figure of eight of elbow 39. Spiral reverse of forearm 
40. Figure of eight of forearm 41. Figure of eight of hand 42. 
Spiral reverse of hand 43. Spica of thumb 44. Spiral reverse of 
- finger 45. Figure of eight of finger 46. Gauntlet, or figure of 
eight of fingers and wrist 47. Recurrent of finger. 

Bandages of the lower extremity 657 

48. Ascending spica of one groin 49. Descending spica of one 
gioin 50. Ascending spica of both groins 51. Descending spica' 
of both groins 2. Ascending spica of buttock 53. Crossed 
perineal 54. Spiral reverse of thigh 55. Concentric figure of 
eight of knee 56. Eccentric figure of eight of knee 57. Figure of 
eight of both knees 58. Figure of eight of the leg 59. Spiral 
reverse of leg 60. Figure of eight of ankle -61. Figure of eight of 
foot and leg 62. Eccentric figure of eight of heel 63. Modified 
eccentric figure of eight of heel 64. Spica of foot 65. Circular of 
toe 66. Spica of great toe 67. Complex spica of great toe 68. 
Recurrent of stump. 

CHAPTER XXII. SURGICAL DRESSINGS 

Textile materials 681 

Absorbent cotton Lamb's wool Gauze Gauze sponges; strips; 
bandages Muslin Flannel Canton flannel Stockinette Silk 
Rubber Crinoline -Gutta-percha tissue Oiled muslin, silk, 
and paper. 

Ligatures and sutures 689 

Catgut: Plain; chromic Kangaroo-tendon Silk Silkworm gut 
Horsehair Cotton and linen thread Celluloid thread Silver wire 

Drains 694 

Glass and metal tubes Soft rubber tubes Gutta-percha drains 
Cigarette drains Gauze drains Handkerchief drains Horse- 
hair drains. 

Splints .698 

Wood Metal Wire netting. 

Gypsum or plaster of Paris 700 

Gypsum bandages Circular splints Cutting a fenestrum 
Molded splints Reinforcing a splint Gypsum or plaster casts 
Plaster jackets. 
INDEX . 715 



LIST OF ILLUSTRATIONS 



HEAD 

F1Q. PAGE 

1. Hematoma of ear from a blow 4 

2. Hematoma of ear from a blow, three weeks previous .... 5 

3. Powder grains in face from a recent explosion 7 

4. Powder grains removed by scrubbing with a stiff brush ... 8 

5. Instruments for extracting foreign bodies from the nose and ear . 1 1 

6. Division of Steno's duct by a razor cut 16 

7. Fracture of right malar bone with depression 18 

8. Four-tailed bandage for fracture of the inferior maxilla ... 21 

9. Necrosis and slough of skin due to cellulitis 34 

10. Abscess of the lip 38 

11. Alveolar abscess from upper incisor tooth 40 

12. Alveolar abscess from upper molar teeth 41 

13. Alveolar abscess from upper tooth, secondary in lymphatic gland . 42 

14. Recurrent alveolar abscess 43 

15. Chronic alveolar abscess with sinus 44 

16. Chronic alveolar abscess; chronic edema; no sinus .... 45 

17. Tumor following alveolar abscess; probably malignant ... 46 
18. Sketch of the normal right tympanic membrane, showing the correct 

site for incision 52 

19. Angular knife for incision of tympanic membrane .... 52 

20. Chancre of lip, of nine days' duration 60 

21. Chancre of lip, of three weeks' duration 60 

22. Chancre of cheek,. developing in burn from cigarette .... 61 

23. Chancre of cheek with a granulating ulcer 62 

24. Papilloma of lip due to syphilis 63 

25. Tuberculosis of the gum, secondary to pulmonary tuberculosis . . 65 

26. Tense sebaceous cyst of forehead, about to rupture .... 67 

27. Sebaceous cyst of scalp, skin prepared for operation .... 68 

28. Sebaceous cyst of scalp, overlying skin divided and retracted . . 69 
29. Sebaceous cyst of scalp, collapsed redundant skin after removal of 

cyst 70 

30. Inflamed sebaceous cyst behind the ear 70 

31. Cyst of sublingual gland ranula 71 

32. Dental cyst, mistaken for alveolar abscess 73 

33. Dermoid cyst of the nose 74 

34. Dermoid cyst in front of the ear 75 

35. Dermoid cyst behind the ear 75 

36. Papilloma of skin occurring in a scar, diagnosed as cancer . . 77 

xvii 



XVlii LIST OF ILLUSTRATIONS 

FIG. PAGE 

37. Lipoma of forehead 79 

38. Fibrolipoma of auditory canal . .80 

39. Pulsating angioma of scalp; congenital; fully distended . . . 82 

40. Pulsating angioma of scalp, compressed 83 

41. Acne hypertrophica of the nose, of seven years' duration ... 84 

42. Acne hypertrophica of the nose, of four years' duration ... 85 

43. Same subject as Fig. 42, side view 85 

44. Same subject as Fig. 42, after two operations 86 

45. Same subject as Fig. 42, after two operations, side view ... 86 

46. Instruments for the removal of the tonsil 88 

47. Instruments for the removal of adenoids 90 

48. Exostosis of jaw .91 

49. Epithelioma of face near nose 93 

50. Epithelioma of the lip developing in a soft wart which had existed 

since childhood 93 

51. Same subject as Fig. 50, three months after removal of the tumor . 94 
52. Epithelioma of the nose, recently growing rapidly . . . .95 

53. Epithelioma of the cheek existing two years 96 

54. Epithelioma of face 96 

55. Epithelioma of the scalp "97 

56. Epithelioma of lip, of four weeks' duration 98 

57. Epithelioma of the tongue, showing milky white patches of leuco- 

plakia and papillomatous growths 99 

58. Longitudinal section of the epitheliomatous tongue in the median line 99 

59. Transverse section of the epitheliomatous tongue .... 100 

60. Epithelioma of lower lip, of one year's duration 101 

61. Epithelioma of lower lip, showing line of incisions .... 102 
62. Epithelioma of lower lip, showing suture after excision of the V- 

shaped piece 102 

63. Tumor of head, extradural 105 

64. Angiosarcoma of lower jaw 105 

65. Tumor of parotid gland, of twelve years' duration .... 106 

66. Diagram of the septum of the nose 109 

67. Scissors for the amputation of the uvula Ill 

68. Harelip, the cleft, not entering the nostril 113 

69. Harelip, the cleft entering the nostril .113 

70. Congenital cleft of lower lip 114 

71. Cleft of lobe of auricle, congenital 116 

72. Deformity of ear, congenital 116 



NECK 

73. Instruments for tracheotomy 121 

74. Carbuncle of neck 128 

75. Carbuncle of neck, of four weeks' duration, incised three times . 129 
76. Same patient as shown in Fig. 75, eleven weeks later . . . .129 

77. Abscess of neck, secondary to pediculosis capitis . . . . . 130 

78. Abscess under sternomastoid muscle, probably tubercular . . . 131 

79. The primary lesion of anthrax 132 

80. Thyreoglossal cyst; operation; recurrence 136 



LIST OF ILLUSTRATIONS xix 

FIG. PAGE 

81. Simple lipoma of neck, of two years' duration 138 

82. Diffuse lipoma of neck, bilateral 138 

83. Fibroma of the neck of nine years' duration 139 

84. The tumor of Fig. 83 after removal 140 

85. Single cyst of thyroid 146 

86. Goiter with exophthalmos 146 

87. Cicatricial contractions following burn of the neck .... 148 

88. Torticollis (wryneck) of right side of moderate degree . . . 149 

89. Extreme degree of torticollis (wryneck) 150 

90. Back view of patient, shown in Fig. 89 150 

TRUNK 

91. Large hematoma of mammary region, five weeks after a blow . . 153 

92. Strips of adhesive plaster, gridiron pattern, for sprain of back . . 160 

93. Strips of plaster applied diagonally, for sprain of back . . . 160 

94. Tests for injury of the spine. Forward flexion 161 

95. Tests for injury of the spine. Backward flexion 161 

96. Tests for injury of the spine. Lateral flexion 162 

97. Tests for injury of the spine. Rotation 162 

98. Fracture of left clavicle, usual situation 163 

99. Sayre dressing for fracture of clavicle. Rear view .... 165 
100. Sayre dressing for fracture of clavicle. Front view .... 165 
101. Multiple burns of body of five days' duration, produced by spatter- 
ing liquid iron 170 

102. Instruments for drainage of chest in empyema 176 

103. Fibrolipomata of the back of five years' duration . . . .185 

104. Lipoma of back of two years' duration 186 

105. Lipoma shown in Fig. 104 after removal 187 

106. Epithelioma of back at an early stage 190 

107. Cross-section of tumor shown in Fig. 106 191 

108. Melanosarcoma of lower abdomen of four months' duration, growing 

from a mole or soft wart 191 

109. Cyst under scapula of one week's duration 192 

110. Removal of displaced coccyx ". . 193 

111. Dorsal hernia 196 

112. Method of holding a trocar 200 

MALE GENITALS 

113. Edema of penis and scrotum from mercuric ointment . . .211 

114. Abscess of scrotum of five days' duration 212 

115. A good type of steel sound 218 

116. Eczema of penis of four months' duration 223 

1 17. Primary lesion of syphilis in an aged patient 225 

118. Unilateral syphilitic orchitis 227 

1 19. Gumma of testicle with ulceration 228 

120. Cyst of prepuce; left inguinal hernia 231 

121. Cyst of prepuce after circumcision 232 

122. Squamous celled carcinoma of penis 233 



XX LIST OF ILLUSTRATIONS 

FIQ. PAGE 

123. Hydrocele of four months' duration 237 

124. Hydrocele of ten years' duration; never treated . . . . . 237 

125. Varicocele of moderate degree 242 

126. Varicocele of fourteen years' duration 243 

127. Tight phimosis; congenital 245 

128. Operation for phimosis. Dorsal and ventral incisions . . . 248 

129. Operation for phimosis. All sutures inserted 249 



FEMALE GENITALS 

130. Urethroscope for examining female urethra 259 

131. Multiple syphilitic tumors of vulva 268 

132. Syphilitic condyloma of thigh near the vulva 269 

133. Pessaries for prolapse of uterus 276 

134. Hard rubber plugs for use in stenosis of the cervix .... 279 

ANUS AND RECTUM 

135. Suitable rectal speculum for office examination 282 

136. Bivalve rectal speculum 283 

137. Small superficial ischiorectal abscess 292 

138. A larger and deeper ischiorectal abscess 293 

139. -Fistula accompanying a syphilitic stricture of the rectum . . . 296 

140. Syphilitic condylomata about anus of a young male .... 300 

141. Venereal warts about the anus of a man 307 

142. Acute external hemorrhoid of one week's duration .... 309 

143. Internal hemorrhoids of sixteen years' duration 312 

ARM AND HAND 

144. Hematoma under nail . . . 326 

145. Incision for hematoma under nail 326 

146. Diagram to show position of radial and ulnar arteries . . . 328 

147. Test for division of the profundus tendon 330 

148. Test for division of the sublimis tendon 330 

149. Traumatic ulcers of the hand . 331 

150. Tendon suture. (A) Mattress stitch. (>) Simple stitch . . . 333 

151. Tendon suture, one method of elongation of a tendon .... 333 

152. Tendon suture, a long silk stitch being left in place .... 334 

153. Nerve suture 335 

154. Sprain of finger with serous effusion in joint 339 

155. Plaster strapping for sprain of the thumb 340 

156. Diagram to show the relations of the extensor tendons and the radius 343 

157. Effusion of bloody serum into the right shoulder-joint . . . 345 

158. Same shoulder after aspiration of six ounces of bloody serum , . 345 

159. Dislocation of thumb of seven years' duration 349 

160. Radiograph showing the bones seven years after a dislocation of the 

thumb 349 

161. Radiograph of forward dislocation of the head of the radius and 

fracture of the ulna 352 



LIST OF ILLUSTRATIONS xxi 

FIG. PAGE 

It)!'. Radiograph showing backward dislocation of both radius and ulna, 

about five months' duration 353 

163. Overextension of adult thumb . . 356 

164. Posterior dislocation of finger with radiograph 357 

165. Reduction of dislocated finger by operation 358 

166. Lateral dislocation of finger, due to bite of horse 359 

167. Radiograph of lateral dislocation of finger 359 

168. Drop-finger 361 

169. Traumatic drop-finger of three months' duration 361 

170. Radiograph of traumatic drop-finger, anteroposterior view . . 362 

171. Radiograph of traumatic drop-finger, lateral view .... 362 

172. Radiograph of fracture of the neck of the radius . . . . . 376 

173. Radiograph of fracture of neck of radius, side view .... 377 

174. Molded gypsum splints for fracture of the lower end of the radius . 382 

175. Molded gypsum splints applied 383 

176. Old fracture of radius (Colles') with marked deformity . . . 384 

177. Fracture of second right metacarpal 385 

178. Compound fracture of the forefinger 387 

179. Injuries of the hand from contact with a buzz-saw .... 388 

180. Amputation through the metacarpal phalangeal joint . . . 389 

181. Amputation of finger with the head of the metacarpal . . . 390 

182. Same hand as in Fig. 181; dorsal surface 390 

183. Amputation of two central fingers with the metacarpals . . . 391 

184. Same hand as in Fig. 183; dorsal surface 391 

185. Partial gangrene of finger due to carbolic acid 395 

186. Carbolic gangrene of distal half of finger 396 

187. Carbolic gangrene of thumb, complicated by cellulitis . . . 397 

188. Recovery following carbolic gangrene of thumb 398 

189. Anatomical tubercle 400 

190. Erysipeloid dermatitis in wound of hand of seven days' duration . 401 

191. Cellulitis of finger with abscess . 402 

192. Moist gangrene of finger, following cellulitis 403 

193. Boil of wrist with secondary pimples 405 

194. Section of the terminal segment of finger to show various sites of 

suppuration 406 

195. Abscess of tip of thumb with spontaneous rupture .... 406 

196. Acute paronychia of three weeks' duration 408 

197. Acute paronychia, ten days after removal of old nail .... 409 

198. Chronic paronychia of four months' duration . . . . 410 
199. Abscess in tendon sheath of thumb from a splinter . . . .411 

200. Suppuration in index-finger extending into the palm .... 414 

201. Same subject as Fig. 200. Posterior view 415 

202. Same subject as Fig. 200. Temperature chart 416 

203. Same subject as Fig. 200. Ultimate result 416 

204. Suppuration in tendon sheath of four weeks' duration . . . 420 

205. Same subject as Fig. 204. Dorsal view 420 

206. Cicatricial contraction of finger following suppuration . . . 421 

207. Loss of extensor tendons from suppuration 422 

208. Suppuration in joint following penetration by splinter . . . 422 

209. Suppurative arthritis and loss of metacarpal 423 



xxii LIST OF ILLUSTRATIONS 

FIO. PAGE 

210. Radiograph of a hand showing result of suppurative arthritis . . 424 

211. Tin splint for use in suppurative arthritis 426 

212. Suppurative olecranon bursitis . 427 

213. Infected wound of finger with secondary lymphatic abscess . . 428 

214. Superficial axillary abscess from infection about hairs . . . 430 

215. Primary lesion of syphilis developing in the finger .... 436 

216. Syphilitic ulcer of the hand of four months' duration .... 436 

217. Same hand as Fig. 216, after four weeks of treatment . . . 437 

218. Chronic syphilitic inflammation of hand with sinus .... 437 

219. Syphilis of hand with amputation of a finger 438 

220. Tuberculosis of flexor tendon sheaths of hand 439 

221. Tenosynovitis, probably tubercular 440 

222. Diagram to show the range of motion in a joint 441 

223. Tuberculosis of the wrist with sinus 442 

224. Ganglion of wrist of five years' duration . . . . . . 445 

225. Ganglion of wrist, lateral view 446 

226. Ganglion of the wrist, the skin incised and dissected .... 447 

227. Ganglion of the wrist, showing ligation of the sac .... 448 

228. Nevus of hand of seven years' duration 449 

229. Extensive varices of the arm and hand 450 

230. Inclusion cyst of palm 451 

231. Simple lipoma of arm 451 

232. Fibrosarcoma of finger, of six years' duration 452 

233. Radiograph of fibrosarcoma of finger showing normal bone . . 453 

234. Fibroma of hand 453 

235. Fibrolipoma of wrist papilloma 454 

236. Osteoma of finger 455 

237. Radiograph of osteoma of finger, showing affected bone . . . 456 

238. Fibrolipoma of finger . 457 

239. Radiograph of the same hand, showing normal bones .... 457 

240. Granuloma of finger 458 

241. Old wart of index-finger 459 

242. Metastatic carcinoma of the bones of the hand 460 

243. Same patient as shown in Fig. 242, showing the site of the original 

tumor, and numerous cutaneous metastases 461 

244. Spindle-cell sarcoma of hand of ten years' duration . . . . 462 

245. Cicatricial contractions from burns 464 

246. A quick method of lengthening a tendon without suture . . . 464 

247. Dupuytren's contraction of six months' duration .... 465 

248. Radiograph of the webbed hand of an infant ... . 466 

249. Web-fingers of a child 467 

250. Result after operation for web-fingers 467 

251. Supernumerary thumb 468 

252. Radiograph of supernumerary thumb 469 



LOWER EXTREMITY 

253. Hematoma of foot produced by turning the ankle .... 472 

254. Hematoma under left great toe-nail 472 

255. Subperiosteal hematoma of the head of the tibia ..... 473 



LIST OF ILLUSTRATIONS XXlii 

FIO. PAGE 

'Jf><>. Prepatellar bursitis 477 

257. Suppuration in prepatellar bursa, with rupture of the .skin . . 478 

258. Chronic prepatellar bursitis; the bursa laid open 479 

259. Operation for chronic prepatellar bursitis . . . ... . . 480 

260. Inflammation of the outer metatarsophalangeal bursa . . . 482 

261. Floating cartilage from the knee-joint 485 

262. Incision for removal of floating cartilage from the knee . . . 486 

263. Relation of the great trochanter to the ilium 488 

264. Demonstration of floating patella 490 

265. Strapping with adhesive plaster for sprain of the knee . . . 493 

266. Strapping a sprained ankle with adhesive plaster .... 495 

267. Radiograph showing fracture of the great trochanter .... 498 

268. Application of adhesive plaster for fracture of patella . . . . 499 
269. Correct method of holding foot and leg during the application of a 

splint in cases of malleolar fracture 505 

270. Strap splints for fracture of malleoli in position .... 506 

271. Strap splints for fracture of malleoli removed 506 

272. Frost-bite of both feet three weeks after injury 511 

273. Frost-bite of both feet; the results after treatment .... 512 

274. Burns of the back of the leg and thigh 513 

275. Gangrene of toe possibly from frost-bite 514 

276. Abscess in front of the knee from infection on the skin . . . 517 

277. Ulcers of the leg from pediculosis and scratching 518 

278. Ulcer of the leg 519 

279. Chronic ulcer almost encircling the leg 520 

280. Ulcer of leg, spread by a vaseline dressing 522 

281. Chronic ulcer of the leg with proliferation 525 

282. Ulcers of leg due to syphilis 527 

283. Traumatic ulcer of the leg exposing the tibia 529 

284. Perforating ulcers of the foot 530 

285. Perforating ulcers of the toes of two years' duration .... 531 

286. Dorsal view of the same patient as shown in Fig. 285 .... 531 

287. Osteoma of the tibia 541 

288. Osteoma under the nail of the great toe 541 

289. Sarcoma of the great toe from injury 543 

290. Carcinoma of the leg developing in an old ulcer 543 

291. Twisted nails 544 

292. Longitudinal and transverse sections of great toe showing the nail, 

matrix, phalanx, and joint 545 

293. Ingrown nail 546 

294. Drawings to illustrate operation for ingrown nail 547 

295. Great toe after operation for ingrown nail 548 

296. Great toe ten days after operation for ingrown nail .... 549 

297. Hallux valgus 550 

298. Hallux valgus with hypertrophy of the head of the metatarsal, sup- 

purative bursitis and synovitis 551 

299. Lateral splint for holding the toe after operation for hallux valgus . 553 
300. Interwoven adhesive strips for correcting the deformity of hammer- 
toe after operation 555 

301. Testing the degree of rigidity in flatfoot 557 



XXIV LIST OF ILLUSTRATIONS 

FIG. PAGE 

302. Markedly rigid flatfeet put up in corrected position .... 559 

303. Congenital hypertrophy of the second toe . . . . . .561 



OPERATIVE TECHNIQUE 

304. Injection of cocain for local anesthesia 567 

305. Method of tying ligatures 569 

306. Drains for clean and suppurating wounds 571 

307. Silk and horsehair in straight and curved skin needles . . . 573 

308. Lumbar puncture: diagrammatic sagittal section of the spine . . 581 

309. Lumbar puncture: transverse section of the spine .... 582 

310. Lumbar puncture: the lumbar spine as seen from behind . . . 583 

ROLLER BANDAGE 

311. Rolling a bandage on a small machine 589 

312. Making a reverse in a spiral bandage 591 

313. Making a figure of eight turn about the forearm 592 

314. Fastening a bandage by splitting the end and tying .... 594 

315. Occipitofrontal bandage of the head 595 

316. Oblique circular bandage of the head 596 

317. Double oblique circular bandage of the head 597 

318. The crossed circular bandage 598 

319. Knotted bandage of the head 599 

320. figure of eight bandage of the head 600 

321. Single roller bandage of the head 601 

322. Single roller bandage of the head completed 602 

323. Double roller bandage of the head . 604 

324. Double roller bandage of the head completed 604 

325. Partial recurrent bandage of the head 605 

326. Figure of eight bandage of one eye 606 

327. Figure of eight bandage of both eyes 608 

328. Four-tailed bandage of the jaw 609 

329. Barton's bandage, with first layer completed 610 

330. Gibson's bandage for the lower jaw 611 

331. Gibson's bandage completed . . 612 

332. Figure of eight bandage of the forehead and chin . . . .612 

333. Circular bandage of neck 614 

334. Posterior figure of eight bandage of head and neck 614 

335. Anterior figure of eight bandage of the head and neck . . . 615 

336. Figure of eight bandage of neck and axilla 616 

337. Figure of eight bandage of neck and axilla with additonal turns . 617 

338. Figure of eight bandage of both axillae 618 

339. Oblique circular bandage of the neck and axilla 619 

340. Complete bandage of the neck at an early stage 621 

341. Complete bandage of the neck in skeleton form . . . . . 622 

342. Complete bandage of the axilla, composed of six parts . . . 624 

343. Anterior figure of eight bandage of the neck and chest . . . 625 

344. Anterior figure of eight bandage of chest 627 

345. Posterior figure of eight bandage of chest 628 



LIST OF ILLUSTRATIONS XXV 

FIG. PAGE 

34(i. Descending spiral bandage of the chest 629 

347. Descending spiral bandage of the chest completed .... 630 

348. Spica bandage of one breast . . 631 

349. Spica bandage of one breast completed 632 

350. Spica bandage of both breasts 633 

351. Spica bandage of both breasts nearing completion .... 634 

352. Velpeau's bandage, showing the first turn 635 

353. Velpeau's bandage at the beginning of second oblique turn . . 636 

354. Velpeau's bandage nearly completed 637 

355. Desault's bandage, showing the spiral of the chest .... 638 

356. Desault's bandage, showing the fixation of the arm to the chest . 638 

357. Desault's bandage, showing the application of the third roller . . 639 

358. Desault's bandage completed 640 

359. Descending spiral bandage of abdomen 641 

360. Posterior view of many tailed bandage of abdomen .... 642 

361. Anterior view of many tailed bandage of abdomen .... 642 

362. Ascending spica bandage of the shoulder 644 

363. Descending spica bandage of shoulder 645 

364. Ascending spiral bandage of the upper arm 645 

365. Concentric figure of eight bandage of the elbow 646 

366. Eccentric figure of eight bandage of the elbow 647 

367. Spiral reverse bandage of forearm 648 

368. Figure of eight bandage of forearm in application .... 649 

369. Figure of eight bandage of forearm completed 649 

370. Figure of eight bandage of the hand 650 

371. Spiral reverse bandage of the hand 651 

372. Spica bandage of the thumb . . 652 

373. Spiral reverse bandage of the finger 653 

374. Figure of eight bandage of finger 654 

375. Figure of eight bandage of the fingers and hand, the " gauntlet " . 655 

376. Recurrent bandage of the finger 656 

377. Recurrent bandage of the finger at a later stage 657 

378. Ascending spica bandage of one groin 658 

379. -Ascending spica bandage of one groin completed 659 

380. Ascending spica bandage of both groins 660 

381. Ascending spica bandage of the buttock 661 

382. Ascending spica bandage of the buttock completed .... 662 

383. Crossed bandage of the perineum in application ..... 663 

384. Crossed bandage of the perineum at a later stage .... 664 

385. Spiral reverse bandage of the thigh 665 

386. Spiral reverse bandage of thigh completed 665 

387. Concentric figure of eight bandage of knee 666 

388. Concentric figure of eight bandage of knee completed .... 667 

389. Eccentric figure of eight bandage of knee 668 

390. Figure of eight bandage of both knees 669 

391. Figure of eight bandage of the leg 670 

392. Spiral reverse bandage of the leg 671 

393. Figure of eight bandage of the ankle 672 

394. Figure of eight bandage of foot and leg 673 

395. Figure of eight bandage of foot and leg, at a later stage . . . 673 



XXVI LIST OF ILLUSTRATIONS 

FIG. PAGE 

396 Figure of eight bandage of the foot and leg completed . . . 674 

397. Eccentric figure of eight bandage of heel 675 

398. Modified eccentric figure of eight bandage of heel .... 676 

399. Spica bandage of foot 677 

400. Spica bandage of the great toe 678 

401. Complex spica bandage of the great toe 679 



SURGICAL DRESSINGS 

402. Two yards of gauze cut and folded to make twenty-four gauze 

sponges 684 

403. Angular splint made from wire netting 699 

404. Making gypsum bandages from crinoline 702 

405. Making a "dart" in a gypsum bandage . . . . . . . 704 

406. Making a cast of a foot in gypsum 711 

407. Cast of foot in gypsum : the mold removed 712 



SECTION I 
AFFECTIONS OF THE HEAD 



CIIAPTEK I 

INJURIES OF THE HEAD 

General Considerations. It is sometimes difficult to deter- 
mine the extent of an injury to the head either from the history 
of the accident or from the symptoms. The following two cases 
from the author's experience will illustrate this fact : 

A girl fell backward down some stone steps, striking her head 
on the edge of one of them. Blood flowed freely from a wound 
in the scalp, and she walked to the hospital to have it dressed. 
There was no shock, nor any other symptom indicating that she 
had suffered serious injury, and yet retraction of the edges of the 
wound showed that there was a compound depressed fracture of 
the skull. 

A man of middle age, pushed by a horse, fell against a sloping 
bank of earth. lie was apparently uninjured except for an insig- 
nificant contusion of the head. Yet subsequent events showed that 
this slight accident had ruptured a blood-vessel within the skull, 
as a result of which, many days afterward, the first symptoms 
of paralysis developed and progressed to complete unconsciousness. 

Such cases are a warning against a hasty diagnosis in head 
injuries. Every patient whose head has been injured should be 
carefully examined, and kept under observation for two or three 
days, as otherwise serious complications are likely to be over- 
looked. This is especially important if no clear history of the 
accident can be obtained, either because the patient is suffering 
from intoxication or for any other reason. 

Contusions. The scalp is firm and well protected by hair 
from external injury. It is loosely attached to the skull, but the 

absence of fatty tissue between it and the bone makes it more 
3 1 



2 INJURIES OF THE HEAD 

liable to suffer in the case of a sharp blow. A contusion of the 
scalp may or may not be accompanied by a great deal of edema. 
If the swelling is discrete and evenly curved it is usually due to 
the pouring out of blood underneath the scalp, a hematoma (p. 2). 
The eyelids, nose, and lips are all frequently the seat of contusion, 
with marked ecchymosis. 

TREATMENT. If the patient is seen soon after the accident, 
very hot, wet compresses (p. 7) should be applied and bandaged 
in place with moderate pressure in order to relieve pain and pre- 
vent edema and hemorrhage. Later, a wet dressing of acetate 
of aluminum, four per cent solution, may be applied to prevent 
infection and facilitate recovery. The hair, even of a man, should 
not be needlessly sacrificed. In many cases a patient is mortified 
by the appearance of a black eye, and desires to have the normal 
color of the skin restored as quickly as possible. The hot, moist 
applications are of benefit, and in a day or two they should l>e fol- 
lowed by very gentle massage in the direction of the lymph cur- 
rent, for this will facilitate the absorption of the extravasated 
blood. Considerable improvement in appearance may be obtained 
by painting over the blackened area with theatrical face paint or 
with oxid of zinc ointment. If the latter is used most of it should 
be wiped off and a little face powder dusted over it to remove the 
shiny, greasy appearance which the ointment causes. 

Subconjunctival Ecchymosis. Blows upon the eye may be fol- 
lowed by an accumulation of blood beneath the conjunctiva, either 
of an eyelid or of the eyeball, frequently extending as far as 
the iris. Such a hemorrhage, due to rupture of a small blood- 
vessel, also occurs as a result of violent coughing or straining, espe- 
cially in persons past middle life. It is also a symptom of frac- 
ture of the skull, in which case the blood trickles through a wall 
of the orbit and collects beneath the conjunctiva. Blood beneath 
the conjunctiva of the eyeball is so freely supplied with oxygen 
that it remains a bright red. 

The treatment for this ecchymosis is similar to that already 
given for contusions of the face. It is only fair to state that treat- 
ment has little effect in hastening the resorption of the extrava- 
sated blood, which usually requires from ten days to two weeks. 

Hematoma. Hemorrhage occurring beneath the scalp or be- 
neath the periosteum, sufficiently free to produce a hematoma, is 



HEMATOMA 3 

most common at those points at which the scalp is most exposed 
to blows, viz., over the parietal, frontal, and occipital bones, about 
where a man's hat touches his head. The surface of a hematoma 
is even and rounded. If small, the swelling rises more sharply 
from the surrounding surface than if extensive. Edema of the 
skin may be slight or wholly wanting. Fluctuation can usually 
be obtained. The overlying skin may be discolored by an accom- 
panying contusion, but even if this is absent the hematoma will 
have a bluish look, due to the underlying blood. Absorption of 
so large a quantity of blood takes place very slowly, but the scalp 
is so abundantly supplied with blood-vessels that necrosis of the 
skin rarely follows. However, the time of recovery will be much 
shortened by removal of the effused blood. Suppuration is an 
occasional complication in both operated and non-operated patients. 

TREATMENT. Removal of the effused blood may be accom- 
plished by aspiration if the contents are sufficiently fluid, or the 
fluid and clotted blood may be turned out through a small incision. 
The head should be prepared by a careful washing with hot water 
and soap, and then with alcohol. ]f an incision is to be made it 
is better to shave a small area, but if sufficient care is given to 
cleansing the scalp and hair in the vicinity, primary union may 
be obtained without this. A scalpel, clamps, two small hooked 
retractors, thumb-forceps, and scissors are the only instruments 
needed. They should be boiled before using. The skin is divided, 
one side of the wound is elevated with a retractor or with for- 
ceps, and the clotted blood is thoroughly wiped out with pieces of 
absorbent cotton wrung out in weak bichloride of mercury solu- 
tion (1: 5,000). The fingers of the operator should not come in 
contact with the wound. The edges of the incision should then be 
drawn together \vith sutures of fine black silk or horsehair, and a 
firm dressing of dry, sterile gauze applied to keep the involved tis- 
sue planes in contact and to prevent exudation. A similar dressing 
should be applied after aspiration. The dressing should be 
changed on the following day and the pressure kept up for several 
days. The blood in a recent hematoma is not easily aspirated. 

Whether or not drainage is required will depend upon circum- 
slanres. A folded gutta-percha drain, if removed in two days, docs 
not materially delay union, and leaves no scar. Such a drain 
should be inserted at the time of operation, if it seems likely that 



INJURIES OF THE HEAD 



the blood will reaccumulate. It should certainly be inserted at 
the first dressing, if the wound was not drained at operation, and 
there has been a partial reaccumulation of blood. 

Hematoma in the New Born. Blood often collects between the 
periosteum and the skull of a child that is delivered by forceps. 
It may be difficult to distinguish between a hematoma of this char- 
acter and a contusion with edema. Two or three days later, when 
the edema of the scalp has subsided, but a fluctuating swelling 
persists beneath it, the diagnosis is clear. This effused blood 
should be evacuated through a small incision, in the manner de- 
scribed above, because its resorption is very slow and because the 
periosteum lifted from the skull continues to form new bone. In 
this manner in some cases a prominent and permanent thickening 
of the skull develops. Hence the desirability of removing the blood 
as soon as possible, and of keeping the loosened periosteum pressed 

against the skull for a few 
days until it reattaches itself. 
Hematoma of Ear (Boxer's 
Ear) . Blows upon the ear 
may give rise to hemorrhage 
beneath the perichondrium. 
The effused blood causes' a 
rounded fluctuating tumor 
(Figs. 1 and 2) which may 
stretch the ear far beyond its 
normal size and completely 
change its appearance, or it 
may be confined to a small 
portion of the pinna (Fig. 2). 
It is more often anterior than 
posterior. Absorption of the 
effused blood is extremely 
slow, and the tumor should 
therefore be promptly incised, 
the blood clots thoroughly re- 
moved, and the wound su- 
tured. The skin of the ear has a good blood supply, and wounds 
in it heal promptly if the edges arc accurately approximated by 
sutures. 




TIG. 1. HEMATOMA OF EAR FROM A BLOW. 
The perichondrium is lifted over a con- 
siderable portion of the pinna. 



TIKMORRHAGE FROM THE XOSK 



Hemorrhage from the Nose. Hemorrhage from the 
or epislaxis, may follow a blow either with or without fracture of 
the nasal bones, or it may result from picking at, the nose or the 
removal of dried secretion. It 
is one of the forms of vicari- 
ous menstruation. It is also 
a symptom of tuberculosis, of 
syphilis and malignant tu- 
mors, ;ind of many fevers. It 
is one of the signs of fracture 
of the base of the skull. 

The blood may flow in 
drops or in a steady stream, 
or occasionally it may be seen 
to spurt from an artery of the 
septum. 

TKKATMENT. In the ma- 
jority of instances the hemor- 
rhage will cease spontaneously 
in a few minutes. The pa- 
tient should not lean forward 
nor lie upon his face. The 
head should be held erect, or 
it should be bent slightly back- 
ward, so that the blood may 
accumulate and form a clot in 
the nostril. If the blood tric- 
kles into the naso-pharynx, it should be quietly expectorated. The 
patient should avoid any attempt to clear the nostrils by blowing. 
The application of cold in the shape of ice or some metallic object, 
like a large door-key, to the back of the neck is a well-tried house- 
hold remedy which has often proved effective. The holding of ice 
in the mouth or snuffing ice-water up into the nostrils may also 
suffice to stop the bleeding. Many popular remedies have doubt- 
less won fame because of the tendency of the hemorrhage in most 
cases to cease in a few minutes. In adults of a plethoric type fre- 
quent nosebleed seems to be really beneficial by reducing the ten- 
sion in the arteries. There are cases, however, in which the hemor- 
rhage is alarming, and the patient may even be in danger of 




FIG. 2. SMALL HEMATOMA OF EAR FOL- 
LOWING A BLOW THREE WEEKS PRE- 
VIOUS. Patient a man aged forty-one 
years. 



6 INJURIES OF THE HEAD 

bleeding to death. In other cases Ilic bleeding is so annoying that 
it becomes desiniMe l<> check it at once. 

To check the hemorrhage the nostril from which the hemor- 
rhage comes should be sponged clean and a systematic search made 
for the bleeding point. The head should be tipped back to allow 
the blood to flow out of the posterior nares. In this manner the 
anterior nares can be carefully inspected. The bleeding point will 
often be found low down upon the septum, about half an inch 
above the floor of the nasal passage and half an inch or more from 
the anterior orifice. Here it may be touched with a chemical 
caustic or by a hot probe, the shaft of which has been wrapped 
in order to avoid burning the tip of the nose, or by the finest point 
of a .thermo-cautery. By far the best styptic is adrenalin or the 
extract of the suprarenal gland. Cotton moistened with this 
should be applied to the bleeding spot, or a dilute solution 
(1: 10,000) may be snuffed up the nostril. Peroxide of hydro- 
gen is another excellent styptic. 

If the bleeding cannot be stopped in one of the ways mentioned, 
it may be necessary to plug the nasal cavity through the anterior 
nares. A narrow strip of gauze about two feet long is soaked with 
peroxide of hydrogen and squeezed dry. ' The anterior nares is 
dilated and the end of the strip passed well back in the nose with 
slender forceps. The packing is continued from behind forward 
until the cavity has been filled. Should this packing fail to con- 
trol the hemorrhage, the gauze should be withdrawn and the pos- 
terior nares plugged. This disagreeable procedure is best accom- 
plished by passing through the anterior nares a catheter or small 
rubber tube, through the eye of which a thread has been drawn. 
As the catheter appears in the pharynx the thread can be caught 
with a hook and one end of it drawn out of the mouth. The 
catheter is then withdrawn, the string remaining in position 
through the nose and out of the mouth. A specially devised in- 
strument for this purpose, known as Bellocq's canula, has a curved 
spring which carries the thread forward beneath the soft palate, 
thus making its extraction more easy. When the string is once 
in position, a pledget of cotton may be tied to the end which 
emerges from the mouth, and passed well into the posterior nares 
by drawing the string through the nose. The anterior nares 
should then be plugged with gauze or cotton. Both ends of the 



A Ml!. \Sln.\S 



string should lie secured by ivin^ ihcm together or fastening 
them on tlie check by adhesive plaster. Otherwise there may 
be difficulty in removing the posterior plug. This procedure is at 
hcst a clumsy method of stopping hemorrhage, and should not be 
ivs..rtcd to unless other measures fail. 

When once a clot has formed and hemorrhage has ceased, both 
patient and physician should for a day or two resist the tempta- 
tion to remove the tampon until the secretions of the nose lift it 
from the surface of the mucous membrane, so that it can be ex- 
tracted easily and without starting fresh hemorrhage. After that, 
gentle irrigation with a weak alkaline solution should be employed 
to cleanse the nostril. 

Abrasions. Abrasions of the scalp and face are of impor- 
tance as possible sources of infection. Abrasions of the face are 
important also because 
they may contain par- 
ticles of sand, coal dust, 
etc., which healing in 
the wound may perma- 
nently disfigure the pa- 
tient. Hence the neces- 
sity that all abrasions 
of the head should be 
cleansed thoroughly and 
then covered with gauze 
moistened with a weak 
antiseptic, such as alu- 
minum acetate (four 
per cent solution) or 
creolin (1:200) held 
in place by a gauze 
bandage. The dressing 
should be moistened 
with cold water every 
two hours. If kept 
moist in this way the 
dressing can be changed every day without irritating the wound. 
It is more easy to keep a wound of the scalp clean if a border an 
inch wide has been shaved around it. In a day or two the risk of 




FIG. 3. POWDER GRAINS IN- FACE FROM A RE- 
CENT EXPLOSION. 



INJURIES OF THE HEAD 



infection will have passed, and the abrasions may be allowed to 
dry, or they may be covered by boracic acid ointment until new 
epithelium has formed. 

Removal of Powder Grains. In abrasions of the face the sur- 
geon's attention should be directed to the removal of every particle 

of dirt, as insoluble sub- 
stances, such as grains 
of sand, may be covered 
over by epithelium and 
form permanent colored 
marks in the skin, like 
tattooing. This is es- 
pecially the case with 
powder grains. These 
are so small and soft 
and numerous that it is 
hopeless to attempt to 
pick them out one by 
one. It is most impor- 
tant, however, that they 
be removed. It is best 
to give the patient an 
anesthetic and then to 
scrub the wounded area 
with a stiff brush until 
every trace of powder 
has been scraped aw r ay 
(Figs. 3 and 4), for 
once the skin has healed 
over them it is impos- 
sible to get them all out by cutting or caustics without leaving 
marked scars. 

Foreign Bodies. Foreign bodies frequently lodge in the eye, 
ear, nose, or mouth, and the rules for their extraction vary in these 
different situations. Foreign bodies in wounds are described on 
page 14. 

Foreign Bodies in the Eye. A patient will usually make the 
diagnosis of a foreign body in the eye by a feeling of pain or dis- 
comfort. Frequently he can locate a small foreign body with great 




FIG. 4. POWDER GRAINS REMOVED BY SCRUBBING 
WITH A STIFF BRUSH WHILE THE PATIENT is 
FULLY ETHERIZED. All the grains were re- 
moved in this manner. The dark spots in the 
photograph are the slight resultant wounds. 
There was no permanent scar. 



FOREIGN MODI US 9 

although usually unable to say whether it is in the 
eyelid >r eyeball. 

The eye should be examined in a good light, first by direct 
light, and then if the foreign body is not discovered, by side light. 
The lower lid should be depressed to permit examination of the 
Jmver half of the eye. The patient should then be directed to look 
downward. The eyelashes of the upper lid are seized, and the lid 
is everted by lifting its lower edge outward and upuard at the same 
time that the upper margin of the tarsal cartilage is depressed with 
the tip of a finger, or with the end of a glass rod or pencil. 

When the foreign body is discovered, it may be wiped away 
with a bit of absorbent cotton wrung out of saline solution, or 
out of a solution of boracic acid ; or it may be removed with a blunt 
instrument, such as a spud or a match whittled to a not too fine 
point. 

If the cinder or minute particle of steel or glass is embedded 
in the cornea, it is well to drop a little weak cocain solution (one 
or two per cent) into the eye to assist the patient in keeping the 
eyeball quiet while the operator works out every particle of the 
foreign body. 

Most writers upon diseases of the eye advocate the use of fairly 
strong antiseptics for the purpose of disinfecting the wound in 
which the foreign body lay. This method of treatment was for- 
merly advocated in the case of larger wounds of the body, but it is 
now pretty generally understood by surgeons that such solutions 
have little effect other than that of the fluid itself. The rational 
procedure, therefore, is to bathe the eye with a weak antiseptic, 
such as a half saturated solution of boracic acid, or a normal 
saline solution every two or three hours, and to trust to the 
antiseptic action of the tears and of the internal fluids of the 
body to protect the eye from infection. Pain is much relieved 
by the application of ice cloths, and protection of the eye from 
strong light. 

If the foreign body has penetrated more deeply into the eye 
than the cornea, the aim of treatment is to remove it with as little 
damage to the eyeball as possible. A patient with such a serious 
lesion should be treated from the first by a specialist when circum- 
stances permit. Some writers upon the eye praise the use of a 
magnet for the removal of bits of steel and iron, while others say 



10 INJURIES OF THE HEAD 

that it is of no use, even when such a foreign body is situated 
superficially. 

Foreign Bodies in the Ear and Nose Beans, shoe buttons, and 
other objects are poked into the ear or nose by children. If they 
are smooth they may set up no irritation, but generally there is 
enough swelling of the mucous membrane to reduce the size of the 
opening and make their extraction difficult. If a foreign body is 
sharp, so that the mucous membrane is broken, either at the time 
or later, there will be a continuous discharge from the affected 
nostril, or from the ear, as the case may be. A persistent uni- 
lateral nasal discharge in the case of a child always suggests a 
foreign body. 

The amount of pain varies in different cases, according to the 
situation, size, and shape of the article, and the amount of injury 
done at the time of its entrance. 

The diagnosis may be suspected from the history or symptoms, 
but it rests chiefly upon the results of direct inspection through a 
suitable speculum. If the patient is a young child, complete anes- 
thesia is desirable for this examination as well as for subsequent 
treatment. 

TREATMENT. It is absolutely necessary that the patient's head 
should be still during attempts at extraction even if general anes- 
thesia has to be employed to accomplish this object. If the foreign 
body is one which may be firmly grasped with mouse-tooth for- 
ceps, it can be slowly and steadily extracted. The necessary in- 
struments are shown in Figure 5. If the foreign body is smooth 
and hard as, for instance, a round glass bead, a bit of shoe- 
maker's wax may be utilized to obtain a hold upon it, or a probe 
or blunt hook of bent wire may be passed alongside of it. Light 
substances, such as insects, may possibly be floated out of the 
ear on the surface of olive oil poured into the meatus. This 
is also a good way to drown an insect, and stop its motions in 
the ear. 

- One of the commonest foreign bodies the surgeon is called upon 
to extract from the ear is a mass of ear-wax. Normally the wax 
which is secreted in the ear works outward as a thin, hollow cylin- 
der, the outer edges of which dry up and break off in scales. If 
an overzealous individual attempts to free his ear of wax by means 
of a slender cone, for example, the twisted corner of a wet towel, 



FOREIGN HODIES 



it sometimes happens thai the edges of tlic tliin cylinder of wax 
are pushed inward from lime In lime until a large ball of wax is 
formed. This is not usually noticed until some jar dislodges it 
and it falls against the drum-membrane, causing a constant buzz- 




FIG. 5. INSTRUMENTS FOR THE EXTRACTION OF FOREIGN BODIES FROM THE NOSE 
AND EAR: A, Cotton carriers made of flattened copper wire; B, Pure silver slender 
probe; C, Ear specula; D, Nasal speculum; E, Forceps bent at a convenient 
angle; F, Curette. 

ing sound and a general feelinir of uneasiness inside the head. As 
this coiiiinues and hearing is possibly inleri'ered with, the indi- 
vidual seeks medical aid, under the supposition lhat lie has some 



12 INJURIES OF THE HEAD 

serious ear trouble. From the symptoms alone the diagnosis can 
usually be made. 

Ail examination through an car speculum reveals the ball of 
wax at a greater or less depth from the surface. Through as 
large a speculum as the ear will conveniently receive, slender for- 
ceps bent at a suitable angle may be passed into the car until 
they touch the wax (Fig. 5). The ball may be seized and a 
number of fragments drawn outward through the speculum. The 
success of this method depends as much upon the consistency of 
the wax as upon the dexterity of the surgeon. If the wax is firm 
it can all be removed in a few minutes. If it is soft very little 
of it can be extracted in 'this manner, and removal by syringing 
has to be resorted to. A fountain syringe or irrigator is filled with 
a warm dilute solution of bicarbonate of soda (a teaspoonful to the 
pint) and placed high enough to give slight force to the escaping 
stream, which is then directed, either with or without the specu- 
lum, full against the plug of wax, the ear being lifted upward and 
backward to dilate and straighten the canal. The wax is made less 
viscid by the fluid, and is separated from. the walls of the meatus 
to a certain extent,, and in most cases half an hour's syringing, 
interrupted by occasional extraction of fragments with the forceps, 
or with the curette, will suffice to empty the meatus. If not, the 
procedure can be resumed the following day. When the wax or 
other foreign body has been removed, the ear should be carefully 
examined for the presence of inflammation. If the surface is 
merely excoriated, an occasional antiseptic irrigation or dusting 
with powdered boracic acid is sufficient treatment. 

Foreign Bodies in the Mouth and Throat. Small foreign bodies 
may become lodged in some crevice of the mouth or throat, or if 
sharp, they may penetrate the mucous membrane, and thus resist 
the patient's efforts to eject or swallow them. A fish bone, a 
splinter, or a fragment of straw is the object that usually be- 
comes embedded. 

The sensations of the patient are in most cases a reliable guide 
to the location of the foreign body. It is possible for a rough 
object to scratch the throat during the act of swallowing, and leave 
behind it the sensation of a foreign body. It is the exception, 
however, for the patient to be mistaken in this way, so that the 
physician ought in every case to make an examination with a 



wor.NDs 13 

strong reflected .! direct lij-lit ;ind a throat mirror. The latter i- 
of the greatest service in hiintini: I'm- >mall, colorless object-;, ~im-e 
it enal'les the examiner to inspect the tonsil and the pillars of the 
fauces from different angles. These are the situations in which 
most small foreign bodies become lodged. When found, the foreign 
body can he extracted with the forceps, or worked loose with a probe 
or hent wire. If the search is fruitless, it should he resumed on 
the following day., provided the symptom- in the meantime have 
not subsided. 

Foreign bodies in the larynx and esophagus are described <n 
page 1 1."). 

Wounds. The different varieties of wounds incised, lacer- 
ated, et cetera are found with frequency upon all portions of the 
head. The blood supply of the scalp and of the skin of the face 
is so free that no matter how jagged a wound may be, the vitality 
of its points is usually preserved. 

Owing to the smooth, hard surface of the skull, a blow upon 
the scalp with a blunt instrument, such as a policeman's club, will 
produce a fairly clean cut wound, almost like that made with a 
knife. A careful inspection of its edges, however, will show a con- 
tused area more or less circular, and about an inch in diameter, 
which represents the area of contact of the instrument with which 
the blow was given. 

TKKATMKXT. The first object of treatment is to control hem- 
orrhage, either by pressure or ligation of the bleeding vessels; 
the second is to determine the extent of the wound, the third 
to remove any foreign bodies which may be present, and the fourth 
to approximate, by suture or otherwise, the tissues which have been 
divided, whether skin or deeper structures. 

It should be an invariable rule never to pass a probe into a 
wound, especially a wound of the scalp, until the skin has been 
cleaned as for operation; otherwise the probe may spread infec- 
tion to the deeper portions of the wound, which in the particular 
case mentioned may be the surface of the brain. 

The skin should be thoroughly washed with soap and water, 
then with some solvent of grease, such as ether, or turpentine fol- 
lowed by alcohol, and dried by gjin/e sponges or cotton swabs 
wrung out of an antiseptic solution (p. 34). The wound should 
be cleansed with saline solution, or stronger solutions, according 



14 INJURIES OF THE HEAD 

to circumstances. Its edges should be retracted, aiid the possi- 
bility of deep injury determined. Small foreign bodies should be 
removed. 

If a foreign body such as a splinter passes under the skin, the 
sinus made by it should be split up and thoroughly cleansed, for 
if allowed to remain undisturbed it is almost certain to cause sup- 
puration and delay recovery. A bullet of small caliber may pene- 
trate the scalp at one point, pass along outside of the skull, and 
emerge at another, or remain between the periosteum and the skin. 
In such a case the bullet should be removed by an incision over it, 
the sinus irrigated with peroxid of hydrogen solution, 1:8 or 
weaker, and 1 : 2,000 bichlorid solution, and pressure applied 
throughout its length except at its ends, which should be kept open 
by small strips of gutta-percha tissue or gauze. In this manner 
union can ordinarily be secured without dividing the intervening 
scalp. 

Most small wounds of the face and scalp should be sutured 
without drainage, or at most, a flat gutta-percha or horsehair 
drain should be employed (Fig. 306). Carefully applied pressure 
obtained by bandaging a dry compress of gauze to the head will 
prevent reaccumulation of blood in the wound. 

While it is generally true that all the ragged points of a wound 
of the face or scalp will live, it is better for the sake of a clean 
scar to trim the edges of the wound so that they may be smoothly 
approximated. Especial attention should be given to the direction 
of hairs whose roots are often twisted and displaced by rough 
injuries. Horsehair or fine black silk is the best material for the 
suture. 

Some surgeons have advocated a subcuticular suture. This is 
introduced with a curved needle which passes into and out of the 
skin, first on one side of the wound and then on the other, without 
reaching the surface. This suture is more difficult of application 
than other sutures, and it sometimes fails to approximate accu- 
rately the overlying epidermis. If the thread used for an inter- 
rupted suture is a very fine black sewing-silk (No. A), and the 
sutures are taken out in from two to four days, no permanent soars 
due to the punctures will remain. 

Wounds of the Eye. If a laceration extends through both the 
skin and conjunctiva of the eyelid, some of the sutures should pass 



\\OUNDS 15 



through both structures, so ;is l<> approximate the cd^es of the 
conjunctiva. Other siilurcs should In- placed in (lie skin .nl\. 
All lit' them should he removable from llic oiil-ide. In treating 
wounds of tho eyeball, rejmir with the least distnrhiinee of the nor- 
mal relations should he the aim of the operator. Protruding por- 
tions of (he iris should be snipped off. "Wounds of the sclerotic 
coat, if sufficiently large, should be sutured with the finest catgut. 
The eye should IK> washed with Thiersch's solution (salicylic acid 
l', boric acid 12, boiled water 1,000 parts) one-half strength, or a 
half-saturated solution of boracic acid, or a normal salt solution. 
A light pad of gauze moistened with one of these solutions should 
be applied. The bandage (Fig. 320) should be light so that evap- 
oration may keep the eye cool. No rubber protective is permissible. 
The moisture should be kept up by adding from time to time more 
of the solution or cold boiled water. If the injury is serious the 
patient should remain in bed until repair is well established. The 
services of an ophthalmic surgeon should be obtained in these cases 
whenever possible. 

Wounds of the Mouth. Wounds within the mouth are con- 
stantly tilled with bacteria, some of them pathogenic. Neverthe- 
less, they usually heal with little delay, owing to constant mois- 
ture and the extremely free blood supply. It is rare that the 
surgeon is called upon to treat a bitten tongue or cheek. If, how- 
ever, so large a flap has been separated from the main tissue that 
untreated it would cause a permanent roughness in the mouth, one 
or more sutures of fine black silk should be inserted with a curved 
needle. Plain catgut soon swells and softens and loses its grip. 
Catgut prepared so as to resist moisture (e. g., chromicized) is stiff 
and unpleasant; fine silk, dyed black so as to be readily seen, is 
therefore the best suture material for the mouth. 

If the lip or cheek is cut through, cutaneous sutures passed 
through all the tissues except the mucous membrane will suf- 
ficiently hold the parts in place, or the mucous membrane may first 
he sutured with catgut or silk, the knots being tied inside the 
mouth. If silk is used the sutures should lie so placed that their 
extraction will be easy. The mouth should be kept clean by rins- 
ing with a mild antiseptic solution, and, if necessary, remnants of 
food should be wiped with wet cotton swabs from the vicinity of 
the wound. 



16 



INJURIES OF THE HEAD 



Steno's duct, or the facial nerve, may be divided in wounds 
of the cheek (Fig. 6). Immediate suture should be performed, 
or even late suture if the accident is overlooked at first. If the 

two divided portions of 
Steno's duct have become 
separated by scar tissue, 
the anterior portion of 
the duct can usually be 
probed, and the probe 
thrust into the posterior, 
then dilated portion. 
The channel may be re- 
stored by tying the probe 
in place for a day or 
so, or a ligature may be 
passed through the duct 
beyond the scar and into 
the mouth. As soon as 
the normal channel is re- 
established, such an arti- 
ficial fistula will close as 
soon as the thread is re- 
moved. A small exter- 
nal fistula due to an in- 
cision into the substance 
of the gland, will usu- 
ally close of itself in a 
few days. 

The paralysis of the mouth, and possibly also of the eyelids due 
to division of the facial nerve, can hardly be overlooked. The 
nerve should be sutured at once ; see Chapter XIII for the technic. 
Wounds of the Periosteum. In incised and punctured wounds 
of the scalp, the periosteum is often injured. This serious com- 
plication can be recognized by retraction of the edges of the wound 
and inspection and probing of its deeper portion. If merely the 
overlying aponeurosis is divided, one may be misled into supposing 
that it is the periosteum. If the latter is also divided the probe 
will clearly detect the underlying bone. Such a wound should be 
thoroughly examined, cleansed, and drained. It is better to ,delay 




FIG. 6. DIVISION OF STENO'S DUCT BY A RAZOR. 
The skin was sutured and the division of the 
duct was not noticed until the obstructing 
scar caused distention behind it. This patient 
was promptly cured by the method described 
above. 



FKACTTTRKS 17 

Illlion for ;i few da\.- I'V the pn -dice of ;i g}l||/e dr.iill than to 

suture the perio.-leiim and run tlic risk of abscess formation I*' 
ncath il. The mere exposure of llie skull for :i few days will not 
result, in necrosis if suppuration does not coexist; whereas an in- 
i'cctcd punctured wound, for example over the eye, may lx- fol 
lowed by suppuration under I lie periosteum which, if neglected, 
iiuiy pass through the skull and set up a fatal suppurative menin 
git is. Therefore the fresh wound should be only partially sutured, 
while a strip of gauze should reach to the periosteum in the center 
of the wound. This drain may l>e withdrawn in forty-eight hours, 
and if the wound is still clean it may be allowed to close ; if it is 
suppurating it should be washed out with mild antiseptics and 
drained again, and a wet dressing applied. 

Fractures. Fracture cf the Skull. In many instances it is 
impossible to diagnose a simple fracture of the skull except by ac- 
companying signs. These are local pain and tenderness, hemor- 
rhage the blood appearing in the orbit or coming from the ear 
headache, shock, partial paralysis, pupils irregularly contracted or 
dilated, and partial or complete unconsciousness. Shock, even to 
complete unconsciousness, may be present from concussion of the 
brain (really contusion of the brain) without fracture- of the: skull; 
and fracture of the skull, especially if it is caused by a fairTy^sJiarp 
instrument and if it involves bone which overlies the less impor- 
tant portions of the brain, may be unaccompanied by shock. This 
is especially true of the occipital region.- Hemorrhage in the orbit, 
appearing usually under the conjunctiva, or from the nose (if -frac- 
ture of the nose is absent), or from the ear, or appearing under the 
skin in these localities, is considered to be pathognomonic of frac- 
ture of the base of the skull. Under such circumstances operative 
treatment is out of the question. Absolute quiet in a cool, dark 
room, with external heat to the extremities, and cardiac stimulants, 
if necessary, are the best means to be employed. If external 
wounds are present the most rigid asepsis should be observed in 
their treatment. If the lesion in the skull is extensive or a por- 
tion of the bone is depressed, it is better not to attempt repair at 
the time of the accident, but simply to protect the wound by a moist 
antiseptic, or dry sterile dressing, until arrangements for a for- 
midable operation can be completed. 

Fluctuating hematoma of the scalp, surrounded by a ring of 
4 



18 



INJURIES OF THE HEAD 



resistant edema, may give the impression that the bone in its center 
is depressed. This error is to be avoided by noting the natural 
curve of the skull outside of the edematous area. 

Fracture into a Frontal Sinus A fracture of the frontal bone 
just about the orbit may involve only the outer wall of the frontal 
sinus. This is not usually a serious lesion, but the bone should lx? 

replaced in its normal 
position so that per- 
manent disfigurement 
may be avoided. 

To accomplish this 
it may be necessary to 
make an incision be- 
neath the eyebrow. 

Fracture of the Ma- 
lar Bone. This injury 
is due to direct vio- 
lence, and the bone is 
almost invariably dis- 
placed backward so 
that one cheek is less 
prominent than the 
other (Fig. 7). 

To replace it in po- 
sition, anesthetize the 
patient, chisel a hole 
into the antruin just 
above the first bicuspid 
tooth and introduce a curved steel sound. With this instrument 
as a lever, firm, steady pressure may be exerted upon the inner 
surface of the malar until it is brought into its normal position. 
A mouth wash is the only after treatment required. 

Fracture of the Nasal Bones. The nose is frequently injured 
by blows and falls, so that the nasal bones may be fractured, or the 
cartilages torn loose from them. An injury of this sort is usually 
followed by more or less hemorrhage from the nares. There is 
also subcutaneous hemorrhage and edema, so that it is difficult to 
determine from external examination alone whether the rigid struc- 
tures have been altered. Gentle manipulation of the bridge of the 




FIG. 7. FRACTURE OF RIGHT MALAR BONE WITH 
DEPRESSION FROM BLOW. 



FRACTURES 19 

will usually elicit crepitus if there is a fracture. This should 
be combined with inspection of the nares through a bivalve specu- 
lum. Deformity may of course have existed previous to the injury, 
and the patient should be questioned upon this point. 

The hemorrhage stops in a few minutes, and the pain is slight; 
but the patient may be distressed by his appearance, or by the fact 
that the swelling and iiemorrhage prevent him from breathing 
through his nose ; but both nares are not usually obstructed. 

TREATMENT. The chief object of treatment is the reduction 
of deformity, and the maintenance of correct relations for a few 
days. Whenever possible, existing deformity should be so cor- 
rected or overcorrected that there is no further tendency for the 
bones to slip out of place. A blunt steel sound, or some similar 
instrument passed into the nostril, is of assistance in correcting 
displacement. 

If deformity tends to recur, it may be necessary to insert a hol- 
low, perforated rubber cone into one nostril, or to apply an external 
splint. This can be made of dental composition, softened in hot 
water, and molded to the nose, or a pad of gutta-percha tissue 
may be similarly employed. As the swelling diminishes, the splint 
must be remolded. The surgeon can then better judge whether 
all deformity has been corrected, and if not this should be accom- 
plished before union becomes solid. If the patient is seen several 
times with this object in view, it will rarely be necessary to make 
use of a complicated nasal splint, or to scar the face by passing a 
hat pin directly through the nose. 

Fracture of the Superior Maxilla. This is one of the less com- 
mon fractures. Deformity is easily overcome, and after reduc- 
tion the fragments will usually remain in a correct position, since 
there are no strong muscles tending to displace them. As an addi- 
tional safeguard, wires and threads may be used to bind together 
teeth attached to the fragment, and those of the remaining part of 
the superior maxilla, as described below in connection with frac- 
ture of the inferior maxilla. 

Fracture of the Inferior Maxilla or Mandible. This injury is 
very common, and often seriously affects the patient's health. 
Moreover, the difficulty of keeping the fragments in correct posi- 
tion often taxes the ingenuity of the surgeon to the utmost. The 
fracture is due to direct violence, and almost always to blows re- 



20 INJURIES OF THE HEAD 

ceived in a fight. The line of fracture usually passes through the 
body of the jaw, back of the canine or the bicuspid tooth. It may, 
however, occur at other places, and often there is a second fracture, 
either on the other side, or possibly on the same side, in which case 
it may be above the angle of the jaw. If the fracture is situated 
in that portion of the jaw occupied by the teeth, it is almost always 
compound into the mouth. 

Diagnosis is made from inspection and manipulation, as well as 
from the subjective symptoms of pain and disability. There is 
local swelling and tenderness. Inspection of the gums will usually 
show a break in the continuity of the mucous membrane at the 
roots of the teeth. The patient cannot open his mouth fully, nor 
can he bite on a hard substance, for example a cork. Attempts to 
open and close the mouth may produce motion at the site of frac- 
ture, shown by changes in the relation of the teeth on either side 
of the break. Such displacements can be readily produced by the 
examiner, if, grasping the jaw between his thumb placed under 
the patient's chin and two fingers placed on the incisor teeth, he 
rocks it from side to side. 

The disability due to this fracture is great. The patient is 
absolutely unable to chew solid food, even if it were desirable to let 
him do s.o, or to open the jaw except to a slight extent. Pain pre- 
vents him from sleeping, and abnormal fermentations within the 
mouth increase the swelling and inflammation, and add to his dis- 
gust and discomfort. 

TREATMENT. The first step in treatment is the perfect reduc- 
tion of the fragments, under a general anesthetic if necessary. In 
some cases this is a very simple procedure, and the ends of the 
bone when reduced show no tendency to become displaced. In 
other cases reduction is easy, but the moment that the surgeon lets 
go of the jaw displacement recurs. In a third class of cases per- 
fect reduction is impossible, or can only be accomplished by the. 
exercise of considerable force. This means that a tooth has become 
loosened and wedged between the fragments, or that there is a dis- 
placed small fragment of bone which has intervened in a similar 
manner to prevent the reduction. Such offending tooth, or frag- 
ment, should of course be removed. 

The simplest method of keeping the fractured ends of the bone 
in apposition is to bandage the jaws firmly together, thus making 



I l; UTl'HKS 



21 



the upper jaw act as a splint for the lower one. A four tailed 
bandage with a slil, <>r narrow ellipse nit in its center through 
which the point of the chin protrudes snllicientlv to keep the band- 
age from slipping, is tied across the occiput ami over the forehead, 
one end being left long in each situation (Fig. 
8). These two ends are then tied together over 

the top of the head. The ha lid age after this 
application is shown in Figure .'>:iS, Chapter 
XXI. In this manner any desired amount of 
pressure can be produced upon the jaw, the pull 
heing both backward and upward. This meth- 
od of treatment makes it difficult for a patient 
to keep his mouth in proper condition, and in- 
terferes with feeding, as he has to take fluid 
nourishment through a tube. Pressure of the 
bandage over the seat of fracture often adds to 
the patient's discomfort; but it is by far the 
commonest method employed on account of its 
ready application. There are cases in which it 
answers the purpose admirably, and the patient 
is even able to open his teeth sufficiently to 
brush them without disturbing the fractured 
ends. In other cases the bandage is a miser- 
able failure. Xon-success is usually due to 
the fact that reduction has been imperfectly 
accomplished, or to the fact that the patient 
has not two full sets of teeth. If a person has 
all of his natural teeth, pressure of one set 
against the other, and the repeated slight blows 
given by the act of chewing will, during the 
later weeks of convalescence, correct any slight 
irregularity of the lower jaw which still exists, 
provided that reduction does not require much force, and that there 
are at least two teeth back of the line of fracture. 

If this simple treatment does not succeed, or if for other rea- 
sons a more exact method of treatment is indicated, the teeth may 
be wired together. For this purpose two flat wires should he 
passed along the lower teeth, one inside of them and one outside 
of them, and they should be lashed to the teeth and to each other 



FIG. 8. FOUK-TAILED 
BANDAGE FOB 
FRACTURE OF THE 
INFERIOR MAXILLA. 



22 INJURIES OF THE HEAD 

by threads; but no threads should be placed around the two teeth 
nearest the fracture, for they are usually loosened and incapable 
of enduring the strain. In many cases absence of teeth, or the 
situation of the fracture far back, makes this plan of treatment 
impossible. 

Fracture of the lower jaw may be treated by means of an in- 
terdental splint. Success in the use of this form of apparatus 
depends not a little upon the manual dexterity of the surgeon. The 
first step is to secure a good impression of the teeth and gums of 
the whole of the lower jaw. This impression may readily be taken 
by means of modeling composition such as dentists use, and it is 
not at all necessary that -the fracture be reduced when the impres- 
sion is taken. It is just as easy to set the fracture in the im- 
pression as it is in the jaw, but the fracture must be reduced, of 
course, before the splint is applied. The impression should show 
the line of the gums both inside and outside the teeth, and should 
extend well back to the angle of the jaw on the fractured side. 
From such an impression, if well made, an excellent splint may 
be ordered from any dental manufacturing house at a cost of ten 
dollars or more. Counter-pressure is obtained by the four-tailed 
bandage already described, or the splint may be pressed against 
the lower jaw by means of a pad or a bit of board which is attached 
to the splint by a broad spring curling over the chin. Another plan 
is to fix wires in the interdental splint. These come out at 
the angles of the mouth and turn backward along the cheeks, and 
are bound together, the bandage passing beneath the jaw. Pres- 
sure will be more exact if a board nearly as long as the distance 
between the wires is placed under the jaw. If a splint of this 
character fits accurately, it enables the patient to open his mouth 
and often to chew soft food, if the interdental splint is made to 
fit both upper and lower teeth. In many cases, this splint will 
keep the broken bone in place without the use of a bandage. 

The form of apparatus selected must be worn for a month 
or more, depending upon the amount of tendency to displacement 
and the rapidity with which the ends of the bone unite. Even in 
favorable cases it will be several weeks before the patient regains 
the full power of the jaw and the ability to open wide the mouth. 
If the line of union is a correct one, the surgeon need not hesitate 
to promise complete restoration of function. 



FRACTURES 23 

Complications of Fracture of the Lower Jaw. Fracture of the 
lower jaw is usually compound into the mouth. It is therefore 
not surprising that infection sometimes develops. In a certain 
number of cases this is of mild character; the pus which forms is 
discharged into the mouth, the wound heals by granulation, and 
the union of the fractured bone, although delayed, is not other- 
wise interfered with. In a good many cases, however, an abscess 
forms which drains imperfectly and gives rise to pain, swelling 
and edema of the neck and possibly fluctuation below the margin 
of the jaw. This is an unfortunate complication, since it may 
lead to a sequestrum and greatly delay recovery, and possibly 
make it necessary to perform one or more operations to provide 
drainage or remove dead bone. It is therefore important to keep 
the mouth of every patient as clean as possible by the use of 
astringent and antiseptic mouth washes. If an abscess forms, it 
should be promptly drained within the mouth if good drainage 
can be thus secured, and if not, through an external incision. 
Such an incision should be parallel to the margin of the jaw, and 
just below it. If the fracture is near the center of the horizontal 
ramus, the possibility of division of the facial artery or vein 
should be borne in mind. A drain should be placed in the external 
wound, but should be of such a character as to favor the escape 
of pus, and not to prevent it. Frequent irrigation with a solution 
of peroxide of hydrogen (1:8) assists in keeping the wound free 
from bacteria. Meanwhile treatment of the fracture itself should 
be continued as described above. 

A sinus which has formed spontaneously, or which follows an 
external incision for drainage usually lasts some weeks. No at- 
tempt should be made to close the opening in the skin until the 
deeper portion of the sinus has become filled by granulation. 
When this takes place, the opening in the skin will quickly close. 

Persistence of the sinus means that some foreign material is 
present : either the loosened root of a tooth or a sequestrum of the 
bone itself. The opening should be enlarged, such foreign mate- 
rial removed, and another period of drainage instituted. Care 
should be taken not to break up newly formed bone, which is often 
thrown out around the sequestrum in great abundance in cases of 
compound fracture of the lower jaw. 

Xon-uniou of the mandible is almost unknown; therefore a 



24 INJURIES OF THE HEAD 

persistent following out of the principles here outlined will lead 
to complete restoration. If the resulting scar is unnecessarily dis- 
figuring by reason of its close attachment to the bone, it should 
be removed; but not until some months have elapsed (p. 47). 

Dislocation of the Jaw. This is a rare accident which 
is brought on by extreme gaping or laughter. The condyloid 
process on one or both sides slips forward out of its socket. It is 
impossible to close the mouth, and the pain due to stretching of 
the ligaments is excessive. The patient should be anesthetized 
and the jaw grasped firmly with two hands, the thumbs of which, 
Avell wrapped about with bandage, are placed upon the molar teeth. 
Pressure downward and then backward will restore the bone to 
its correct position. In some persons dislocation of the jaw takes 
place "easily, owing to abnormal laxity of the ligaments. Under 
these circumstances reduction is readily accomplished without an 
anesthetic. ~No after treatment is necessary. 

There are certain long standing cases of unreduced dislocation 
of the jaw which cannot be reduced in the manner described, and 
for which resection of the articular portion of the bone has been 
advised, or the bone may sometimes be dragged into place by a 
specially contrived hook which is inserted through a small wound 
in the cheek and is passed around the neck of the jaw. This 
enables the surgeon to make very strong traction in the most advan- 
tageous manner. 

Subluxation. A few young men and girls especially the lat- 
ter complain of a partial dislocation of one or both maxillary 
articulations every time the mouth is opened. This trouble occurs 
at the period of development of the wisdom teeth, and in most 
cases is due to it. The pain is slight. Some patients have thought 
themselves benefited by the application of tincture of iodin or 
small blisters. In most cases a spontaneous cure takes place in 
some months. Therefore nothing should be done which will per- 
manently stain or scar the skin. 



CHAPTER II 

INFLAMMATIONS OF THE HEAD 
EFFECTS OF HEAT AND COLD 

Burns. The burns of the head which the surgeon is called 
upon to treat are not usually very deep. The scalp is protected by 
hair, and if flames or steam rise into the face sufficiently to burn 
deeply, they will usually be inhaled and produce fatal internal 
injury. Most of the deeper burns of the face are, therefore, the 
result of a gas explosion or the electric flash caused by short cir- 
cuiting. The importance of avoiding a scar is, of course, very 
great, so that slight burns should be carefully attended to. 

Burns have been variously classified according to the depth to 
which the tissue is destroyed. For practical purposes, they may 
all be placed in three classes. 

BURNS OF THE FIRST DEGREE. The symptoms are swelling, 
redness, and tenderness of the skin. There is no visible destruc- 
tion even of the epidermis, although this usually peels off in strips 
a few days later. A familiar example is a mild sunburn. There 
is increased redness of the burned area for a week or more, but no 
permanent scar. 

TREATMENT OF BURNS OF THE FIRST DEGREE. The chief 
indication for treatment is the relief from pain. This is best accom- 
plished by smearing the surface with one of the lighter ointments 
which contains a considerable amount of water, such as rose water 
ointment, or one of the ointments sold under the names of Let- 
tuce Cream, Cucumber Cream, etc. Cow's cream is excellent for 
the purpose. Recovery promptly follows the application of any 
non-irritating substance. 

BURNS OF THE SECOND DEGREE. Much of the epidermis 
within the burned area is destroyed. There are blisters either full 
of serum or collapsed, or the injured epidermis may have been 
more or less removed. Hairs within the burned area are also 

25 



26 INFLAMMATIONS OF THE HEAD 

burned away. There is redness, swelling, and tenderness, and a 
more or less free oozing of serum, and possibly of some blood. 
Repair in this class of burns takes longer than in burns of the first 
degree, but no slough of the true skin occurs. If the whole thick- 
ness of the epidermal layer is here and there destroyed, these areas 
are very small and are rapidly covered by spreading of the deeper 
layer of epithelial cells. There is, therefore, no permanent scar. 
Redness will persist longer than in burns of the first degree, pos- 
sibly for a month or more. 

TREATMENT OF BURNS OF THE SECOND DEGREE. The chief 
indication for treatment is the relief of pain. The permanent 
result is certain to be good. There are four plans of treatment: 
One is to apply a dressing soaked with oil or spread with ointment 
in order to protect the injured surface from the air and from 
changes in temperature. A second plan is to cover the burn with 
strips of rubber tissue or with gauze wet with normal saline solu- 
tion. The third plan is to treat the burned area with an antiseptic 
dressing, which may be allowed to dry or which may be kept moist. 
The fourth plan is to leave the burned area exposed to the air in 
order that it may dry up. Various dusting powders are employed 
to further this last plan. 

The author favors the first or the second of these four plans, 
believing that these dressings are more comfortable to the patient, 
and that they favor the vitality of those portions of the skin which 
have been injured but not destroyed by the burn; and because 
such dressings, provided plenty of ointment is used, or plenty of 
water if a wet dressing is employed, can be removed with less pain 
and damage than other dressings which are allowed to dry out. 
Powders are objectionable, since they form, with the exuded se- 
rum, hard crusts which are veritable culture tubes for bacteria. 
It is impossible to make or keep aseptic an area of skin which 
has been burned below the superficial portion of the epidermis. 
Protection against infection depends, therefore, on the vitality of 
the remaining skin rather than on the antiseptic qualities of the 
dressing. Hence, the latter should be soothing to the skin rather 
than deadly to the bacteria. 

A good example of an oily dressing is carron oil, a mixture of 
equal parts of linseed oil and lime water. If this is used the 
gauze should be thoroughly saturated with it, as otherwise the oil 



BURNS 27 

will soak into the outer dry dressings, and the iim<T layers will 
become very firmly attached to the skin. For this reason an oint- 
ment is preferable in nnt eases. A good one is composed of one 
drain of boric acid to the ounce of vaseline. The ointment should 
he sterilized by setting the jar which contains it in a pan of boiling 
water. It can, of course, be sterilized in a steam sterilizer. The 
ointment should be used freely. A good plan is to spread it over 
the burned area with a spatula, much as one spreads butter with a 
knife. Dry gauze can then be applied in pieces small enough to 
fit the part, and the dressing fixed by a loose gauze bandage. 

The principle of the normal saline solution when used as a 
dressing for a burn is the same as when used as a dressing for 
a skin graft. It is to reproduce as far as possible the normal 
surroundings of growing epithelium. If this plan is adopted, the 
burned area should be immersed in a saline solution, or lightly 
sponged with swabs saturated with the same. It is then covered 
with several thicknesses of gauze saturated with saline, and evapo- 
ration is prevented by covering the whole with a sheet of gutta- 
percha tissue, or strips of gutta-percha tissue may be applied 
directly to the burned surface, and these in turn be covered by the 
wet gauze. When the dressing is applied in this manner, a sheet 
of impervious material may be applied externally, or this may be 
omitted and the gauze kept wet by more frequent saturation with 
saline or boiled water. 

Picric acid is recommended by those who favor antiseptics in 
the treatment of burns of the second degree. Gauze is saturated 
with a one per cent solution, either before or after it is applied to 
the burned surface. This dressing is supposed to control the pain, 
but I have seen patients suffer severely after its employment. It 
has a tendency to dry up the exudate, so that in many cases burns 
treated in this way are greatly improved in appearance. The in- 
tense yellow color of the picric acid stains the clothing. 

A mild antiseptic solution suitable for use in burns of the 
second as well as of the third degree, is a four per cent solution 
of aluminum acetate. The gauze should be saturated with it, and 
then kept wet by the addition of sterile water from time to time. 

If it is decided to treat the burn by the dry method, it may be 
left exposed to the air or cleansed and dusted with a powder, such 
as bismuth subiiitrate, or bismuth subgallate, or nosophen. 



28 INFLAMMATIONS OF THE HEAD 

BURNS OF THE THIRD DEGREE. Portions of the corium, and 
possibly still deeper structures have been destroyed by the heat. It 
is easy to be misled in this matter by the early appearance of the 
skin. In a burn of the first or second degree the affected skin is 
red from the congestion of the vessels in it. If the vitality of the 
corium is destroyed, the blood cannot circulate through its vessels, 
and the skin will therefore appear white. The difference between 
this skin and normal skin is easily recognized if one looks for 
changes in color due to pressure made upon it. Such changes 
will, of course, be wanting in the dead skin. Furthermore, such 
a white, dead area will invariably be surrounded by a hyperemic 
zone in which the burn is -only of the second degree. I have known 
several instances in which intelligent physicians overlooked a burn 
of the third degree, being misled by the lack of redness of the 
skin. This dead skin will, of course, slough, and in time will 
become entirely loose. During this process, which sometimes takes 
two weeks or more, there is danger that the slough will interfere 
with the exit of underlying pus. 

TREATMENT OF BURNS OF THE THIRD DEGREE. We have, 
then, in burns of the third degree, three indications for local treat- 
ment the relief of pain, protection of the injured but living tis- 
sues, and drainage of any pus pockets which may form. A moist 
antiseptic dressing best fulfils the requirements. In most cases 
morphine should be given either hypodermically or by mouth dur- 
ing the first twenty-four hours. Few persons can sleep without an 
opiate the first night after a burn, even if they can endure the 
pain while awake. 

The moist dressing should be applied warm and kept warm. 
The gauze may be saturated with aluminum acetate, as mentioned 
above, or boric acid, or any other feeble antiseptic. The dressing 
should be kept constantly moist, and in some instances a continu- 
ous bath is desirable. 

Frequent dressings are to be avoided, but if the dressings be- 
come saturated with pus and serum, the comfort of the patient is 
usually promoted by changing them. Sloughs should be cut away 
as soon as they loosen, but not before. If a large area is burned, 
the central portions of the skin may loosen before the edges. If 
so, incisions should be made through the slough or portions of it 
excised to permit free escape of pus and secretions. 



BURNS '- )c .) 

The repair after a burn <>i tin- ln->\ r -rcond degree is accom- 
j ills 1 ic<] by the luiriiial growth of the epidermis. Jn every burn of 
the third degree the removal of the <l<.nuhs is accomplished l>y the 
urowth of granulations beneath them. These granulating areas 
must be covered by the lateral growth of the epithelial cells, either 
from the edge of uninjured skin, or from islands of epithelium 
which have been left, or from the epithelium which lines the fat 
and sweat glands. This new epithelium at first has no color of 
its own, and simply looks like a dark red glaze over parts of the 
granulating surface. Later, as the epithelial cells multiply, a 
whitish appearance results. It will be evident, therefore, in two 
or three weeks whether the burned area will become covered with 
epithelium within a reasonable time. An epithelial edge will grow 
about an eighth of an inch a week. A granulating area, therefore, 
which is an inch in its smallest diameter, will require a month for 
its complete repair. Areas larger than this, and which are with- 
out epithelial islands should be skin-grafted (see Chapter XX). 

There is one other thing to be borne in mind during the repair, 
and that is the possibility of cicatricial contraction. This can be 
avoided to a certain extent by the judicious use of plaster ban- 
dages and splints to keep the burned area fully extended during 
the healing process ; but a far better means of prevention is the 
early covering of the granulating surface with pedicled flaps, or 
when this is not practical, with Thiersch, or better, with Wolfe 
grafts. In this way the amount of scar tissue is kept at a mini- 
mum and the power of contraction will be slight. 

Sunburn. This injury, though not serious, should be pre- 
vented many times when it is not. Before exposure to the rays 
of the sun the skin should be rubbed with cold cream or some sim- 
ple ointment, such as boracic acid ointment, and when the skin 
shows the first pink color, it should be covered with clothing. If 
one waits until the sensation of burning is present, the mischief 
will have been accomplished. The treatment of sunburn is that 
of a burn of the first degree. Washing with soap is to be avoided.. 

Sunburn of the Up is very annoying because it takes from one 
to two weeks for recovery. This is because the thinner epithelium 
in the burned area is totally destroyed, and the little ulcer which 
results must heal entirely by growth of epithelium from its 
at the rate of one-eighth of an inch per week. 



30 INFLAMMATIONS OF THE HEAD 

X-Ray Burn. Exposure to the X-ray in some cases for a few 
minutes only, produces a redness of the skin which somewhat re- 
sembles sunburn. It does not, however, appear until some hours 
after the exposure. If the exposure is frequently repeated, an 
ulcer may form. 

The milder lesions quickly disappear, and require no other 
treatment than soothing applications. The ulcers are often very 
painful. Ointments containing cocain, morphine, menthol, or 
orthoform should be tried. Stelwagon recommends curettage and 
skin-grafting in obstinate cases. 

Frostbite. The ears, cheeks, and nose are the parts of the 
head most often frozen. If the part is still frozen when the 
patient is first seen, it should be rubbed lightly in the cold 
until the circulation is reestablished, in order to avoid a violent 
reaction. 

Frostbite of the head requiring surgical treatment is almost 
always confined to the ears. The symptoms of cyanosis, swelling, 
pain, and tenderness are here well marked. Occasionally blisters 
form ; but gangrene is uncommon, at least in this latitude. 

Various applications have been recommended for frostbite. 
The good effect of treatment seems to be due merely to the main- 
tenance of an even temperature which facilitates the flow of blood 
to the part. Moreover, the dressing protects the ear from sudden 
changes in temperature. Any astringent, or a simple ointment, 
such as one containing tannic acid or ichthyol, spread in a thick 
layer upon gauze applied to the ear and covered with a layer of 
cotton, forms a satisfactory dressing. 

If a portion of the ear is gangrenous, it should not be removed 
until a line of demarcation is well established. It may then be 
seen that gangrene does not extend deeper than the skin, or pos- 
sibly the epidermis. (Compare gangrene of the extremities from 
frostbite, Chapters XV and XVIII.) 

Dermatitis. Sunburn and frost-bite are forms of dermatitis 
due to heat and cold. Dermatitis may also be due to traumatism, 
the treatment for which is essentially the same as that given for 
sunburn. In other cases, dermatitis follows the unwise use of 
drugs externally or internally, while a very common form of der- 
matitis is due to contact with poison ivy. These have the general 
name of dermatitis venenata if due to an external application ; if 



HERPES 31 

<l iif In ;in invested drug or poison, the name dermatitis medica- 
meutosa is used. 

lodoform, mercury, carbolic acid, cantharides, dyestuffs, etc., 
will poison certain skins. There may be simply a redness and 
burning, or there may be a profuse eruption of vesicles. In ivy 
poisoning these vesicles are of various sizes, and a number of small 
ones often merge. 

In most cases of dermatitis, as soon as the cause is removed 
there is a prompt recovery. Treatment consists, therefore, of 
soothing applications, such as a two per cent solution of boracic 
acid, or the application of a simple ointment. Larger vesicles 
should be punctured and their contents expressed. In some cases 
an opiate is required. If the eruption is due to the ingestion of a 
drug, the drug should, of course, be stopped and a diuretic and 
cathartic should be given. 

ACUTE INFLAMMATIONS 

There are four common skin lesions of an inflammatory nature 
frequently found upon the face, with the diagnosis and treatment 
of which every physician should be familiar. They are urticaria, 
herpes, impetigo, and acne. A brief description of these four dis- 
eases is given here because of their acute character, as well as to 
differentiate them from forms of inflammation in the skin gener- 
ally considered surgical. 

Urticaria. Urticaria is a form of eruption greatly resem- 
bling the bites of insects. Indeed these bites are classed as lesions 
of urticaria by some writers. Other external irritants, and vari- 
ous articles of food, especially shellfish, pork products, and straw- 
berries, will produce urticaria in some persons. The lesions come 
up quickly and usually subside in a few hours. 

A saline cathartic should be given, or under certain circum- 
stances an emetic. The affected skin should be bathed with a 
lotion, usually containing one or two per cent of carbolic acid, to 
relieve the itching. Three ounces of alcohol, three ounces, of cam- 
phor water, and one dram of carbolic acid, make a good lotion for 
the purpose. 

Herpes. The lesion of simple herpes, or fever sore, is a 
group of half a dozen vesicles, each of which is about as large as 



32 INFLAMMATIONS OF THE HEAD 

a pin-head. These contain at first serum, but later the fluid may 
become purulent. By drying, a crust results which falls off with- 
out leaving a permanent scar. The lesions are usually found 
either upon the face or the genitals. They are often seen on the 
lips in the beginning of acute disease, especially acute inflamma- 
tions of the respiratory tract. 

Any one group of vesicles lasts only a few days, but new 
vesicles may form in the vicinity. A good plan is to paint the 
affected skin every two or three hours with spirits of camphor, 
or with tincture of benzoin. Carbolic salve may be applied to 
the surrounding skin in the hopes of preventing new lesions 
from forming. When a crust has formed, cold cream may be 
applied. 

Impetigo. Impetigo contagiosa is an acute contagious dis- 
ease, the lesions of which are usually found upon the face. There 
is first noticed a number of vesicles which soon become pustules, and 
which may coalesce. Crusts form, dry up, and fall off, leaving no 
permanent scar because the lesion is, in most instances, confined 
to the more superficial portion of the skin. For the same reason, 
there is little induration about any pustule. Successive crops of 
vesicles appear, especially if the patient breaks the formed blisters 
or pustules by scratching. 

The essentials of treatment are cleanliness and antisepsis. 
Blisters should be punctured, crusts removed, and an antiseptic 
lotion or ointment applied. A good preparation is cold cream to 
which ammoniated mercury has been added in the proportion of 
fifteen grains to the ounce, or twenty grains of sulphur to the 
ounce. The sound skin in the neighborhood should be sponged 
with an antiseptic solution. A good one for the purpose is given 
under Urticaria. 

Acne. Acne is defined as an inflammatory disease of the 
sebaceous glands of the face, chest, and shoulders. It is most dis- 
tressing to the patient when it appears upon the face. It is usu- 
ally chronic. A careful examination of the skin within the area 
affected will show that many ducts of the sebaceous glands are 
blocked up, and contain sebaceous material mixed with dust, hence 
the common name " blackhead." Other obstructed ducts are the 
centers of little red, inflamed papules. Pustules have formed 
around others, while there are numerous scars of similar lesions 



33 

which have In-lied. Manx of these !< ion, run their life hi 
withoui Millh-irii! suppuration lo leave ;i |I<TIII;IIICHI .-car. 

There ;ire lliree factors in I he (lcvchi|niient of acne 1 (locking 
lip of | he sehaeeons duct, presence of in iero-organisins, iilld a low- 
ered power of resistance to these organisms on tho part of the 
individual. Thus, digestive disturbances, the use of irritatij 
drugs, ineiistrnal irregularity, and other general causes exert a con- 
siderable inllnence. Acne is especially coimnjjjj^befween the ages 
of tifteen and twenty-five. 

TKKAT.MENT. Both general and local treatment should be era- 
|)loyed. Krrors in diet sliould be corrected, out-of-door exercise 
encourage*!, and such other measures instituted as will tend to 
improve the patient's general condition. Free action of the bowels 
should he secured. Tonics are helpful, but no drugs should be 
gi ven which are likely to upset the stomach. 

Local treatment is most important. The affected part should 
be washed every night with very hot water, and as strong a soap 
as the skin will tolerate. Tincture of green soap acts well in many 
cases. The soap should be thoroughly removed by hot water, the 
skin dried, and a stimulating antiseptic ointment rubbed into it. 
In the morning this ointment should be washed away with soap 
and warm water, the skin dried, and a soothing ointment rubbed 
into it. Cold cream answers the purpose very well. Only a small 
(piantity should be used, and any excess wiped away with a soft 
cloth. A good stimulating ointment is benzoated lard to which 
has been added precipitated sulphur in the strength of one or two 
drains to the ounce. Instead of the ointment a stimulating lotion 
may be employed, such as one composed of four drams of pre- 
cipitated sulphur, two drams of alcohol, thirty minims of glycerin, 
and four ounces of water. The strength of the application used 
must be varied to suit different skins, and it is often of advantage 
to change the formula employed from time to time. There are 
many of these given in every book on dermatology. 

Individual acne pustules should be stabbed with a fine lancet 
or a three sided, straight glover's needle, and their contents gently 
expressed. 

Acno hypeiirophiea is described with new growths on page 83. 

Cellulitis. Cellulitis of the head, whether it affects the hairy 
or smooth skin, presents the usual characteristics: namely, edema, 



34 



INFLAMMATIONS OF THE HEAD 



heat and redness, and, especially if pus is present, there will be 
pain on pressure. The scratch or slight wound through which the 
infection entered can usually be found. Often it is covered with 
a crust, beneath which will be found a drop or two of pus. Two 
questions are of importance. Is the cellulitis due to erysipelas? 
Is there a hidden focus of pus ? The distinguishing marks of ery- 
sipelas are given below. The presence of pus may usually be 
known by a greater tension of the swollen skin, and the pain which 
pressure causes at this point. If there is an abundance of pus 
fluctuation is a valuable sign, but it is unobtainable at an early 
stage. Note the enlargement of regional lymph glands. They 

may suppurate also in 
some cases. 

TKEATMENT. If the 
diagnosis is doubtful, or 
if pus has been found 
and evacuated, a moist 
antiseptic dressing 
should be applied and 
kept wet. No gutta- 
percha tissue, nor other 
impervious material 
should be applied in such 
a manner that evapora- 
tion is prevented. Any 
mild antiseptic solution 
may be used, such as 
aluminum acetate, four 
per cent ; bichlorid of 
mercury, 1 : 2,000 ; creo- 
lin, 1: 200, or one of 
the proprietary articles, 
such as borolyptol, 1 : 4. 
The edge of the cellulitis 
should be marked with 

ran indelible pencil or with nitrate of silver, and the temperature 
and pulse recorded every three hours. Examination on the fol- 
lowing day will determine whether the case is a simple cellulitis, 
or erysipelas, or whether the symptoms are due to hidden pus. 




FIG. 9. NECROSIS AND SLOUGH OF SKIN DUE TO 
CELLULITIS. 



KKYMTKLAS 35 

The seven- ell'ecl, of ;i peculiarly loc;ili/e<| cellulitis is shown 

in Kiii-iire !. The inflammation showed no tendency to spread, and 
no pus w;is present, hut there was a considerable necrosis of the 
skin resulting in the small nicer shown in the photograph. Staphy- 
lococci were present in the tissues and the discharge. 

Erysipelas. The face is the most common seat of erysipelas. 
1 1 usually I levins on one side of the nose as a dark pink blush. 
The atl'ected skin is slightly edema tons, so that the margin of 
the atl'ected area is raised. This edge spreads at an appreciable 
rate, an inch or more a day, though not equally fast in all direc- 
tions. There is often pain in the affected part, and the constitu- 
tional symptoms are out of proportion to the extent of the skin 
involved. There is usually an initial chill, and the temperature 
is commonly above 102 every afternoon as long as the inflamma- 
tion is spreading in the skin. The infection enters the skin 
through some scratch or cut, which can usually be found if looked 
for. In the case of facial erysipelas this break in the akin is usu- 
ally to be found inside of the nose. The patient will often remem- 
ber to have forcibly removed some crust from the nose a day or 
two days previous to the attack. 

TREATMENT. Compresses wrung out of a five per cent solu- 
tion of carbolic acid in equal parts of alcohol and camphor water 
will be found agreeable to the patient, and may assist in limiting 
the spread of the inflammation. The more radical method of em- 
ploying carbolic acid is to paint the skin immediately in advance 
of the inflammation with the liquid carbolic acid, ninety-five per 
cent. If the skin js at once wiped off with pure alcohol no injuri- 
ous caustic action of the acid will result. In this way extension 
of the erysipelas may sometimes-be cut short; but those who have 
the opportunity of treating a large number of cases of erysipelas 
usually doubt the curative power of any application whatever. 

If abscesses form, they should be incised. The general condi- 
t ion of the patient should be watched. Laxatives, light or fluid diet, 
and possibly stimulants, are the essentials of treatment. As ery- 
sipelas is conveyed from one patient to another by contact, the sur- 
geon should, if possible, avoid touching the patient or his clothes, 
and should wash and disinfect his hands at the close of his visit. 
Similar precautions should be observed Iy the nurse or attendant. 
It is a good plan, if the patient is not too ill, to let him. make the 



36 INFLAMMATIONS OF THE HEAD 

applications himself, thereby lessening the risk of infecting some 
one else. 

Boil, or Furuncle. The face is a common seat for boils, 
which do not, however, reach a large size, for the reason that the 
skin is thin and is well supplied with blood. Every effort should 
be made to cut short the infective process, because the lesion is so 
conspicuous, and also to avoid the disfigurement of a permanent 
scar. 

The diagnosis is simple. The swelling, redness, and tender- 
ness early attract the patient's attention. The only point to be 
decided is whether or not pus has collected in sufficient amount to 
make its evacuation desirable. If it shows as a yellow spot in the 
center of the swelling, the patient will usually permit its evacua- 
tion ; and yet the necessity for this is sometimes far greater when 
the pus does not lie so near the surface. The presence of a tender, 
tense, and well localized swelling in or beneath the skin, always 
indicates a collection of pus under these circumstances. 

TKEATMENT. The best treatment is prompt incision, to allow 
the escape of pus and necrotic material. Specific directions for 
opening boils and abscesses are given in Chapter XX. A minute 
incision will often suffice for these small boils of the face. (Com- 
pare the treatment of acne pustules, page 33.) One should resist 
the temptation to squeeze pus out of the tissues after the incision 
has been made, as infection is often spread in this manner. A 
very short incision, say not more than a quarter of an inch in 
length, which should usually be crucial or T-shaped to prevent tlie 
rapid reattachment of the cut surfaces, is long enough for many 
boils of the face at an early stage. 

In most cases a minute drain, consisting of a loop of thread 
or a narrow strip of gutta-percha tissue, should be placed in the 
wound for twenty-four or forty-eight hours. A wet dressing greatly 
favors recovery. If it is necessary for the patient to go about, lie 
may cover the wound with a bit of gauze and a piece of rubber 
plaster, removing this Once or twice a day in order to soak the 
parts with hot water, and at night a large wet dressing should 
be applied. 

In some cases the application of ninety-five per cent carbolic 
acid directly into the center of the boil will stop the process mid 
hasten the expulsion of the necrotic portion. In the case of minute 



STY I-:, OR IIORDKOl.r.M 37 

h-.il. , lllr arid may IC applied upon ;| Ion) llpirL, e\cn tho||<;ll lli 

incision liiis heen made. 

The general condition ,,f the patient should he investigated, 
mid necessary advice given concerning diet and exercise. Laxa- 
tives arc usually heiicficial. A tablespoonful <>f brewer's yeast 
three times a day before meals is thought by many to have a 
specific action in recurrent cases. Sulphur and its compounds may 
also he given with heiich't; for example, half a grain of snlphid 
of calcium twice a day. 

Stye, or Hordeolum. A small boil at the root of an eyelash 
is called a stye. If untreated, one of these minute abscesses re- 
quires several days for its full development. It often causes great 
pain. Pus then escapes at the edge of the lid, the pain is relieved, 
and in several days the swelling disappears. There is a strong 
tendency to recurrence of the trouble in some other portion of the 
lid, so that it is no uncommon thing for a person to suffer from 
a -cries of styes, one or more developing at the same time, the 
whole series lasting possibly several weeks. 

Prophylactic treatment, which w r ill also sometimes serve to 
abort a commencing suppuration, consists in the application of an 
ointment containing eight grains of the yellow oxid of mercury 
to the ounce of vaseline. It is also well to wipe the edges of the 
lids occasionally witli a cotton swab wet with a 1 : 2,000 solution 
of corrosive sublimate. A formed abscess should be punctured 
with a sharp, narrow lancet. If the blade is thin and very sharp 
this is not a.very pahiful procedure, and no anesthetic is required. 
To relieve pain either before or after puncture, hot, moist com- 
presses may be applied. Constipation should be corrected. 

Boils of the Nose and Ear. Small but very painful boils 
form in the skin or mucous membrane attached to the cartilage of 
the ear or nose. Because of the close attachment of these struc- 
tures, the pain caused by the swelling is intense. An early incision 
is therefore demanded. Even the injection of a local anesthetic 
is very painful. Hence a strong solution, say a four per cent solu- 
tion of cocain, should be employed, and only a minim should be 
injected at first. When this has taken effect, the injection of the 
amount necessary to benumb the area of incision should be com- 
pleted. A moist dressing should be applied, or the part should be 
soaked with hot water every hour or so, in order to keep the cut 



INFLAMMATIONS OF THE HEAD 



open until all the discharge has made its escape. As such boils 
tend to recur, the affected area should be wiped twice daily 
with an antiseptic (creolin, one per cent; bichlorid of mercury, 
1:1,000). 

Abscess. Suppuration in the deeper tissues of the face, the 
result of injuries and wounds, is usually prevented by the very 

free blood supply. 
Abscess may form, 
however, in the 
cheek, lip, or even 
in the tongue. Such 
an abscess occurring 
in the lip is shown 
in Figure 10. 

Abscess of the 
scalp, or rather be- 
neath the scalp, of- 
ten follows the too 
hasty suture of a 
scalp wound; or it 
may develop from 
small infected 
wounds, especially 
in marasmic chil- 
dren. This is not 
to be wondered at. 
While the blood supply of the scalp itself is very free, there is 
just beneath it a loose fascia with large spaces and few blood- 
vessels a favorable tissue for the multiplication of germs, once 
they are introduced "into it. 

DIAGNOSIS. These abscesses are not difficult of recognition. 
The classic symptoms of heat, redness, tenderness, and edema are 
well marked. A small abscess in the tongue feels like a buried 
kernel. An abscess of the lip or cheek causes a very great swelling, 
which may obscure the exact presence of the pus until it is revealed 
by palpation. An abscess beneath the scalp yields a distinct wave 
of fluctuation. 

TREATMENT. The length of the evacuating incision should 
be determined by the extent and nature of the abscess. In an 




FIG. 10. ABSCESS OF THE LIP. Infection due to a blow 
by which the lip was cut against the decayed incisor 
teeth. Photograph six days after the injury. 



ABSCESS 3D 

unite, rapidly spreading, suppiiralive celhilitis, incision should l>e 
made lo extend at least as far as the visible pus formation, whereas 
it is quite unnecessary to apply the same rule to the slowly form- 
ing abscess of a marasmic child. In the latter case a small open- 
ing, equal to one-half the diameter of the abscess, is sufficient to 
etVect a cure, and thus hemorrhage is lessened and considerable 
time is saved in the healing of the wound. 

The cavity of the abscess should be washed and wiped clean 
with saline solution or sterilized water and moist cotton swabs or 
dry sterilized gauze. It has been commonly recommended to break 
down any septa which may exist, but, unless these interfere with 
the thorough cleansing of the abscess, they should not be disturbed, 
as they almost invariably contain blood-vessels, and if broken 
down, hemorrhage follows and blood clots are added to the con- 
tents of the abscess cavity, and the nutrition of the overlying 
skin is interfered with. Many abscesses of a sluggish nature, if 
emptied and cleansed, will heal without further suppuration. 
Such a result is favored by the introduction of a granular gelatin 
containing formalin. This acts as a drain and contains enough 
formalin to retard suppuration. Or the wound may be kept open 
by slender strips of gutta-percha tissue or gauze, moistened with a 
weak antiseptic solution. 

Alveolar Abscess. A common and often severe abscess of the 
face has its origin, as its name indicates, about the root of a de- 
cayed or broken tooth. The first sign of its presence is almost 
invariably a toothache. This may be due to congestion merely, 
but a violent toothache indicates pus with far greater certainty 
than most dentists are ready to admit. The pain is at first re- 
ferred to the affected tooth; but as the inflammation spreads the 
nerves leading to other teeth may be pressed upon, and the pain 
referred to those teeth. There are three confirmatory tests to deter- 
mine the exact location of the suppuration. Inspection will show 
the greatest amount of swelling in the mucous membrane along- 
side of the tooth involved. Secondly, if the teeth are lightly 
tapjxid with a metal instrument, the patient can usually recognize 
which one is diseased. In the third place, palpation will usually 
reveal the point at which there is the greatest swelling, and this, 
at least in the early stages of the trouble, corresponds to the root 
of the affected tooth. 



40 



INFLAMMATIONS <>K Till-] 1IKAI) 



The pus first forms between the root of the affected tooth and 
the bone in which it is placed that is to say, in the tooth socket. 
As the pus increases in amount some of it may work its way to 
the surface and escape into the mouth alongside of the tooth. This 




FIG. 11. -ALVEOLAR ABSCESS FROM UPPER INCISOR TOOTH. Note the site of maximum 
swelling at the root of the nose. This is not a common type, as the pus usually 
breaks into the mouth early. 

will relieve most of the symptoms, and aside from slight tender- 
ness, the only remaining ones may be a little swelling and the 
escape of pus when the patient sucks the tooth or pressure is made 
on the gum. In most cases, however, absorption takes place, and 
the swelling extends beyond the gum immediately around the 
affected tooth. This swelling will next be noticeable in the face, 
and its situation will depend, of course, on the situation of the 
decayed tooth; thus, if an upper incisor is at fault, the swelling 
will appear first at the base of the nose (Fig. 11). If the upper 
bicuspid or molar teeth are involved, the swelling may appear 



ABSCMSS 



41 



further hack in the check; whereas if one of the lower teeth is 
decayed, the swelling will bo most marked just below it. 

The infection may travel still further, and involve a lymphatic 
gland. This may be very misleading. The upper teeth drain into 
lymphatic glands situated at the angle of and below the lower jaw. 
If the regional swelling above mentioned is slight and the first 
prominent swelling is due to involvement of the lymphatic glands 
which drain the sockets of the Tipper teeth, the most marked swelling 
will then appear in the vicinity of the angle of the lower jaw. It is 
well to bear these facts 
in mind, lest finding a 
swelling near the an- 
gle of the lower jaw, 
one may falsely con- 
clude that a lower 
tooth is at fault. This 
is what happened in 
the ease of the boy 
shown in Figure 12, and 
a dentist extracted a 
sound lower tooth. The 
infective process con- 
tinued, of course, until 
more intelligent treat- 
ment was instituted. 

If an alveolar ab- 
scess starts from one of 
the lower teeth, the 
situation of the swell- 
ing is a more reliable 
guide to the source of 
the infection. 

COURSE OF THE INFECTION. The pus at the root of the tooth 
may work its way out along the tooth and discharge into the 
mouth. Or, it may bore through the periosteum, and possibly a 
thin layer of bone, and discharge through the gum a little distance 
away from the juncture of the tooth and mucous membrane say 
a quarter of an inch. This sinus is more often on the outer than 
on I lie inner side of the jaw. With the discharge of pus the acute 




FIG. 12. ALVEOLAR ABSCESS FROM UPPER MOLAR 
TEETH. Note the site of maximum swelling at 
level of the lobe of the ear. 



42 



INFLAMMATIONS OF THE HEAD 



symptoms subside, but unless the tooth is tilled or removed the 
process may repeat itself. 

The pus may strip the periosteum from the maxilla, rupture 
the periosteum, burrow between the mucous membrane and the 
skin, or rupture through the skin externally, either in the cheek 

or beneath the lower jaw 
(Figs. 11, 12, 13). At 
this advanced stage of 
the process fluctuation 
can usually be made out. 
The lymphatic glands 
swell early in the course 
of the inflammation, but 
they do not always sup- 
purate. When they do 
suppurate, the hard 
swelling which they 
form below the jaw be- 
comes fluctuating. Such 
a condition, secondary 
to infection from an up- 
per tooth, is shown in 
Figure 13. 

If an alveolar abscess 
is left to itself, its spon- 
taneous rupture either 
into the mouth or ex- 
ternally may give tem- 
porary relief of symp- 
toms or even effect a 

cure. Such relief is often postponed until a portion of the maxil- 
lary bone, deprived of its periosteum and bathed in pus, becomes 
necrotic. The sequestrum thus formed will keep up the suppura- 
tion. If a patient is examined in this stage he will have a general 
hard swelling, not easily indented by pressure with the finger, 
and which varies in size according to the drainage or lack of it 
through the existing sinus. The decayed tooth which was the 
cause of the trouble may or may not be recognized. Not infre- 
quently the patient has had it removed too late to stop the suppu- 




FIG. 13. ALVEOLAR ABSCESS FROM UPPER TOOTH, 
SECONDARY IN LYMPHATIC GLANDS. The max- 
imum swelling is beneath the lower jaw. This 
is also the site of swelling in cases of alveolar 
abscess of the lower teeth, without glandular 
involvement. 



ABSCESS 43 

ration, as the bone has already become necrotic. In other cases 
several decayed teeth are present, but no longer sensitive, so that 
it may be difficult to decide which one has caused the trouble. 

A probe passed into the sinus may or may not touch bare bone. 
The positive result of such examination is worth more diagnos- 
ticully than a negative result. Furthermore, if bone is bare under 
such circumstances it is almost certainly dead. If necrotic bone 
exists the probe may fail to touch it because the sinus is tortuous. 
The sequestrum usually lies to the inner side of the lower jaw, 
and the sinus passes beneath the jaw and reaches the surface of 
the face on the outer side of the jaw. It is not surprising if so 




FIG. 14. RECURRENT ALVEOLAR ABSCESS. Duration, twenty-five days. 

badly drained an abscess recurs from time to time. Such an ex- 
perience was that of the patient shown in Figure 14. 

If the sequestrum is a large one, two or more sinuses may 
exist. In such a case a part of the swelling which exists is due 
to the formation of new bone. The periosteum of the lower jaw 
is abundantly supplied with blood, and does not die easily. If 



44 



INFLAMMATIONS OF THE HEAD 



it is stripped up from the old bone by the pus it immediately Lo- 
gins to form new bone, so that in long standing cases the removal 
of the sequestrum may be rendered difficult by the thick shell of 
new formed bone which surrounds it. 

Another possible termination of an acute abscess is a persistent 
sinus. So long as this suffices to carry away the slight discharge, 

it will prevent the re- 
formation of an ab- 
scess. Usually, how- 
ever, the drainage 
obtained in this man- 
ner is imperfect, 
swelling or granula- 
tions block the sinus, 
edema reappears, and 
if the sinus is not re- 
opened another abscess 
forms. Such a sinus 
giving imperfect drain- 
age existed in the Chi- 
nese patient shown in 
Figure 15. The per- 
sistent discharge is an 
indication of the exist- 
ence of dead bone or 
a decayed root of the 
tooth. 

A continued swell- 
ing is usually an indi- 
cation of decay of the 

root of the tooth or of the adjacent bone; there are also cases 
in which, although 110 sequestrum can be made out and no pus 
escapes externally, the irritation about the roots of the affected 
tooth is sufficient to form a chronic swelling. Possibly in such a 
case there may be a little suppuration which constantly makes its 
escape into the mouth. Figure 16 shows a patient who gave a his- 
tory of continued hard swelling long after the active suppuration 
had ceased. As long as such a patient retains the roots of the de- 
cayed tooth he is exposed to a recurrence of the acute suppuration. 




FIG. 15. CHRONIC ALVEOLAR ABSCESS FROM DE- 
CAYED TOOTH, OF SEVEN MONTHS' DURATION. 
The abscess was lanced, but a sinus persisted. 



ABSCKSS 



Finally, alveolar abscess may lead to the development of u 
malignant growth, as slmun in Figure 17. 

TKK AT. \IK.NT. Treatment at any stage of an alveolar abscess, 
t> he considered intelligent, must be directed toward removal of 
the cause. If a toothache is due .simply to congestion, a local irri- 
tant, such as oil of cloves, chloroform, etc., with or without the 
internal administration of morphine or some other anodyne, may 
be considered appropriate treatment. If, however, the toothache 
is due to an inflammation about lhe root of a tooth, it must be 
looked upon as a real infection, similar, for example, to a cellu- 
litis preceding from an unclean sliver in the finger. The site of 
the infection should be 
thoroughly exposed and 
drained so that absorp- 
t ion of the poisonous ma- 
terial may cease. The 
source of the infection 
is invariably found in 
the decay of a tooth or 
the root of a tooth pre- 
viously extracted. Such 
a tooth should be treated 
or extracted without de- 
lay, no matter in what 
stage the infection may 
be. If the tooth is con- 
sidered by the dentist to 
he worth saving, its cav- 
ity should be cleaned 
and disinfected so that 
further absorption shall 
not take place. The fill- 
ing of such a tooth may 

be postponed Until the FlG ; 16. ALVEOLAE ABSCESS FHOM DECAYED 

LOWER TEETH; lanced inside and outside six 

acute Symptoms have weeks previously. Roots of teeth not removed. 

Subsided. If a tooth is Selling due to fibrous induration. No sinus 

and no pus, us far as can be made out. 

too far i^one to be saved, 

it should be immediately extracted. Many dentists object to the 

removal of a tooth if an abscess is present, and advise the patient 




46 



INFLAMMATIONS OF THE HEAD 



to wait until the abscess has been cured. This is bad advice. 

It would be just as logical to wait for a cellulitis of an arm to 

subside before extract- 
ing the splinter in the 
hand which caused it. 
In a great many in- 
stances the extraction of 
a decayed tooth or of 
an old root will give 
the pus formed about its 
deeper portions a free 
opportunity to escape 
into the mouth, so that 
the abscess drained in 
this manner will rap- 
idly subside, in a -few 
hours. Even if suppu- 
ration has extended so 
far from the tooth that 
the extraction of the 
latter will not afford 
sufficient drainage, it 
should still be insisted 
upon, as removal of the 
source of trouble will 

FIG. 17. TUMOR FOLLOWING ALVEOLAR ABSCESS, hasten the recovery 
THOUGHT TO BE SARCOMA. Tooth ulcerated . ,. , 

three and one-half months previously. Will relieve the patient 

at once of a consider- 
able amount of pain, and will prevent also the recurrence of the 
abscess and the other complications spoken of above. 

If further drainage is necessary, as it is in every advanced 
case of alveolar abscess, the incision should be made through the 
gum rather than through the cheek. In suppuration of the lower 
jaw the drainage through the mouth is an attempt to cause pus 
to flow up hill, but it will in many cases succeed if the incision 
through the gum is a wide "one and the abscess cavity is syringed 
out once or twice daily with diluted peroxid of hydrogen and kept 
open by antiseptic gauze. A day or two will prove whether or 
not this attempt will be successful. If not, an external incision 




ACUTE CONJUNCTIVITIS 47 

should also be made. This need not !< ;i very long one, since the 
internal incision should still be kepi open, and will pn>\ ide for 
the escape of most of the ]>us. An external incision is to be 
avoided, not only on account of the annoyance to the patient of 
a bandage around the head, hut because the resulting scar is some- 
times attached to the jaw bone, and thus forms a prominent dim- 
ple. This need not be a permanent disfigurement, however, for 
such a dimple may be removed by excision of the scar, dissection 
of the skin for a half inch in every direction, and suture of 
the skin. It is better not to perform this plastic operation till 
some months have passed, lest viable germs in the tissues may 
be roused into activity, and suppuration defeat the end of the 
operation. 

A sequestrum of the jaw, due to delayed drainage, will usually 
loosen in a few weeks, so that it may be extracted through an en- 
larged sinus, either within the mouth or externally. Sometimes 
it is necessary to chisel away some newly formed bone to make 
a larger exit. In most cases, if a general anesthetic is given, so 
that the surgeon does not feel the need of haste, he can twist the 
sequestrum back and forth, and perhaps break off some portions 
of it, until it can be withdrawn without chiseling away any living 
bone. 

INFLAMMATIONS OF THE EYE 

There are some inflammations of the conjunctiva which will 
be here discussed because of their frequency and importance, and 
because they are amenable to local treatment. 

Acute Conjunctivitis, or Simple Catarrh. Acute in- 
flammation of the conjunctiva may be divided, for practical pur- 
poses, into the cases which are due to the gonococcus, and into those 
which are not thus caused. The latter cases are sometimes called 
simple or catarrhal or muco-purulent conjunctivitis. 

The usual signs of a mild catarrh are present. The secretion 
is increased, the blood-vessels are injected, there is a little swell- 
ing of the conjunctiva. There is a sense of heat and heaviness in 
the eye. In cases which develop spontaneously both eyes are 
affected at the same time or one soon after the other. 

A number of micro-organisms have been isolated from eyes 
in such a mild state of inflammation, and it has been demon- 



48 INFLAMMATIONS OF THE HEAD 

strated that catarrhal conjunctivitis may occur in epidemic form. 
One eye may be involved alone as tho result of traiiiuatism. 

The inflammation, in catarrlial conjunctivitis may go on until 
small ulcers are formed, but this is the exception rather than the 
rule, and the outcome is complete recovery in almost all cases. 

TREATMENT. It is well to remember that most cases of ca- 
tarrhal conjunctivitis are distinctly contagious, and the infection 
may be transferred from one eye to the other, or from one person 
to another. Anything, therefore, which comes in contact with the 
affected eye should be immediately sterilized or -destroyed. 

In serious cases the patient should be kept in a dark room, and 
several pads of gauze, four or five layers thick, should be kept on 
a lump of ice by the bedside and placed by the patient upon his 
closed eye. Every few minutes, as they become warm, they should 
be changed. Several times a day the eye should be irrigated with 
a three per cent solution of boracic acid. When the irritation is 
less intense, an application of a twenty per cent solution of argyrol, 
or a one per cent solution of nitrate of silver, should be applied 
by the surgeon to the everted lids, and almost immediately neu- 
tralized by a saline solution. Or the patient may be given a solu- 
tion of sulphate of zinc, two grains to the ounce, a few drops of 
which he should instill into the affected eye once or twice daily. 
The edges of the lids should be smeared at night with a simple 
ointment, so that they may not adhere and prevent the escape of 
secretion. 

Purulent Conjunctivitis. Infection of the conjunctiva 
with the gonococcus is a serious affection, since it often produces 
extensive corneal ulcers, which may perforate and allow the iris 
to prolapse, and which in any event are likely to heal with opacity. 

The disease oc"curs generally in new born infants, or in adults. 
If the child's eyes are infected during birth, the inflammation ap- 
pears from the second to the sixth day. If it appears later than 
this, it is due to postnatal infection. In both infants and adults 
the inflammation is due to contamination of the eye by the fingers, 
or some object which has been in contact with a discharge contain- 
ing gonococci. 

In the first day or two the patient notices pain in the eyelids 
and eyeballs, and sensitiveness to light. There are fever and 
swelling of the lymph glands in front of the ears. Later the dis- 



(il{. \NULAR LIDS OR GRANULAR CONJUNCTIVITIS 40 

charge from the eves becomes purulent, and llie Swelling of the 
lids is so great tluil they overl;i| or are everted, ('leers of llie 
cornea levelo|>. The disease lasls in moderate eases from four 
to six weeks. 

TIIKATMENT. Prophylactic treatment is most important for 
infants and for adults as well. The eyes of every child after 
birth should be carefully washed with sterile water or boracic 
acid solution, and if there is the slightest possibility of contagion 
from the mother, a few drops of a one per cent solution of nitrate 
of silver should be instilled into each eye. Most cases in adults 
are due to autoinfection, and therefore every physician caring for 
a patient with gonorrhea should explain to him the risk of infect- 
ing his eyes, and give him directions in regard to the use of towels, 
cleanliness of his hands, etc. 

The patient with purulent conjunctivitis should remain in bed 
in a darkened room. Ice compresses should be kept on the eyes 
at least one-half of the time, and the eyes should be frequently 
irrigated with a solution of permanganate of potash (1: 10,000). 
The free use of small doses of calomel will do, much to decrease 
the swelling and lessen the risk of corneal ulcers. The edges of 
the lids should be smeared with boric acid ointment to prevent 
their adhering. After the first few days a three or four per cent 
solution of nitrate of silver may be applied by the surgeon to the 
everted lids and neutralized with a saline solution. This treat- 
ment may be repeated once a day, or once every second day. The 
patient should be careful not to infect the sound eye, and should 
sleep with this eye uppermost, so that no secretion may trickle into 
it. At the first sign of redness, the sound eye should be treated 
with a two per cent solution of nitrate of silver. 

Stye. (See p. 37.) 

Granular Lids or Granular Conjunctivitis. Repeated 
irritation of the eye will often result in an injection of the blood- 
vessels of the eyelids, and a dry and rough, almost sandy feeling. 
Badly nourished individuals, such as anemic children and overfed 
adults with a uric acid diathesis, are especially liable to this con- 
dition. In many persons it is brought about in a mild degree by 
the excessive use of the eyes, or by the lack of suitable glasses, or 
by exposure to wind or dust. 

An inspection of the lids, and especially the upper one, will 
6 



50 INFLAMMATIONS OF THE HEAD 

show that the normal smooth pinkish lining presents an angry 
appearance, due to the injection of the blood-vessels,, ;iiul lh;it liy 
oblique illumination the surface is irregular, suggesting granu- 
lations. 

In mild cases the removal of the cause and the instillation into 
the eye of a few drops of concentrated boric acid solution twice 
daily will speedily effect a cure. If lithiasis exists, urinary dilu- 
ents should be given with several glasses of water daily in addition 
to the local treatment. If these simple measures fail, the con- 
junctiva of the lids should be wiped occasionally with a crystal 
of copper sulphate. 

Trachoma. The disease is marked by the formation of 
whitish or pinkish bodies in the conjunctiva, especially of the 
upper lid. It is generally considered to be contagious, although 
it is much more common among anemic children, and those who 
are crowded together in rather unhealthful surroundings. 

The affected eye, in addition to the granules above mentioned, 
usually shows the signs of catarrhal inflammation, and in a later 
stage there are dilated blood-vessels and the formation of fibrous 
tissue over the cornea as well as over other portions of the eye. 
In this manner the vision may be completely lost. 

TREATMENT. One of the best methods of treatment is the 
application of a smooth crystal of sulphate of copper to the af- 
fected conjunctiva. For fifteen minutes thereafter, cold wet appli- 
cations should be made to the eye. In severer cases, the granula- 
tions are scraped or cut away or squeezed out. For the details of 
such treatment the reader is referred to special text-books upon 
the eye. 

Any treatment to be successful must be continued for months, 
until the tendency to form new granulations has been entirely 
overcome. As the presence of this disease keeps a child out of 
school, and for that reason, even without a permanent impairment 
of sight, seriously handicaps his future, those in charge of public 
institutions containing children should spare no pains to prevent 
this disease and to eradicate it when it occurs. 

Ingrowing Lashes or Trichiasis. It sometimes happens 
that the eyelashes, instead of growing in the normal direction, 
curve inward and thus become a constant source of irritation to 
the eyeball. This is one of the complications of granular conjunc- 



OT1T1S MKDIA 51 

tivitis. A wedge-shaped strip may bo cut from the outer surface 
of i lie eyelid and I lie wound sutured. The wedge must, of course, 
include the whole thickness of the cartilage of the eyelid in order 
to secure a permanent eversion of the lashes. The lines of the 
incisions should he parallel to the edge of the lid, and the one 
nearest (lie edge should he distant from it an eighth of an inch, so 
as to avoid the roots of the eyelashes. For the details of this 
operation the reader is referred to text-hooks upon the eve. Single 
lashes may he extracted hy means of smooth forceps that is, for- 
ceps whose points are free from ridges or teeth, for the latter 
would he apt to break the hairs. This is naturally a purely palli- 
ative procedure, as the lash will soon grow in exactly as before ; 
but the relief occasioned by it is immediate and so gratifying that 
the patient will gladly return month after month to have the 
offending hairs again extracted. 

If only two or three hairs forming a single group are turned 
inward, the simplest method of cure is the removal of a small sec- 
tion of the edge of the lid containing these hairs, and the suture 
of the gap thus caused. 

INFLAMMATION OF THE EAR 

Otitis Media. This is a common disease of childhood, usu- 
ally following a cold in the head. The prominent symptom is ear- 
ache. Every physician ought to be able to recognize the bulging 
outward of the membranum tympani and to relieve the pressure 
by incision of the membrane at the most favorable situation viz., 
the inferior and posterior portion. The introduction of warm 
olive oil into the external meatus will sometimes relieve pain, and 
the application of external heat may also be tried ; but the pain of 
a severe earache, unless relieved by puncture of the membrane, 
usually demands the internal administration of morphine. The 
membrane usually ruptures spontaneously in the course of a day 
or two. Pain is then relieved, and a muco-purulent discharge be- 
gins and continues for a time. After it ceases the membrane soon 
heals over. While the discharge continues, the treatment consists 
in cleanliness. The ear should be syringed gently once or twice a 
day with warm normal salt solution, and wiped dry with absorbent 
cotton. 



52 



INFLAMMATIONS OF THE 11KAI) 



Unfortunately, this simple termination is not the only one 
which is possible, for inflammation of the middle ear may extend 
to the mastoid cells, and result in abscess within the cavity of the 
mastoid bone. If prompt drainage is not instituted, the suppura- 
tion may extend into the lateral sinuses and to the membranes of 
the brain, causing the death of the patient. Hence the necessity 
of early recognition of the disease and prompt treatment before 
these serious complications have arisen. 

The external ear should be cleansed by washing it with small 
cotton swabs wet with a warm antiseptic solution, and the mem- 
brane anesthetized by the instil- 
lation of a few drops of a ten 
per cent solution of cocain. An 
ear speculum should then be 
introduced, the membrane in- 
spected by reflected light or a 
headlight, and incised in its 
lower and posterior portion by 
means of a long slender scalpel 
bent in the handle at an angle. 




\ 



FIG. 18. SKETCH OF THE NORMAL RIGHT 
TYMPANIC MEMBRANE. Showing the 
correct site for incision. 



FIG. 19. ANGULAR KNIFE FOR INCISION- 
OF THE TYMPANIC MEMBRANE. 



Figure 18 shows the normal membrane, and the correct' si 7.0 of an 
incision, which should lie of sufficient length to permit, the cscnpc 
of the pus and mucus. Figure 1 10 shows a good knife for making 
the incision. 

When the incision has been made through the bulging mem- 



IN mi: Fun.NTAL sixi'SES :.:; 

hrane. it fr\v drops of pus Mini mucus ;md often M little blood will 
<pe. Irrigation i> not neec-,-,;iry, hul the auditory <-.\\\;\\ should 
lie sponged ele;ui with cotton-tipped prohes dipped in ;i warm 
antiseptic solution. In the e;ise of M nervous or restless child, it 
is hest to perform this operation in general anesthesia. The inci- 
don can then he more accurately ina<le. 

The after treatment consists in cleanliness. The canal should 
lie wiped or washed clean, and the iniu r ear protected from tem- 
perature changes hy a small cone of dry absorbent cotton intro- 
duced after each cleansing and as often as the previous cone be- 
comes moist. 

Boils. rA description of boils of the external auditory ineatus 
is given on page 37. 

INFLAMMATIONS OF THE NOSE 

Acute rhinitis may be accompanied by a troublesome herpes 
of the lower portion of the anterior nares and the upper lip. The 
application of menthol in albolene (gr. x-5J) gives some relief. 
The surrounding skin should be smeared with carbolic salve to pre- 
vent the spread of the process. 

Chronic Rhinitis. The usual outcome of chronic rhinitis is 
hypertrophy or atrophy of the mucous membrane of the nasal pas- 
sages. 

Hypertrophy of the inferior turbinate bone in many cases is 
best cured by removal of the major portion of this bone. This is 
a minor surgical operation, and one whose technical difficulties 
are not great, but the decision as to the necessity for its per- 
formance and as to the manner of its removal demands a thorough 
knowledge of the pathology of the nose, which the reader will find 
fully given in books upon that special topic. 

There are, however, two complications of rhinitis which may 
require immediate treatment, and which are therefore here de- 
scribed. 

Suppuration in the Frontal Sinuses. In many cases of 
influenza and other forms of rhinitis the inflammation and swell- 
ing of the mucous membrane extends to the accessory sinuses of 
the nose, the most important of which are the frontal sinuses and 
the antrum of Ilighmore. Such extension prolongs the attack and 



54 INFLAMMATIONS OF THE HEAD 

increases the discharge, but usually subsides in a few days. In 
addition to the general symptoms of infection there are usually, 
pain and tenderness throughout the area occupied by the sinus, 
so that the diagnosis is not difficult to make if its possibility is 
borne in mind. 

In certain cases the inflammation becomes purulent in char- 
acter. Even then the patient is ordinarily relieved by a discharge 
of pus and mucus through the natural opening. Should relief be 
not afforded in this manner, the sinus may be drained through 
the nose after removal of the middle turbinate. This requires 
special technic. If the symptoms are severe, and especially if 
there is reason to feel' that extension to the brain is threatened, 
an incision should be made through the eyebrow and the sinus 
drained directly by chiseling through the bone, either above or 
below the margin of the orbit. This operation is extremely sim- 
ple, if one has at hand a small sharp chisel, and in certain cases 
it saves a person's life. The wound should be drained until the 
suppuration ceases. There is only a slight permanent scar. 

Suppuration in the Antrum of Highmore. Like sup- 
puration'in the frontal sinus, this follows acute coryza, but it may 
also be secondary to diseases of the teeth, especially of the canine 
tooth. 

The symptoms are pain and fulness in the roof of the mouth, 
usually with intermittent discharge of pus from the nose. This 
temporarily relieves the symptoms. 

Transillumination is a valuable means of diagnosis. A small 
electric lamp held in the closed mouth shines through the affected 
side with much less power than through the normal. 

TREATMENT. A large, curved trocar and canula should be 
passed through the septum between the antrum and the inferior 
meatus of the nose. Through this canula the pus can be washed 
out. This washing should be repeated daily with warm Dobell's 
solution. A smaller canula should be employed for the subsequent 
treatment, so that it can be passed through the opening first made 
without difficulty. 

More direct drainage is obtained by chiseling away a part 
of the anterior wall of the antrum through an incision made at 
the reflexion of the mucous membrane from the upper jaw to the 
cheek. This incision should extend from the canine tooth to the 



l'Ki;n'o.\SlU,.\l! AKSCKSS .").") 

lirsl moliir. If the eanine or one of tlic hienspid teeth is already 
diseased, the opening may lie made through its socket. The sinus 
should he irrigated daily for a week or two until the suppuration 
subsides. 

Boils. (See p. 36.) 



Stomatitis and Gingivitis. The occurrence of these low 
decrees of inflammation in the mouth usually indicates a low" 
decree of vitality, or in certain cases that the vitality has been 
reduced by poisons for example, mercury. 

TREATMENT. The general condition should be improved by 
changes in diet and tonics. If there is a local cause for the trouble, 
such as decayed or neglected teeth, this should be attended to. 
The patient should be given a stimulating mouth wash, such as 
a solution of permanganate of potash, one grain to the ounce ; or 
a mixture of tincture of myrrh, one part in twenty of water. The 
inflamed gums may be painted with the tincture of myrrh. 

Such inflammations, even when severe, rarely lead to suppu- 
ration, and require no operative treatment. 

Alveolar Abscess. (See p. 39.) 

Peritonsillar Abscess. Certain cases of acute tonsilitis are 
followed by the formation of an abscess, either within the tonsil 
or, as is more common, in the tissues around it. In the latter 
ease the most common situation is above the tonsil. 

It is of importance to recognize early the collection of pus, 
either within or outside of the tonsil, since its early evacuation 
before a large abscess cavity has formed greatly" shortens the 
course of the disease. Sometimes the patient first recognizes the 
extension of the swelling outside of the tonsil. Inspection will 
show the mucous membrane over the abscess to be of a dusky red 
hue, and the palpating finger will reveal an area of induration with 
fluctuation in its center. Under such circumstances an incision 
should be promptly made. Nothing but pain is gained by delay. 

TREATMENT.- As soon as the abscess is recognized it should 
he evacuated through a suitable incision. The mucous membrane 
is readily cocainized by the application to it for five minutes of a 
swab wet with a ten per cent solution of cocain. If there is any 



5G INFLAMMATIONS OF THE HK\1> 

doubt as to the situation of the pus, aspiration should be per- 
formed. A hypodermic syringe is sufficiently large for the pur- 
pose, provided a needle of good size be employed. The incision 
should be made in the center of the abscess, the stroke being from 
without inward in order to avoid wounding any deep vessel. 
When the abscess cavity has been opened, the incision may be 
enlarged with knife or scissors in whatever direction will give the 
best drainage. If a drain is to be employed, it is a good plan to 
cut out a small triangular portion of the mucous membrane to 
insure an opening sufficiently large to permit the reinsertion of 
the gauze. It is a good plan to syringe the cavity once or twice a 
day with a mixture of one part of peroxid of hydrogen to eight 
of water. 

Retropharyngeal Abscess. Abscess between the posterior 
wall of the pharynx and the cervical vertebrae is usually seen in 
badly nourished children, and is secondary to infective processes 
in the nose or throat or ear in the large majority of cases. The 
immediate symptoms of an abscess in this situation are pain and 
difficulty in swallowing and in breathing. The general symptoms 
of unrelieved suppuration, high pulse and temperature, anorexia, 
etc., are well marked. 

The posterior wall of the pharynx bulges forward toward the 
soft palate, and may often.be felt to fluctuate when palpated. As 
a further confirmation of the diagnosis, and as a guide to the inci- 
sion, the boggy swelling should be aspirated with a needle of good 
size. Pus having been located, should be at once evacuated. It 
is exhausting to the patient to allow it to remain, and there is 
in this case the added danger that the abscess may rupture dur- 
ing sleep, and the patient be drowned in the pus which pours into 
his throat. 

TREATMENT. When the pus has been recognized, it should be 
evacuated through an incision made in the median line of the 
pharynx as low down as possible. A child should be wrapped 
and pinned in a sheet so that his arms can be easily controlled, 
and a good mouth-gag placed in position. A few inhalations of 
chloroform do not materially add to the risk of operation, and 
spare the feelings of patient, mother, and doctor. Various posi- 
tions for the patient have been recommended, all of them with 
the idea of giving the operator a good view of the throat and pre- 



i-xyjvMA 57 

venting I lif evacuated pus from Mowing down into the larynx. A 
horizontal lateral position is perhaps as good as any. The finger 
should guide the knife, all but the point of which should be pro- 
le* -led by wrapping it with adhesive plaster. The most prominent 
point in the swelling should be punctured, and the incision quickly 
enlarged either upward or downward, as the case may require. 
The knife is then withdrawn and the body of the child somewhat 
elevated and turned so that the pus may flow out of the mouth. 
The abscess cavity should be irrigated with saline solution, but 
not drained. By palpation the operator should convince himself 
that a sufficient opening has been made to assure free drainage. 
Hemorrhage may be controlled by a temporary packing of the 
wound with gauze. 

The after treatment consists in attention to the general health 
of the child and irrigation of the cavity, should it show any tend- 
ency to close and allow accumulation of pus. Should this not be 
the case, it is unnecessary to annoy the child with irrigation, which, 
of course, has to be carried out in a partially inverted position. 

It has been recommended to open a retropharyngeal abscess 
laterally through an incision made in front of the sternomastoid 
muscle. This route should only be followed in case the pus has 
already burrowed in that direction. Otherwise the dissection is 
difficult and not without risk, and the drainage is not always satis- 
factory by this route. 

INFLAMMATIONS OF THE SKIN 

Acute suppurations of the skin are described on page 32. 

Eczema. Eczema of the face or scalp is often accompanied, 
especially in children, by abundant secretion, which as it dries 
forms crusts. These in turn increase the itching, and as they are 
torn off, raw surfaces result, so that blood mixes with the serum 
in the formation of new crusts. It is not surprising under the 
circumstances that the skin becomes infected and local cellulitis 
develops, or possibly suppuration in the regional lymph nodes 
(see Fig. 77, p. 130). The risk of infection is greatest when the 
eczema involves the scalp of a young child. 

TREATMENT. In order to avoid the complications of infection, 
the scalp should be saturated with sweet oil for some hours to 



58 INFLAMMATIONS OF THE HKA1) 

soften the crusts. These should then be removed and the head 
gently but thoroughly washed with hot water and soap, and the 
hair cut short. Compresses saturated with such a lotion as four 
per cent aluminum acetate, or one half per cent creolin, should 
then be applied. When the inflammation has somewhat subsided, 
Lassar's paste or boracic acid ointment should be used. It is gen- 
erally supposed that it aggravates an eczema to wash the skin with 
soap and water, but if this is gently done, the skin thoroughly 
dried, and some greasy application is at once made to replace the 
fat extracted by the soap, the benefits of cleanliness are obtained 
without harmful results. 

Whatever the remedy chosen, such general measures as tend to 
improve the nutrition of the child should be attended to, and 
scratching should be prevented, even though the hands have to 
be tied. 

Ringworm. Ringworm, whether of the non-hairy skin, 
scalp, or bearded face, is due to the growth in the skin of certain 
fungi. The disease is therefore contagious, and may be trans- 
mitted by contact or by an exchange of articles of clothing, towels, 
etc. The patient affected is usually a child or young adult. The 
tendency of the infection to spread equally in all directions gives 
the lesion a more or less circular appearance, and if the skin 
affected contains few hairs the center of the area may have re- 
sumed a normal appearance while the growth is still active at the 
periphery. The rate of growth varies, being at first more active, 
so that a ring an inch in diameter may be formed in two weeks 
in the non-hairy skin. Later, there is a tendency for the disease 
to die out, so that the ring may be incomplete or exist only in 
spots. If the ringworm occurs in the scalp or bearded face, the 
scaliness observed upon the non-hairy skin is much exaggerated, 
crusts are added, and there is incomplete loss of the hair within 
the affected area. 

TREATMENT. The affected area should be washed free from 
scales and crusts by green soap and water. If the non-hairy skin 
is affected, the disease can be speedily cured by washing the part 
with a solution of bichlorid of mercury, two grains to the ounce 
of water. Other strong antiseptic solutions are equally efficacious. 
If the hairy skin is affected, a depilatory should be applied to get 
rid of the stumps of hair. Stelwagon recommends a mixture of 



SYPHILIS 50 

three drains of barium sulphid and I wo an<l a half drains each of 

/.inr <i\id and powdered siarch. A I, the time of use, this is rubbed 

l<i a paste with a little water and applied for live to leu minute-, 
and then washed off. Sulphur ointment, diluted if necessary, 
should IK- nibbed into the area every day or two. Another plan is 
to paint it with a solution of chrysarobin in chloroform, and to 
cover this with two or three coats of collodion. Many other anti- 
septics, boih in salves and lotions, have been employed with suc- 
cess. One should persist in treatment until every trace of the 
disease has disappeared. 

Ulcers. Simple ulcers of the face occurring in marasmic per- 
sons, especially young infants, are readily healed if the general 
condition of the patient can be improved. Cleanliness and a sim- 
ple dressing for example, a wet dressing of creolin, one per cent 
are the only local treatment needed. The question of syphilis 
ought always to be considered. 

Anthrax, or malignant pustule, is found on the hands and 
arms perhaps more frequently than on the face and neck. It is 
described on page 132, where a clear picture of an early pustule 
is given. 

Noma. This is a localized gangrene of the face and mouth, 
usually seen in a person exhausted by some infectious disease. It 
begins in the mucous membrane of the gums or cheeks. The tis- 
sues are first indurated, and then become gangrenous. There is 
no fever. The process leads to perforation of the cheek, loss of 
the teeth, necrosis of the jaw, etc., and usually terminates in death 
within a week or'ten days. 

CHRONIC INFLAMMATIONS 

Syphilis. The primary lesion of syphilis is occasionally 
found in the lip or cheek or tongue. The unusual site of the lesion 
and the fact that it may be found here in the pure-minded, often 
lead to an error in diagnosis. Hence the .exact appearance of the 
indurated sore is of great importance. Infection usually takes 
place through a visible break in the skin a cigarette burn in one 
of the cases figured in the accompanying illustrations but such 
a break will be obscured by the primary sore in a few days. In 
a week or two the induration and redness become marked. 



60 



INFLAMMATIONS OF THE HEAD 




FIG. 20. CHANCRE OF LOWER LIP OF NINE DAYS' DURA- 



If the lesion is on the lip (Fig. 20), its development is similar 
to that of a chancre of the penis. There is the ha me elevated, com- 
paratively painless 
swelling with shal- 
low ulceration, but 
later the extent of 
the deep indura- 
tion usually" ex- 
ceeds that found in 
an unmixed sore 
of the penis (Fig. 
21). 

When the pri- 
mary lesion occurs 
in still thicker skin 

TION. Patient a man aged thirty-six years. (for example, that 

of the cheek), this 

induration and the subsequent ulcer are still larger than is usu- 
ally the case when the primary sore occurs in the genitals. In a 
few days the surface is covered with a dry scab (Fig. 22) if the 
lesion is out of the area bathed with the saliva. The regional 
lymphatic glands are swollen, but are not very tender. A few days 
later the scab falls off, 
and a shallow ulcer is 
formed (Fig. 23). As 
healing takes place the 
induration subsides, 
the ulcers become 
filled with granula- 
tions, and the epithe- 
lium grows over it. 
The only permanent 
disfigurement is a 

Small SCar containing FIG. 21. CHANCRE OF LOWER LIP OF THREE WEEKS' 
1 . . , -i . DURATION. Patient a man aged twenty-four 

perhaps, a little pig- years, 
ment. This is insig- 
nificant when compared with the active lesion, so that in this 
respect the patient may be encouraged. 

The persistence of the lesion for a week or more in a healthy 




SYPHILIS (il 

patient, mid the large anniiinl of indnral ion without suppuration, 
serve to distinguish the primary sore of syphilis from a simple 
ulcer. The possible youth of the patient, and the disappearance 
of induration either with or without the use of antisyphilitic 
remedies, serve to distinguish it from cancer. Cancer is the more 




FIG. 22. CHANCRE OF CHEEK, DEVELOPING IN BURN FROM CIGARETTE. Duration of 
lesion 2 months. Patient aged 19 years. 

unlikely if the lesion is in the skin of the face, away from the 
mucocutaneous junction of the lip. 

TREATMENT. Local treatment, while not essential, relieves 
the feelings of the patient. The sore should be covered with a 
collodion dressing, or with simple ointment and a small patch of 
muslin. Mercunc ointment, on account of its suggestive color, 
should not lie employed- at lea-! liy day. Internal treatment is 
all important, A tablet of j of a grain of mercuric prqtoiodid 



62 INFLAMMATIONS OF THE HEAD 

should be taken after each meal, or ^ of a grain of mercuric bin- 
iodid with 10 grains of potassium iodid, well diluted in water. 
Some physicians prefer treatment by injection e. g., -J grain of 
bichlorid of mercury in water three times a week, or 5 to 8 drops 
of a ten per cent emulsion of the salicylate of mercury in albolene, 
once a week. 

Secondary Lesions. Mucous patches which develop in I ho 
mouth and throat during the secondary stage of syphilis in some 




FIG. 23. CHANCRE OF CHEEK FROM A BITE. The ulcer is granulating. 

cases make the patient very uncomfortable, and may lead to sup- 
puration in the cervical lymph glands. Gargles and sprays of mild 
antiseptics give some relief, but the chief treatment consists in the 
regular administration of mercury and potassium iodid. The sec- 
ondary eruption on the skin of the face, and particularly of the 
forehead, annoys the patient by calling attention to his disease. 



TUBERCULOSIS 




Mercuric ointment rnhhed into ihc individual patches at night, and 
\vi|K'd oil' \\-itli ;i dry cloth in the morning, is thought In h;islcii the 
disappearance of these lesions. 
Occasionally a well-developed le- 
sion may he mistaken for a n<-\v 
growth ( Fig. 24). 

Tertiary Lesions. ( } u m m a 
may develop in the scalp or face, 
or in the tongue or throat or 
nose. It produces a deep-seated 
ulceratiou which heals only after 
the permanent destruction of 
more or less tissue. There is 
also a chronic syphilitic thicken- 
ing of the tongue known as glos- 
sitis. The whole tongue is harder 
and thicker than normal, and the 
mucous membrane in particular 
is furrowed and ridged and more 
shiny than normal. Gumma of 
the scalp often involves not 

only the skin, but the periosteum and a part of the skull, so 
that there may be necrosis of some portions of the outer table 
of the skull. The separation of these necrotic portions may re- 
quire months. Until they are entirely removed complete heal- 
ing is, of course, impossible. The pus which undermines the 
seal]) around the margins of the sequestrum may require incisions 
for its perfect drainage. These late lesions of syphilis, with the 
exception of the glossitis, usually yield readily to antisyphilitic 
treatment, and especially to the administration of large doses of 
iodid of potash up to a dram three times a day. Local treatment 
is unimportant. There is no excuse for keeping a patient's face or 
head smeared with an offensive mercurial ointment. Mercury can 
be administered more pleasantly and more accurately by mouth or 
by injections or inunctions. Moreover, under suitable moist dress- 
ings, repair takes place more rapidly than when mercuric ointment 
is used. This has been demonstrated by careful measurements. 

Tuberculosis. When the skin is the seat of tuberculosis, the 
lesion is spoken of as lupus vulgaris. The face is the commonest 



J''i<;. 24. PAPILLOMA OF LIP, FOUND 
ON MICROSCOPICAL EXAMINATION 
TO BE SYPHILITIC. Duration of 
lesion 2 months. Patient aged 28 
years. 



64 INFLAMMATIONS OF THE HEAD 

situation for this disease, especially I he skin of tin- nose and 
cheeks. A number of reddish areas as lai-ge as. a pea, perlia-ps, 
are first noticed in the corium. They pale on pressure, appear- 
ing yellowish or brownish. As the disease spreads, the tissue first 
involved may ulcerate, or it may atrophy and become cicatricial 
in character. As the course of the affection is a very chronic one, 
often lasting for years, the appearances of the lesion vary greatly 
and a variety of names have been applied to indicate these differ- 
ent stages, the minute description of. which will be found in any 
book upon skin diseases. 

DIAGNOSIS. Small patches of lupus may be confounded with 
psoriasis, but inquiry into the history will usually serve to elimi- 
nate this error. The lesions of psoriasis are persistent, but do not 
involve the deeper parts of the skin, do not extend so steadily, 
and do not ulcerate. Lupus may also be confounded with rodent 
ulcer. In this disease the destructive process is more notice- 
able, while the reparative is less so; but in certain instances 
a microscopical examination may be necessary to differentiate 
the two. 

TREATMENT. The diseased tissue may be removed by the 
curette, or by caustics, or by the knife. The advance of the growth 
has sometimes been checked by linear scarifications about one- 
eighth of an inch apart and crossing each other at right angles. 
Ultra-violet rays and the x-ray have also been employed with good 
effect in many cases. These last-named agents have the merit of 
destroying the pathologic tissue with far less resulting scar than 
chemical caustics or the knife. 

Tuberculosis of Nose and Mouth. Tuberculosis of the nose, 
mouth, or throat is of rare occurrence, and when seen is usually 
secondary to tuberculosis of the lung. It appears in two forms, 
either productive or ulcerative. Both processes may be exhibited 
in a single lesion. It may be difficult to differentiate tuberculosis 
from syphilis until a microscopic examination of an excised por- 
tion of tissue has been made, or the patient has been subjected to 
treatment by mercury and iodine. 

Tuberculosis of the mouth, secondary to the pulmonary dis- 
ease, is shown in the accompanying photograph (Fig. 25). 

TREATMENT. General hygienic treatment is important. Local 
treatment, such as the application of caustics or the partial exci- 



ACTINOMYCOSIS 



65 



sion of tuberculous tissue, has little effect upon the progress of the 
disease, while in this situation a thorough excision is impossible. 




FIG. 25. TUBERCULOSIS OF THE GUM, SECONDARY TO PULMONAKY TUBERCULOSIS. 

Actinomycosis. This should be borne in mind as one of the 
chronic inflammatory lesions liable to occur in the face, and espe- 
cially about the mouth or jaw. It begins as a smooth swelling, 
but later abscesses form and discharge pus containing yellowish 
granules. These may be recognized by the naked eye or under 
the microscope as colonies of the ray fungus. They are character- 
istic of the disease. The fungus of the disease in man is similar 
to, but probably not identical with, that of the disease in cattle 
called " lumpy jaw." 

Treatment consists in the excision of diseased tissue, and the 
administration of iodid of potash. The results are not very sat- 
isfactory in many cases. 



CHAPTER III 
TUMORS AND DEFORMITIES OF THE HEAD 

CYSTIC TUMORS 

Milium. There are often found in the skin of the face, espe- 
cially near the eyes, and also in the skin of the external genitals, 
male and female, little whitish masses. They are called milia. 
They are made up of closely packed epithelium and sebaceous 
material, and are situated just beneath the epidermis. A milium 
is distinguished from a comedo, or blackhead, by the fact that 
there is 1 no obstructed duct in the epithelium which covers it. The 
nature of this small tumor is in doubt. 

]\lilia show little tendency to change their form. As they are 
persistent, their removal is often requested by the patient. The 
overlying epidermis should be split with the point of a small sharp 
scalpel and the contents expressed. This method is less painful 
and more successful than attempts to pick out the mass with a 
needle. 

Comedo. A comedo, or blackhead, is the lesion produced 
by. the blocking of a sebaceous duct. The dark color is due to an 
admixture of dust with the sebaceous material. They are most 
often found upon the face and neck. 

The general treatment which is given for acne (p. 33) is of 
service. After the skin has been softened by hot bathing, the 
individual plug may be loosened by a needle and squeezed out by 
lateral pressure. This pressure sliould in all cases be slight, lest 
a sluggish inflammatory process be converted into an acute one. 

Sebaceous Cyst. The tumor of the head that most often 
attracts notice is a sebaceous cyst. These cysts occur either singly 
or in groups, and vary in size from the smallest nodule which can 
be recognized to a sac two inches or more in diameter. They are 
commonest in the scalp, but also occur behind the ear, in the eye- 
brow, or (in males) in the skin from which the beard springs. 
66 



SEBACEOUS CYST 



67 



They are found in young adults, but are most common in those of 
middle age. They are due to the blocking up of the duct of a 
sebaceous gland. The sebaceous material manufactured by the 
da ud collects within its lumen and gradually distends its cavity. 
As the distention increases, the epithelial lining is also increased 
by a multiplication of its cells. Within such a cyst are found the 
cast-off epithelial cells in a state of fatty degeneration. The mate- 
rial contained in a small cyst is semisolid and pasty, while that 
contained in a large one is usually more fluid. The tumor grows 
rapidly at times, but often has long dormant periods during which 
it seems not to grow at all. 

DIAGNOSIS. The cyst at first grows within the skin, and can- 
not be moved independently of it. As it increases in size, it 
spreads in the areolar 
tissue beneath the 
skin. It follows, 
therefore, that in the 
case of a large, non- 
inflamed cyst, the over- 
lying skin is movable 
upon it at all points 
excepting at the cen- 
ter. This single fact 
will usually serve to 
differentiate a sebace- 
ous cyst from a wholly 
subcutaneous tumor 
for example, a li- 
poma. 

If left to itself, a 
sebaceous cyst may 
attain a considerable 
size, possibly having 
a diameter of two 
inches, if it is situated 
in the scalp. The usual fate of a sebaceous cyst situated in the 
face is to undergo inflammatory changes (Fig. 26), possibly with 
nipt ure and discharge of its contents. Such a discharge is, how- 
ever, but temporary, as the sac generally refills in a short time. 




FIG. 26. SEBACEOUS CYST OF FOREHEAD, MODER- 
ATELY INFLAMED, AND ABOUT TO RUPTURE. 



68 



TUMORS AND DEFORMITIES OF THE HEAD 



TREATMENT. Treatment of a sebaceous cyst is operative. To 
guard against its recurrence, one should remove the whole sac. An 
operation to accomplish this is readily performed under cocain, 

unless the patient is 
more than usually 
sensitive. 

In the case of 
a sebaceous cyst of 
the scalp, one should 
proceed as follows: 
First shave and 
cleanse an area of 
the scalp a little 
larger than the 
tumor (Fig. 27). 
While shaving adds 
to the convenience 
of the operator, it 
not absolutely nec- 
essary, and primary 
union can usually 
be obtained without 
it. In certain cases, 
therefore, it may be 
better not to sacri- 

FIG. 27. OPERATION FOR SEBACEOUS CYST OF SCALP. . 

Skin prepared. nee any of the hair. 

The rest of the 

head outside of the field of operation should be covered with 
towels wrung out of bichlorid solution, 1 : 1,000. A few drops 
of one per cent cocain solution are next injected along the line 
of incision. This weak solution is desirable in these cases, since 
cocain injected into the head appears to have a more pronounced 
toxic effect than when used in other portions of the body. The 
writer has known the injection of a few drops of a four per cent 
solution of cocain into the median line of the scalp to produce such 
a marked reaction that artificial respiration was twice necessary 
before its effect passed off. 

A straight incision should be made directly across the center 
of the tumor, from one edge to the other, extending down to the 




SEBACEOUS CYST 



69 



sac without entering it. If the correct tissue-plane is reached, it 
is usually possible to sweep around the entire sac with the handle 
of the scalpel, or with a curved, closed scissors, and in this manner 
to lift the sac out without rupture (Fig. 28). 

Jf, however, I lie sac is ruptured, the operator need not fear 
that the contents will infect the wound. If this is a risk at all, 
it is certainly a very slight one, since primary union regularly fol- 
lows operation in all non-inflamed cases. Even when suppuration 
is present, union of the sutured skin is often obtainable. 




I'K;. 28. OPERATION FOR SEBACEOUS CYST OF SCALP. Skin divided to the sac and 

retracted. 

If the sac is ruptured, its contents should be at once evacuated, 
and the sac itself peeled out or dissected out. If the cyst is a large 
one, there will be considerable redundant skin after the sac has 
been removed (Fig. 29). This will shrink in time, so that it is 
not usually necessary to cut any of it away. 

The wound should be closed by interrupted sutures of fine 
black silk or horsehair, and pressure applied most carefully to 
prevent the formation of a blood clot. For this reason a bandage 



70 



TUMORS AND DEFORMITIES OF THE HEAD 




FIG. 29. OPERATION FOR SEBACEOUS 
CYST OF SCALP. The redundant, 
skin collapses after the removal of 
the sac. 

feat primary union if the 
sac is dissected away. It 
does make it very difficult 
to recognize the wall of the 
sac, however, and unless the 
wall is entirely removed re- 
currence will take place. 
If, therefore, the abscess is 
pronounced, it is better to 
lance and drain it, explain- 
ing to the patient that the 
sac will later fill again with 
sebaceous material and must 
then be removed (Fig. 30). 

An interesting case in 
which a tumor growing 



about the head, at 
least for two or three 
days, is necessary, ex- 
cept in the case of a 
very small cyst. Af- 
ter that a cotton-col- 
lodion dressing is 
preferable. 

A sebaceous cyst 
of the face or behind 
the ear is more apt to 
suppurate than one 
of the scalp. This 
suppuration is of such 
a mild character that 
it does not usually de- 




FIG. 30. INFLAMED SEBACEOUS CYST BEHIND 
THE EAR. Of many months' duration; in- 
fected three days. 



DERMOID CYST 



71 



from or beneath the skull and lifting the scalp was erroneously 
diagnosed as a sebaceous cyst, is described on page 105 with an 
accompanying illustration. 

Mucous cysts may appear in any. portion of the mouth as 
the result of obstruction to the secretion of a mucous gland. They 
are more common on the inner surface of the lips and cheeks. 
They are extremely thin-walled, and are filled with a clear, glairy 
fluid. It is not possible to dissect out the filmy sac, nor is this 
necessary, for if a triangular or circular portion be cut from the 
mucous membrane overlying the sac, the latter will be destroyed 
by granulation during the healing process, so that recurrence need 
not be feared. 

Ranula, or Sublingual Salivary Cyst. Sometimes a duct 
of one sublingual gland becomes obstructed, and as the saliva accu- 




FIG. 31. CYST OF SUBLINGUAL GLAND RANULA. Existing one week. Patient, a 
woman aged twenty-eight years. 

mulates a soft cyst forms under the tongue called a ranula (Fig. 
31). In rare cases both sides are affected at once. If the cyst 



72 TUMORS AND DEFORMITIES OF THE HEAD 

is pricked with a scalpel a teaspoonful of viscid opalescent fluid 
may be expressed. A portion of the wall of the sac should be 
excised, and a rubber tissue drain kept in if possible for several 
days, in order to give the epithelium of the mouth time to unite 
with that lining the cyst. Otherwise the cyst will refill and the 
operation must be repeated. 

Simple Parotid Cyst. A similar retention cyst may de- 
velop from some portion of the parotid salivary gland. As it lies 
under the skin of the cheek, and is not attached to it, it is most 
readily mistaken for a lipoma. It should be removed in toto, 
and if its attachment to the gland is a close one, allowance must 
be made for a continued salivary discharge. If the wound is com- 
pletely sutured it will almost invariably fill up with a mixture 
of saliva, serum, and leucocytes. It is better, therefore, to leave 
a minute drain for example, four or five horsehairs or threads 
twisted together and doubled or a flat gutta-percha drain in the 
wound, which should elsewhere be sutured. This will allow the 
slight secretion to escape, and in the course of a few days or perhaps 
a few weeks the discharge will cease, and in time the indurated 
nodule caused by the granulation of the little cavity will entirely 
disappear, leaving not so delicate a scar as would have resulted 
from removal of a tumor with primary union, but one which is 
not very noticeable. 

Dental Cyst. A cyst sometimes forms by the side of a root 
of a decayed tooth. The fluid collects slowly and without the 
usual signs of inflammation (Fig. 32). When evacuated it is 
found to be of a mucous character clouded with epithelial debris. 
Such a cyst is thought to be due to overgrowth of remnants of 
cells concerned in the embryonic development of the teeth. The 
cyst forms within the bone, and its projecting portion is partly or 
wholly covered by a thin layer of bone which may crackle when 
palpated. The exposed wall of the cyst should be cut away and 
its cavity filled with iodoform or other antiseptic gauze and al- 
lowed to heal by granulation from the bottom. 

Dermoid Cyst. A dermoid cyst is of congenital origin, and 
occurs in one of the lines of embryonic closure of the skin. It 
may be apparent at birth, or it may not be noticed until some 
years afterward, when its increase in size first attracts the atten- 
tion of the patient or some friend. Some dermoid cysts are made 



DERMOID CYST 73 

up of a single layer of epithelium, with sebaceous contents, in 
which a few hairs are sometimes found. If the attachment of the 
dermoid cyst to the deeper structures is slight, its removal is 
:il most as simple as the removal of a sebaceous cyst. Some der- 
moid cysts have extensive deep attachments, so that their removal 




Fi<;. .32. DENTAL CYST OK Six WKKKS' DURATION. There was freely movable akin 
and absence of heat, redness, edema, and tenderness, but the cyst was mistaken 
for alveolar abscess. 

is difficult and may be followed by a permanent scar. It is of the 
greatest importance, therefore, that a correct diagnosis of dermoid 
cyst be made before its removal is attempted. 

DIFFERENTIAL DIAGNOSIS. A mistake in diagnosis lies chiefly 
between a dermoid cyst and a sebaceous cyst ; hence the importance 
of considering in detail the points of difference. The common 
situations in which sebaceous cysts are found have already been 



74 



spoken of. They include nearly all the situations in which a der- 
moid cyst of the head is likely to be found. Dermoids occur 
chiefly about the inner or outer angle of the orbit, or in front 
of or behind the ear (see Figs. 33, 34, and 35). A sebaceous cyst 
is rare in childhood; dermoids occur in infancy, childhood, and 
adult life. A sebaceous cyst is always attached to the skin at one 
point; a dermoid is usually covered by normal, freely movable 
skin. A sebaceous cyst is invariably movable with the skin on 

the deeper structures; 
the base of a dermoid is 
invariably attached to 
the deep facia or to the 
periosteum, or, in case 
of the ear, to the peri- 
chondrium. This point 
is not always easy to 
make out, since the more 
superficial portion of the 
dermoid cyst may swing 
back and forth upon its 
own fixed base, but to 
slide the cyst as a whole 
backward and forward is 
impossible. Both cysts 
plainly fluctuate when 
they have reached a suf- 
ficient size. 

During the operation 
it will be noticed that 
the sac of a dermoid cyst 
is usually thicker than 

that of a sebaceous cyst, and that this is especially true of its 
deeper portion. Furthermore, the attachment of its base will be- 
come more and more manifest as an attempt is made to dissect it 
free. It can never be freed by blunt dissection, since it is anatom- 
ically connected with the deeper tissues. If it contains hairs the 
diagnosis is certain. 

A dermoid cyst which contains little sebaceous matter and does 
not fluctuate may be mistaken for a liponia or a small, deep-seated 




FIG. 33. DERMOID ('VST or THE NOSE, NOTICED 
SOON AFTER BIRTH. 



DERMOID CYST 



75 



angioma. The size of the latter can always be reduced by com- 
pression, but it is promptly restored when the relief of pressure 

allows the blood-vessels 

to refill. 





FIG. 34. DERMOID CYST IN FRONT OF THE 
EAR, GROWING FOR FIVE YEARS. Pa- 
tient aged twenty-two years. 



FIG. 35. DERMOID CYST BEHIND 
THE EAR, CLOSELY RESEM- 
BLING A SEBACEOUS CYST IN- 
EXTERNAL APPEARANCE. Pa- 
tient aged 24 years. 



TREATMENT. The incision for the removal of a dermoid cyst 
near the orbit should be made through the eyebrow, the hair first 
having been shaved off, or it should follow the direction of a wrinkle 
in the forehead or about the angle of the eye, so that the scar shall 
be insignificant. The separation of the overlying skin from the 
cyst is easily accomplished, while the dissection of the base of the 
cyst from the bone may be difficult. For this reason, unless the 
patient is of a very quiet and courageous disposition, it is better 
to give a general anesthetic, as it is difficult to obtain complete 
anesthesia of the part of the cyst adherent to the periosteum by 
means of cocain or eucain. After most of the sac has been freed, 
it should be split open and emptied, so that the operator may know 
exactly how far its cavity extends. Sometimes the cyst can be 
dissected free from the periosteum without injury to the latter. 
More often a part of its base is really formed by the periosteum, 



76 TUMORS AND DEFORMITIES OF THE HEAD 

so that the complete removal of the cyst will necessitate the re- 
moval of a little periosteum. This is not a serious matter, as 
necrosis will not follow unless the wound suppurates. The oper- 
ative wound should be sutured and a firm dressing applied to 
obliterate the cavity due to the removal of the cyst. 

When the dermoid cyst is situated in front of or behind the 
ear, it may lie so closely associated with the cartilage of the audi- 
tory canal that its inner portion reaches to the base of the skull. 
Under these circumstances, as much of the cyst as is accessible 
should be removed and the remainder should be cauterized with 
carbolic acid. 

Congenital Sinus. The first pharyngeal cleft terminates 
just in front of the ear. This is a region in which inclusion cysts 
and sinuses are found. Such sinuses are often similarly placed in 
front of both ears. They are usually small, and being lined with 
the normal skin, secrete very little. They may become obstructed 
and form cysts. 

The only satisfactory treatment is the removal of the whole 
sinus or cyst by dissection. Any epithelial remainders are apt to 
develop into cysts. 

The sinuses formed by the partial closure of the lower phar- 
yngeal clefts are described in the section devoted to affections of 
the neck (p. 137). 

BENIGN SOLID TUMORS 

Papilloma. This tumor growing from the skin or mucous 
membrane usually resembles a more or less pedicled wart. It is 
composed of fat and fibrous tissue covered with essentially normal 
skin. 

TREATMENT. It may be snipped of? level with the skin, but 
if at all sessile its base should be removed by two incisions, which 
remove an elliptical portion of skin containing the base of the 
tumor. This guards against recurrence, and permits the smooth 
closure of the wound. A papilloma of the lip may be mistaken 
for the primary lesion of syphilis; that of the skin for a cancer 
(Fig. 36). 

Mole. A mole is a congenital pigmented fibroma of the skin 
more or less elevated above the surface. Sometimes in addition 



77 



M( >I.K 



to its excessive pigment, a mole contains liairs abnormally 
for the situation in which they occur. 

While most moles persist for life without undergoing any 
change, a few take on sarcomatous growth, either on account of 
external irritation or for some unknown reason. For this reason 
one is justified in removing any mole. They are chiefly removed, 
however, on account of their unsightly appearance. 

TKEATMENT. In removing a mole, one should be careful to 
take away all the cells of which it is composed, lest those remaih- 




FIG. 36. PAPILLOMA OF SKIN OCCURRING IN A SCAR, DIAGNOSED AS CANCER. The 
diagnosis was corrected by microscopical examination. Compare Fig. 54, p. 96. 

ing be stimulated to increased growth. For this reason caustics, 
whether chemical, thermal, or electrical, are not to be recom- 
mended. Excision is the method of choice, and may be performed 
in two ways. 



78 TUMORS AND DEFORMITIES OF THE HEAD 

If the mole is small it should be seized with fine mouse-tooth 
forceps and elevated slightly above the surrounding skin. It may 
then be snipped off with a sharp scalpel or a pair of curved scis- 
sors. No local anesthetic is necessary. 'When the removal is prop- 
erly done, all of the pigmented tissue is removed, and in its place 
there is a small oval loss of epithelium. This defect heals without 
permanent scar. 

In the case of larger moles, especially if they are so situated 
that a linear scar will not be objectionable, a different method of 
removal is preferable. The mole should be excised, together with 
the underlying portion of the true skin. The area of skin involved 
should first be cocainized. An ellipse is then marked out, having 
the inole as its center. The cut which separates this section of 
skin should everywhere be perpendicular to the surface, in order 
that the cut edges may fit exactly when sutured. The removal of 
the emptical portion of skin is sometimes followed by hemorrhage. 
This can usually be stopped by a few minutes' pressure, or by 
crushing the bleeding vessel with an artery forceps. The next 
step is to undermine the surrounding skin for a distance of a third 
of an inch or less, so that the tension upon the sutures may be 
slight. If the skin is lax, as it is about the eyes, this step may 
be safely omitted. If the skin is firm and is not undermined, the 
scar may stretch after the removal of the sutures until it is nearly 
as broad as the portion of skin which was removed. 

One or two horsehair or fine silk sutures should be inserted. 
It is well to remove these in three or four days, so that there may 
be no permanent marks to indicate the stitch holes. Tension upon 
the scar may thereafter be reduced by a strip of adhesive plaster. 

Lipoma. A lipoma is a tumor composed of fat with a mini- 
mum of fibrous tissue. It usually has a well-marked capsule. 

Lipoma of the face is most often found in the forehead, where 
it forms a smooth, flattened tumor usually about three-fourths of 
an inch in diameter (Fig. 37). Its attachment to the skin is 
slight, being noticeably less than the attachment of a sebaceous 
cyst. Moreover, the tension within the sac of a sebaceous cyst is 
usually greater than that within the capsule of a lipoma. It is 
well known that an encapsulated tumor will sometimes fluctuate, 
although it contains no fluid. This is particularly true of a lipoma 
of the forehead, which gives just as good a fluctuation wave on 



FIBROLIPoMA 



79 



account of the hard bone beneath it as a sebaceous cyst can give. 
A sebaceous cyst is more globular than a lipoma, and projects far 
more above the level of the surrounding skin (cf. Fig. 26, p. 67). 

TREATMENT. If left alone a lipoma shows little tendency to 
increase in size, but it is so conspicuous that its removal is desir- 
able. This is easily accomplished if the lobules of fat are large 
and the capsule well defined. 

The skin is cocainized, and an incision made across the center 
of the lipoma in the direction in which the scar will be least con- 
spicuous. This is in 
a horizontal direction 
in the case of the 
forehead. The inci- 
sion should divide 
the skin and also the 
capsule of the lipo- 
ma. When this has 
been done, the li- 
poma itself can be 
shelled out by blunt 
dissection with little 
difficulty. If one 
finds the dissection 
difficult, it is certain 
that he is not fol- 
lowing the plane be- 
tween the capsule 
and the lipoma 
proper. As this tu- 
mor shows no incli- 
nation to recur, it is 
unnecessary to re- 
move the capsule. 
Tli<> wound should be closed by interrupted sutures, or the sutures 
may be omitted, since in this situation there is little tendency for 
the cut edges to retract. The best dressing is a cotton-collodion 
one. 

Fibrolipoma. A fibrolipoma of the head has the usual 
characteristics of this tumor when found in other portions of 




FIG. 37. LIPOMA OF FOREHEAD, DURATION ONE YEAR. 



80 



TUMORS AND DEFORMITIES OF THE HEAD 



the body (p. 185). A fibrolipoma in an unusual situation is shown 
in Figure 38. Its attachment was to the skin of the external 

auditory canal. 

Angioma. Angioma of 
the face is of common oc- 
currence in early infancy. 
A small patch of dilated 
capillaries and veins, often 
called a nevus, may be pres- 
ent at birth. This lesion in- 
creases rapidly, so that early 
treatment is desirable in or- 
der to avoid unsightly deform- 
ity. The vessels dilated are 
usually those of the super- 
ficial portion of the skin, al- 
though in some instances the 
deeper vessels alone are af- 
fected, or it may be that the 
center of the nevus reaches 
the surface of the skin while 
its edges extend into the 
deeper portions of the skin, 
but are covered with normal epithelium. If the angioma reaches 
the surface it can scarcely be confounded with anything else, but 
a deep angioma containing much fibrous tissue may be taken for 
a fibrolipoma. Possibly a contusion with hemorrhage into the 
loose tissue around the eyelids might be mistaken for a commenc- 
ing nevus, but the lapse of a few days would suffice to distinguish 
the two. Pressure upon a vascular tumor empties its vessels and 
makes it white. As soon as the pressure is removed, the vessels 
immediately refill. Pressure upon effused blood causes its disap- 
pearance only to a slight degree. This difference is most strik- 
ingly shown if the pressure be made with a bit of transparent glass, 
so that the effect can be seen through it. 

TREATMENT. Capillary angiomata are successfully treated by 
punctures with a fine needle which -constitutes the negative pole of 
an electric battery. For this purpose the battery should contain 
from a dozen to thirty small cells. The positive pole should be a 




FIG. 38. FIBROLIPOMA OF AUDITORY CA- 
NAL, DURATION ONE YEAR. Patient, 
aged nineteen years. 



ANGIOMA 81 

moist sponge, while a. fine cambric needle or, better still, a jeweler's 
brooch is screwed inlo the handle connected with the negative pole. 
The sponge is held closely against the face while the needle is 
thrust into the skin at right angles to its surface from one-fourth 
to one-third of an inch. It is important that the needle inserted 
should he the negative pole, for if it is the positive pole bubbles 
of oxygen will form around it and will produce upon it oxid of 
iron, some of which, remaining in the tissues after the needle is 
withdrawn, may cause a permanent discoloration. The current 
should be sufficiently strong to produce a white zone about the 
needle one-eighth of an inch in diameter in ten or twenty seconds. 
If it is too strong the escharotic action is too vigorous and a per- 
manent scar is produced. If it is too weak the cauterization is 
insufficient and the puncture is apt to bleed badly when the needle 
is withdrawn. If the battery is freshly filled, eight or ten cells 
are usually sufficient. Half a dozen punctures may be made at 
one sitting, and the treatment may be repeated twice a w r eek. The 
pain is intense, and a cool assistant is required to hold the head 
and arms of the child. No anesthetic is required, as the pain does 
not continue after the removal of the needle, and even a delicate 
baby suffers no injury from the treatment. If the punctures are 
judiciously made, and the treatment is continued until every red 
vessel disappears, a satisfactory result will be obtained in most 
instances, and in place of the angioma there will be a cicatrized 
area marked here and there by little pits due to too vigorous cau- 
terization. If the nevus is wholly superficial and only capillaries 
are involved, the scar will be extremely slight. The site of a 
deeper tumor, especially if it contains larger vessels, will be 
marked by a thickened and more abnormal patch of skin. It 
may be of advantage to perform a partial excision of such a nevus 
at some stage of the treatment by electrolysis. 

Another method of treatment by which good results are ob- 
tained is the coagulation of blood in the vessels by the injection 
into the nevus of a few drops of water almost at the boiling point. 
The effect of heat applied in this way should be great enough to 
produce coagulation, as shown by the immediate pallor in the 
portion of the nevus so treated. After a few days the permanent 
effect of the treatment will be manifest, and if red spots remain 

additional injections should be made. 
8 



82 TUMORS AND DEFORMITIES OF THE HEAD 

TREATMENT BY OPERATION. If an angioma is made up of 
larger vessels, either veins or arteries, it is readily compressible 
and may pulsate (Figs. 39 and 40). Electrolysis is useless in 
such a case, and the tumor must be removed by operation or its 




FIG. 39. PULSATING ANGIOMA OF SCALP, CONGENITAL. The photograph shows it 

fully distended. 

vessels ligated. This operation is serious in the case of an infant, 
for the bulk of its blood is so small that it will succumb to a 
hemorrhage which does not seem large to one accustomed to oper- 
ate only upon adults. Even when the operation is upon an adult, 
every precaution should be taken to limit the hemorrhage. There 
should 'be plenty of artery clamps at hand. One assistant should 
have nothing to do except to control hemorrhage by pinching the 
surrounding skin or pressing it against the skull. Even then the 
bleeding will not be under perfect control, since the vessels of the 
tumor often anastomose with the veins inside of the skull. As 
fast as the incision is made the cut vessels should be clamped. If 
there is plenty of skin to cover the wound without using any of 



ACNE HYPEKTROPHICA 83 

that which covers the vessels of the tumor, the whole incision 
should be made before the base of the tumor is cut into. In this 
way much of its blood-supply will be shut off before the most dif- 
ficult part of the operation, namely, the dissection of the base, is 




FIG. 40. SAME TUMOR AS FIG. 39, BUT PHOTOGRAPHED IMMEDIATELY AFTEII THE 
FINGERS WHICH WERE USED TO COMPRESS THE TUMOR HAD BEEN REMOVED. As 
the volume of the tumor increased very rapidly when released, this figure does 
not show it at its smallest. 

attempted. If the skin of the tumor is needed, one lateral inci- 
sion should be made, the base next dissected, and the collapsed 
tumor cut away from as much of the overlying skin as is needed 
to cover the wound, which should be accurately closed by suture. 
The dressing should be a firm one, but sufficiently elastic, so that 
the pressure exerted may not threaten the vitality of the skin. 

Acne Hypertrophica. This is an overgrowth of the nose, 
which is generally considered to be one of the forms of acne rosa- 



84 TUMORS AND DEFORMITIES OF THE HEAD 

cea, but is here included with the tumors to which it belongs clini- 
cally, for the appearance of the lesion and the treatment warrant 
this classification (Fig. 41). 

This is a disease of middle life, or later, marked by a great 
overgrowth of the sebaceous follicles, with their ducts, as well as 
of blood-vessels and fatty- tissue. The skin itself is not greatly 
thickened, and may even be thinned, apparently the result of over- 
stretching it. The tumor as a whole is soft and flabby, of dark red 




FIG. 41. ACNE HYPERTROPHICA OF THE NOSE, OF SEVEN YEARS' DURATION. Patient 

aged sixty-nine years. 

color, ;due to the venous congestion. It is not necessarily the result 
of alcoholism, and many of these patients are unjustly accused of 
intemperate habits. 

Lesser degrees of hypertrophic acne of the nose are frequently 
found. Such an extreme overgrowth as is shown in Figures 42 and 
43 is decidedly exceptional, although even more marked instances 
are occasionally seen. 

Although this overgrowth is benign in character, the excess of 



ACNE HYPERTROPHICA 



85 




tissue should be removed, as this can be accomplished without 
much risk, and the feelings of the patient will thereby be sp;uv<] 
many mortifying re- 
marks. 

TREATMENT. This 
consists in the re- 
moval of wedge- 
shaped pieces of the 
growth, so that the 
normal contour of the 
nose may be restored. 
The spongy tissue is 
very insensitive, so 
that a small amount 
of a dilute solution of 
eucain or cocain is 
sufficient. H e m o r - 
rhage is free, but may 
be controlled by pres- 
sure and ligatures. 
Although these pa- 
tients are usually 
plethoric and stand 
very well the loss of 
blood, it may be ad- 
visable to remove 
only a portion of the 
growth at one sitting. 
This plan has the fur- 
ther advantage of en- 
abling the surgeon to 
observe the effect of a 
partial removal of the 
tumor before complet- 
ing the task. Re- 
moval may be effected 
in such a way that 
pedicled flaps are uti- 

li/fd to cover the raw Fia. 43. SAME SUBJECT AS FIG. 42. Side view. 



FIG. 42. ACNE HYPERTROPHICA OF THE NOSE, 
FOUR YEARS' DURATION. Front view. 




86 



TUMORS AND DEFORMITIES OF THE HEAD 




FIG. 44. SAME SUBJECT AS FIG. 42, SHOWING THE 
RESULTS OF OPERATIVE TREATMENT FOR ACNE 
HYPERTROPHICA OF THE NOSE; THREE WEEKS 
AFTER FIRST OPERATION, AND ONE WEEK AFTER 
SECOND OPERATION. 




FIG. 45. SAME SUBJECT AS FIG. 42. Side view, one 
week after the second operation. 



spaces. Their vital- 
ity is low, and unless 
the pedicle is very 
broad, they are likely 
to slough. There- 
fore it is advisable 
not to undermine 
them too extensively. 

The results of this 
plastic surgery are 
very satisfactory 
(Figs. 44 and 45). 
In some cases, if the 
quality of the skin is 
too poor, it is better 
to shave off all of 
the tissue down to 
the cartilage and to 
cover the wound with 
skin grafts. 

Hypertrophy 
of the Tonsil and 
other Lymphoid 
Structures in the 
Naso-pharynx and 
Pharynx. The 
faucial tonsil is fre- 
quently enlarged, es- 
pecially in children, 
either as a sequence 
of repeated attacks of 
tonsillitis or of some 
other infectious dis- 
ease, such as scarlet 
fever, diphtheria, or 
measles. In children 
hypertrophy of the 
tonsils is frequently 
associated with hy- 



HYI'KlvTKOlMlY OF Till'; TONSIL 87 

pertrophy of the lymphoid tissue in the naso-pharynx, commonly 
called adenoids, with hypertrophy of I lie lymphoid tissue at. the 
liase of the tongue, the so-called lingual tonsils, and enlargement 
of the cervical lymphatic glands. 

Symptoms produced by tonsillar hypertrophy may be very 
slight, or the enlargement may be sufficient to interfere with nor- 
mal swallowing and to favor and make more severe attacks of acute 
tonsillitis. Adenoids often obstruct. the posterior narcs to such an 
extent that the patient breathes through his mouth when asleep, 
and sometimes during the day as well. For these reasons, sur- 
gical treatment is frequently indicated. 

DIAGNOSIS. The diagnosis of hypertrophy of the tonsils 
is made by direct inspection. If one can see them during a 
period of acute inflammation, as well as in the intervals be- 
tween such attacks, he can best judge of the necessity for their 
removal. 

The diagnosis of hypertrophy of the lingual tonsil is made 
from the image reflected in a throat mirror. 

The diagnosis of adenoids is made from the image reflected 
in a rhinoscopic mirror, when this can be obtained. It can also 
be made by palpation with the forefinger, and can be assumed 
from persistent mouth breathing, especially if the anterior nares 
are not obstructed. There is also an alteration in the sound of 
the voice, and a postnasal catarrh. In extreme cases the facial 
expression is altered. Partial deafness may result. 

TREATMENT. Tonsilectomy is the term applied to the removal 
of a hypertrophic tonsil. The ancient practise of destroying a por- 
tion of such a tonsil by the cautery, or merely excising the pro- 
jecting portion, lias largely yielded its place to a complete removal 
of the tonsil. This may be done under a local or a general anes- 
thetic. The choice depends more on the character of the indi- 
vidual than on the condition of the tonsils. Those called for the 
first time to operate upon a young child will do well to employ a 
general anesthetic. 

The mouth is opened, a mouth gag inserted, the tonsil sei/ed 
with a slightly curved forceps having two or three prongs, and 
lifted from its bed. It may then be cut off with a tonsillotome, 
or dissected with scissors or a knife. If the latter method is 
chosen, it is only necessary to divide the mucous membrane; the 




FIG. 46. INSTRUMENTS USED FOR THE REMOVAL OF THE TONSIL. A, tonsillo- 
tome (this instrument is not used by many operators) ; B, mouse-tooth forceps; 
C, sponge holder, of which several should be at hand; D, E, blunt pointed knives; 
F, tongue depressor; G, mouth gag; H, tonsil forceps; /, long curved forceps; 
J, long curved scissors. 

88 



HYPERTROPHY OF THE TONSIL 89 

tonsil can then be shelled from its bed by blunt dissection with 
I lie finder or a suitable instrument. In this manner the whole 
tonsil can be removed more perfectly than with a tonsillotome 



If a local anesthetic is decided upon, the mucous membrane 
should he anesthetized by the application of a strong solution of 
cocain or stovain, ten or twenty per cent. There is le-s danger 
of poisoning if the anesthetic is applied upon a swab rather than 
in the form of a spray, but the swab should not be so wet as to 
allow the solution to trickle down the throat. Another good plan 
is to inject a few drops of a ten per cent solution of stovain in 
adrenalin, 1 : 2,000, into the tissues before beginning the dis- 
section. 

Hemorrhage following the removal of the tonsil is free, but 
usually subsides promptly. It is well to have at hand small 
sponges in curved clamps, which can be squeezed out of an adren- 
alin solution and pressed firmly against the bleeding surface. 
An astringent gargle is also serviceable. The patient should gar- 
gle the throat every few hours with iced Dobell's solution some- 
what diluted. In most cases the pain which results is surprisingly 
slight, considering the extent of raw surface which results from 
this operation. 

Hypertrophy of the lingual tonsil, giving rise to persistent 
cough or husky speech, may require operation. The excess of 
tissue can be removed with a galvanocautery or a specially con- 
structed tonsillotome. 

TREATMENT OF ADENOIDS. Although adenoids tend to 
atrophy about the period of puberty, it is unwise to wait for their 
spontaneous disappearance, if they give rise to definite symptoms 
as described above. They should be removed by operation, pref- 
erahly under a general anesthetic, although the postnasal space 
is readily anesthetized by a ten per cent solution of cocain in a 
1:2,000 solution of adrenalin chlorid, applied on cotton wound 
on a bent probe. 

If the child is chloroformed, it may lie with its head lower 
than its shoulders, or not, according to the operator's preference. 
In any case, a mouth gag is inserted and the adenoids are removed 
either with a specially curved curette or with a pair of forceps, 
or, as many prefer, with the finger nail (Fig. 47). 



90 



TUMORS AND DEFORMITIES OF THE HEAD 



Following operation, the nose and throat should be frequently 
sprayed with a diluted Dobell's solution, or some other dilute dis- 
infectant. 




FIG. 47. INSTRUMENTS USED FOR THE REMOVAL OF ADENOIDS. A, tongue de- 
pressor; B, mouth gag; C, adenoid curettes. 

Epulis. A growth which resembles a papilloma in appear- 
ance, but which is much denser, is called an epulis. It usually 
springs from the gum, along the outer side of the molar teeth. As 
it grows it takes on the shape of the space in which it lies, and 
therefore appears to have a broad attachment. When it is lifted 
up from the mucous membrane it will often be seen to have an 
extremely narrow pedicle. It is a dense hard tumor, covered with 
mucous membrane having a normal appearance. 

An epulis grows slowly, and without pain, but it should be 
thoroughly removed because of its constant tendency to increase 
in size, and also because in structure it closely resembles a spindle- 
cell sarcoma. If the growing base of the tumor in the mucous 



OSTEOMA, OR EXOS'I 



91 



is excised, it is not likely to recur. The specimen 
in iill cuscs he examined microscopically. 

Otoliths. Calcareous bodies, called otolitlis, often form in 
tin- fatty portion of the ear. They are similar in character to the 
deposits which are found elsewhere in the body in gouty indi- 
viduals. In the ear these discrete nodules may be so large as to 
be noticeable and to annoy the patient. They are easily removed 
through small incisions. 

Osteoma, or Exostosis. This is a benign tumor, being a 
simple outgrowth of bone. It is easily recognized as having the 
consistence of bone, to which it is firmly attached. It is covered by 
normal skin, fat, etc. Such a tumor is very rare in the face (Fig. 




Fi<:. 48. KXOSTOSIS OF JAW. Two or three years' duration. 

48). It is commoner in the skull. If it is decided to remove it, 
the skin and other parts should be divided and reflected so as to 
expose the exostosis. This should be chiseled away, together with 
the periosteum which covers it, as the possibility of recurrence 



92 TUMORS AND DEFORMITIES, OF THE HEAD . 

should be borne in mind. While, this operation takes only a few 
minutes, it is difficult to anesthetize bone. Therefore, during the 
chiseling .the patient's sensibilities should be benumbed by chloro- 
form of nitrous oxid gas, or, if preferred, the whole operation 
may be performed under a general anesthetic. Such tumors should 
be examined microscopically. 

Spur. An exostosis, or a cartilaginous tumor projecting from 
the floor or septum of the nose and covered with normal mucous 
membrane, is called a spur. If of sufficient size to interfere with 
normal breathing, it should be removed with a blunt-pointed saw, 
the parts having been first anesthetized by the application of co- 
cain.or stovain upon a -cotton swab. Bleeding may be controlled 
by adrenalin, or by the tip of a galvanocautery, an instrument 
which is utilized by some for the removal of the spur. 

Deviation of the nasal septum is considered on page 109. 

MALIGNANT TUMORS 

Epithelioma. An epithelioma may develop in any portion 
of the epithelium covering the head or lining its cavities. It is 
common at the mucocutaneous junctions of the eyes, ears, nose, 
and mouth (Fig. 49). 

Its origin, like that of malignant tumors in all situations of 
the body, is sometimes apparently due to a wound or to a long- 
continued irritation, but often such a provoking cause seems want- 
ing. Sometimes a wart or mole which has remained of essentially 
the same size for years will begin to grow rapidly, and if not 
removed will develop characteristics of a malignant tumor. In 
other cases the tumor starts as an ulcer almost from the beginning. 

It is in the class of cases in which a simple wart or mole as- 
sumes malignant development that surgery has an important part 
to play. A patient may have noticed such a localized thickening 
of the epithelium as is shown in Figures 50 and 51 for years. 
Gradually the cells begin to multiply and the tumor increases a 
little in size. This should inevitably be the sign for removal of the 
growth. At this stage it has not begun to infiltrate the skin. Nor 
has it extended into the deeper tissues. Hence a radical cure can 
be effected by the removal of the tumor without any of the sur- 
rounding tissues. Such a simple operation can be performed in a 



EPITHELIOMA 



93 



few minutes under 
local anesthesia, and 
need not IK- followed 
ly any permanent scar. 
On this account a pa- 
tient will readily con- 
sent to the operation. 

While it is prob- 
able that many of these 
hitherto benign tumors 
will never become ma- 
lignant, it is certain 
that some of them will 
do so, and in any event 
the operation frees the 
patient of an annoying 
blemish. Those that 
develop into malignant 
growths infiltrate, the 
skin and ulcerate in 
the older portions, and 
gradually assume the usual characteristics of carcinoma of the sur- 
face with an elevated growing margin, usually of an irregular 




FIG. 49. EPITHELIOMA OF FACE NEAR NOSE. Du- 
ration six years; slight ulceration. 




FIG. 50. EPITHELIOMA OF THE LIP DEVELOPING IN A SOFT WART WHICH HAD EXISTED 
SINCE CHILDHOOD. New growth noticed nine months previous. Patient aged 
fifty-six years. A similar wart on nose has recently shown increased growth. 



94 TUMORS AND DEFORMITIES OF THE HEAD 

character. But even at this stage epithelioma of the face is not 
of rapid growth, and a year or so may elapse before the tumor' 
reaches the diameter of an inch. This is equally true whether the 




FIG. 51. SAME SUBJECT AS FIG. 50, THREE MONTHS AFTER REMOVAL OF THE EPI- 
THELIOMA OF LIP. The scar could only be seen by close inspection; one of the 
advantages of early operation. 

tumor is at first of the papillomatous type (Fig. 52), or whether 
it early infiltrates the skin and ulcerates (Fig. 53). 

Epithelioma of the face in some individuals progresses so 
slowly that the patient will live for years, the tumor gradually 
eating away more and more of the skin and suffering in its own 
turn from ulcerative processes until possibly the skin of half the 
face is in this manner disintegrated. Such epithelioma is known 
as rodent ulcer. 



EHTHELIOMA 



95 



DIAGNOSIS. The appearance of a well-developed epithelioma 
is characteristic. First there is the very hard infiltration of the 
skin with the cancer cells. This raises the level of the skin affected 
above that of the normal surrounding skin. The blood-vessels in 
the skin involved, and in that adjacent to the new growth, are often 
dilated. As induration extends, the blood-supply may be shut off 
from the older portions of the growth and ulceration result. The 
discharge from the surface of such an ulcer often has a gangrenous 
odor. The regional lymph-glands may be swollen and hard. This 
may be the result of metastasis or of the absorption of septic prod- 
ucts if an ulcer exists. As a diagnostic sign of cancer it has there- 




Fia. .52. EPITBELIOUA OF THE NOSE, RECENTLY GROWING RAPIDLY. Diagnosis 
merely clinical, as the patient would not permit removal of the tumor. 

fore a greater value when the skin is unbroken than it has after 
an ulcer forms. The late diagnosis is of little value to the patient. 
The early diagnosis is life-saving. 

A beginning epithelioma may be mistaken for a wart or papil- 
loma (Fig. 54). If there is any doubt a microscopic examination 




FIG. 53. EPITHELIOMA OF THE CHEEK, EXISTING Two YEARS IN A MAN AGED 
SEVENTY-TWO. 




FIG. 54. EPITHELIOMA OF FACE ; SUPPOSED WART SNIPPED OFF FIVE WEEKS BEFORE 
THIS PHOTOGRAPH WAS TAKEN. Compare Figure 36, page 77. 
96 



EPITHELIOMA 



97 



should IK- made or the tumor should 1*3 removed. In fact, every 
such tumor which shows a tendency to grow/ should be promptly 
excised. When, this is done at an early stage, before the tumor 
heii'ins to infiltrate the skin, it is unnecessary _to sacrifice any of 
the surrounding skin, and no disfiguring scar follows. Hence a 
patient is more likely to submit to operation at this early stage, 
which is sometimes spoken of as the precancerous stage. Micro- 
scopical examination of the removed tissue will sometimes show 
that this term "precancerous" is not justified (see Figs. 57, 58, 
and 59, and the description of them on p. 98). 

Epithelioma of the Scalp. The early appearance of epitheli- 
oma in the scalp is that of a slightly elevated irregular tumor, the 




FIG. 55. EPITHELIOMA OF THE SCALP OCCURRING IN A WOMAN AGED FIFTY-EIGHT. 

surface of which is redder in places than the normal scalp, and 
which is partly covered by the crusts which are: prone to form 
upon the scalp whenever it is irritated (Fig. 55). 

Illustrations showing different types of early epithelioma of 
the face have been given in the preceding pages. 

Epithelioma of the Lip. One type of early epithelioma of the 
lip is shown in Figure 56, the ulcer of which was said to have ex- 
isted only four weeks. Another case in which ulceration was of the 



98 



TUMORS AND DEFORMITIES OF THE HEAD 




FIG. 56. EPITHELIOMA OF THE LIP, SAID TO BE OF 
FOUR WEEKS' DURATION. Patient aged forty- 
two years." 



most superficial character, although the tumor had lasted one year, 
is shown in Figure 60, page 101. This is a favorite seat for epithe- 
lioma. It often follows long-continued smoking of a clay pipe, 
arising at the point where the hot, rough stem of the pipe has 
rested upon the lower lip. It begins as a slight induration which 

the patient scarcely 
notices until little 
scales form upon the 
surface or a very shal- 
low ulceration pro- 
duces slight crusts. 
These from time to 
time are picked off or 
fall off, but the ex- 
coriation fails to heal. 
In the meantime the 
induration spreads 
slightly or creeps into 
the deep tissues, but 
for many months, by reason of its limited extent and lack of pain, 
the patient may look upon the lesion as unimportant. 

Epithelioma of the Tongue. Early appearances of epithelioma 
of the tongue are shown in Figures 57, 58, and 59. Attention is 
especially called to the two types of lesion there shown namely, 
the milky white patches of leucoplakia which had existed for sev- 
eral years, and the elevated, warty nodules which had existed for 
some months at least. In neither of these had the epithelial cells 
begun to grow downward at the time the drawing was made. All 
of the mature cancerous growth for which this tongue was re- 
moved came from an ulcer on its left margin, which does not show 
in this drawing. 

The chief possibility of error in the early diagnosis of epi- 
thelioma of the face lies in mistaking for it the primary lesion of 
syphilis. As already pointed out (page 60) the primary sore 
upon the thick epithelial layer of the skin or even of the lips or 
tongue has quite a different appearance from the primary sore upon 
the more delicate epithelium of the head of the penis. 

Besides illustrating the early appearance of epithelioma of the 
tongue, Figures 57 to 59 show how misleading the negative micro- 




FIG. 57. EPITHELIOMA OF THE TONGUE, SHOWING MILKY WHITE PATCHES OF LEUCO- 
PLAKIA, AND PAPILLOMATOUS GROWTHS, ESPECIALLY IN THE MEDIAN LlNE OF THE 
TONGUE. These were shown by microscopic examination to be not epithelioma, 
the only epithelioma being along the left border and in the center of the tongue. 




FIG. 58. LONGITUDINAL SECTION OF TONGUE IN THE MEDIAN LINE, SHOWING Two 
SMALL "ISLANDS" OF EPITHELIOMA IN ITS POSTERIOR PORTION. Same subject 
as Fig. 57. 

99 



100 



TUMORS AND DEFORMITIES OF THE HEAD 




scopic examination of small sections of tissue may be. Such sec- 
tions were twice removed from the center of this tongue, and were 
correctly pronounced to be not epitheliomatous. A third section 
was then taken from the left lateral margin, and was found to pre- 
sent the usual appearances of epithelioma. 

TREATMENT. The best treatment of a patient who has an epi- 
thelioma in an early stage is a complete removal of the tumor, 

together with a reasonable 
margin of healthy tissue on all 
sides of it and beneath it. 
Just how wide this margin 
should be cannot be stated by 
a general rule. If the tissue 
is lax and abundant, it is well 
to make the incision one-third 
of an inch away from the "vis- 
ible edge of the tumor. If the 
surrounding skin is less flex- 
ible, or if the tumor is so situ- 
ated that a scar will be very 
prominent, one is perhaps justi- 
fied in removing a narrower 
zone of healthy tissue with the tumor. This is more likely to be 
the case if the growth of the tumor is almost wholly upward, and 
infiltration has not yet taken place. 

When the tumor has been removed, hemorrhage is controlled 
by pressure or ligation of vessels, and the surgeon must consider 
the best manner of covering the defect. In many cases the wound 
may be closed by direct suture if the surrounding skin is loosened 
from the deep fascia. In other cases a plastic operation, or skin 
grafting, or a combination of the two methods, will give the best 
results. 

The regional lymph-glands should be examined. If they are 
palpably enlarged the spaces in which they lie should be thor- 
oughly freed by dissection of glands and the connective tissue in 
which they lie. This requires general anesthesia. Some surgeons 
advocate it as a routine measure in all cases, whether the glands 
are palpable or not. In such an early stage of the disease as is 
shown in Figures 54 and 60 ? it hardly seems warrantable to add so 



FIG. 59. TRANSVERSE SECTION OF THE 
TONGUE THROUGH THE ANTERIOR "IS- 
LAND" OF EPITHELIOMA SHOWN IN 
FIG. 58. It will be observed that the 
whole of this epithelial growth was 
from the lateral margin of the tongue. 



EPITHEUOMA 



101 



iinicli to the risk of operation, when the prognosis is so good with- 
out the more extensive dissection. If the glands are palpably 
enlarged, prognosis is much more grave, but is still sufficiently 
good to make a complete removal of glands and tumor desirable. 
Every tumor of the skin which is removed should be examined 
microscopically. 

The removal of epithelioma of the lower lip is accomplished 
as follows : The lower lip is shaved and cleansed thoroughly with 
soap and hot water. The teeth are brushed and the mouth rinsed 
with a dilute antiseptic. The lip is wiped with cotton wet with 
a stronger antiseptic solution. An assistant then seizes the lip at 
its right and left ends, between his thumb and fingers, standing 
behind the patient and putting the thumbs inside the patient's 
mouth. This compresses the inferior coronary and inferior labial 
arteries and absolutely controls hemorrhage. The operator then 
injects from twenty to forty minims of a one per cent solution of 
cocain along the lines of incision, and cuts a V-shaped section 




FIG. 60. EPITHELIOMA OF LOWER LIP. Duration one year. Patient ready for 

operation. 

from the lip, the incisions for the purpose (Fig. 61) passing 
through the whole thickness of the lip. They start in the free 
border at least one-third of an inch from the visible margin of the 
growth. The V should extend well down on the chin. This re- 
duces the amount of deformity as well as guards against recurrence. 
The wound is sutured with fine black silk (Fig. 62). If the 
external stitches include all of the tissues except the mucous mem- 



102 



TUMORS AND DEFORMITIES OF THE HEAD 



brane, apposition will be so perfect that the mucous membrane 
need not be sutured. This saves a rather difficult extraction of 
sutures from within the mouth. A narrow strip of gauze should 




FIG. 61. EPITHEI.IOMA OF LOWER LIP, SHOWING THE LINE OF INCISIONS. 

be placed over the wound and tension relieved by a strip of adhe- 
sive plaster from one side of the chin to the other. One-third of 
the lower lip may be removed with the certainty that no perma- 




FIG. 62. EPITHELIOMA OF LOWER LIP. After excision of the V-shaped piece, the 
gap in the lip is closed by sutures which need not penetrate the mucous membrane. 

nent deformity will result. If the tumor is situated very near the 
angle of the mouth, it may be necessary to extend the incision 
outward through the cheek to give greater freedom to the rem- 
nant of the lower lip. 



EPITHELIOMA 103 

Kpitliclioma of the tongue iiuiv occur upon tlic dorsum of the 
tongue, or along the edge, or in the vicinity of the frenum. As the 
early removal of this tumor has a favorable prognosis, it is ex- 
tremely important that it should be recognized before the growth 
is extensive, and before the lymphatic glands in the neck have 
become involved. Unfortunately patients are indifferent to small 
sores upon the tongue until they give rise to considerable pain. 
The saliva soaks off any discharge, so that the sore, has not the 
striking appearance of an epithelioma of the skin with its cover- 
ing of crusts. For this reason, most physicians fail to recognize 
epithelioma of the tongue as soon as they should do so. 

The disease first appears in one of three ways: There may be 
a white, wartlike growth, without ulceration, and with a scarcely 
noticeable induration at the base. Second, there may be a flat, 
slightly raised, smooth, red tumor which feels like a bit of gristle 
in the surface of the tongue. At a later stage this will ulcerate. 
Third, an old area of leucoplakia which possibly has existed for 
years will take on a malignant growth in some portion, showing 
distinct elevation, and then some induration at the base. This, 
too, will ulcerate later (Figs. 57-59). 

If an epithelioma of the tongue is recognized at an early stage, 
before ulceration sets in, the resection of the tumor with a safe 
zone of healthy tissue around it is a thoroughly safe operation. 
Some surgeons advocate the removal of the fascial tissue contain- 
ing lymph glands from the neck, although at this early stage the 
glands which are removed can rarely be demonstrated to contain 
cancer cells. If the disease is allowed to progress until ulceration 
has taken place, and there is marked infiltration of the tongue, 
and the lymphatic glands of the neck are palpably enlarged, re- 
moval of one-half, or even the whole, tongue, and an extensive dis- 
section in the neck gives slight hope of permanent cure. Radical 
cure, under such circumstances, is achieved in probably not more 
than twenty-five per cent of the cases. The indication is, there- 
fore, strongly in favor of early removal at a time when the opera- 
tion may be performed under cocain if necessary, and most of the 
tongue may be preserved. On account of its free circulation and 
great flexibility the tongue is an excellent subject for plastic work. 

Methods of Treatment other than Excision. Epithelioma of 
the face may be removed by chemical caustics or other agencies 



104 TUMORS AND DEFORMITIES OF THE HEAD 

capable of destroying tissue cells, such as the X-ray. That many 
cures have been effected by these means, every unprejudiced ob- 
server readily admits. They are generally considered to be less 
certain methods of removing the growth. They require a long 
period to effect their object, and evidence is lacking to show that 
recurrence is less likely to occur when a tumor has been destroyed 
by caustics than when it has been removed with a knife. Indeed, 
from what we know of the structure of the skin and of the nature 
of tumor growth, it is probable that recurrence is less likely when 
a zone of healthy tissue is removed with the tumor than when 
the tumor cells are killed in situ, so to speak. 

Methods other than excision are therefore to be adopted only 
when the patient refuses to allow the removal of the tumor by 
means of the knife. One of the best caustics to employ is a one 
per cent solution of arsenious acid in alcohol. A few drops of 
hydrochloric acid increase its solubility. This may be painted on 
with a camel's-hair brush every second day. This is a cleaner 
method of application than the usual one of arsenic paste. 

In using the X-ray for the destruction of an epithelioma, the 
surrounding skin should be protected, and the length of exposure, 
distance from the tube, etc., should be carefully noted at each 
treatment. In beginning treatment it is well to err on the side 
of safety, so that the exposure should be brief, and three days 
should elapse between treatments. Later, when the full effects of 
the X-ray can be estimated, treatments may be increased in sever- 
ity and in frequency. The details of this form of treatment have 
been frequently published in magazines and monographs. 

Sarcoma. Sarcoma of the head, while not very common, oc- 
curs with sufficient frequency to make the differential diagnosis be- 
tween it and benign growths of great importance. The diagnosis 
is often a difficult one in this region on account of the frequency 
here of sebaceous and dermoid cysts and of gummata and other 
inflammatory lesions. Two essential points shown by a malig- 
nant but not by a benign tumor, are the lack of a distinct bound- 
ary and the presence of enlarged blood-vessels in the vicinity of 
the tumor. Both of these signs were present in the case shown 
in Figure 63. This tumor had been growing rapidly for some 
months, but without pain or cerebral symptoms. It had been 
diagnosed as a sebaceous cyst by two doctors, and an immediate 



SARCOMA 



105 



office operation advised and 
a speedy cure promised. An- 
other doctor had affirmed that 
it was cancerous and that its 
removal would prove fatal. 
The surgeon in whose care 
I lie patient finally placed 
herself removed a section of 
the tumor for examination. 
Upon learning that the tumor 
was not sarcoma, and having 
found it to be encapsulated, he 
later removed it without diffi- 
culty, but with so great a loss 
of blood that the patient did 
not rally. It was extradural, 
but had eroded a circular area 
of the skull about two inches 
in diameter. The substance of 

the tumor itself was on gross and microscopic examination like the 
tissue of a rapidly hypertrophying thyroid gland. 




FIG. 63. TUMOR OF HEAD EXTRADU- 
RAL CLASSIFIED ON PATHOLOGICAL 
EXAMINATION AS AN ABERRANT THY- 
ROID. 




FIG. 04. ANGIOSARCOMA OF THE LOWER JAW OF A COLORED GIRL, AGED TWENTY- 
THREE. The tumor had been noticed for one month. 



106 TUMORS AND DEFORMITIES OF THE HEAD 

Sarcoma of the face is far less common than epithelioma. 
Sometimes a small and apparently innocent tumor of the skin will 
prove upon microscopical examination to be sarcoma. 

Angiosarcoma of the jaw occurs, and has a marked diagnostic 
importance because in its early stages (Fig. 64) it may be mis- 
taken for the spongy condition of the gums due to scrofula. The 
history of the disease and the general condition of the patient will 
usually suffice for a correct diagnosis. In doubtful cases a micro- 
scopical examination of a fragment of the tumor should be made. 
Attention to the diet, and the use of an astringent mouth wash 
which will speedily improve scrofulous gums will, of course, have 
no effect upon the development of a sarcoma. 

Parotid Tumors. In the region of the angle of the jaw ma- 
lignant tumors of varied histological structure arise in connection 
with the parotid gland : carcinoma, sarcoma, chondroma, myxoma, 




FIG. 65. TUMOR OF PAROTID GLAND, SAID TO HAVE EXISTED TEN OR TWELVE YEARS. 
The skin was not attached, and the tumor was movable in all directions. 



CANCER OF TONSIL 107 

and a combination in one tumor of the various structures which 
these names imply, may develop in this situation and give rise to 
a rounded, hard mass, usually composed of more than one lobule, 
which grows slowly or rapidly and often reaches the size of a small 
egg before the patient seeks surgical aid (Fig. 65). Such a tumor, 
like malignant tumors of a parenchymatous nature elsewhere in 
the body, is most often seen in middle life or later. If the condi- 
tions warrant it, no time should be lost after the diagnosis is made 
in accomplishing its thorough removal. As the tumor springs 
from the gland it is closely attached to it, but is movable with 
the gland upon the skin and deeper tissues. As it grows it infil- 
trates the surrounding tissues so that this mobility is soon lost. 
It may be distinguished from an inflammatory process by the his- 
tory of its slow development, by its hardness, and by its situation 
in the parotid. It is most likely to be confounded with tubercu- 
losis or syphilis of the cervical lymphatic glands. These are usu- 
ally situated below the angle of the jaw, but they may also extend 
above it. In affections of the lymphatic glands careful exami- 
nation will almost always show that two or more distinct glands are 
involved; whereas if a malignant tumor has nodules they can be 
shown to be connected, being invariably part of the same growth, 
except, of course, in case of secondary lymphatic involvement. 
Furthermore, tubercular and syphilitic glands which have attained 
any considerable size fall to pieces internally so that fluctuation 
can usually be made out in them. 

Cancer of Tonsil. Tumors of the tonsil of a malignant 
character are on the border-line histologically between carcinoma 
and sarcoma. They may be easily mistaken for a chronic hyper- 
trophy of the tonsil, and if there is the slightest question a large 
section of the tumor should be taken for examination by a pathol- 
ogist. Even then the diagnosis may not be an absolute one, and 
the decision between the risk of allowing the tumor to remain and 
the risk of an operation for its radical removal is one of the most 
difficult in surgery. If a presumably hypertrophied tonsil is am- 
putated by means of the tonsillotome and subsequently recurs, 
this fact, even more than the result of histological examination, 
will incline the surgeon to perform a more radical operation for 
removal of the tumor. These tumors affect the deeper structures, 
and do not give rise to ulceration until a late stage is reached. 



108 TUMORS AND DEFORMITIES OF THE HEAD 

Their treatment is beyond the range of minor surgery, but the 
subject is mentioned here on account of diagnostic importance. 



ACQUIRED DEFORMITIES 

Cicatrices. Cicatricial contractions in the vicinity of the 
eye may so pull upon the lids as to cause their partial eversion or 
prevent the tears from flowing through the tear-duct in a natural 
manner. To relieve this in certain cases plastic operations may 
be performed with more or less success, and even where the eyelid 
has been partially destroyed a substitute may be found in a flap 
of skin taken from the adjacent skin. 

Gicatricial deformity of the lip from a burn of the neck is 
shown in Figure 87 on page 148. 

Nasal Deformities. Deformities of the nose are among 
the commonest disfigurements. When hereditary syphilis attacks 
the nose of an infant or child, or contracted syphilis the nose 
of an adult, it often destroys the cartilage to such an extent 
that there is a hollowing out where normally the bones and 
cartilage should be prominent. The result is often called a 
saddle-nose. 

TREATMENT. Numerous attempts have been made to cure 
these deformities in later life by inserting some rigid substance to 
make good the lack of bony support. Any support which is fixed 
to the bones of the face will soon fail, because of the softening 
of the bones upon which it rests, and its removal will be necessary. 
A far better plan, therefore, when the tip of the nose is not de- 
stroyed, is to insert beneath the skin a boat-shaped piece of cellu- 
loid, the upper surface of which is straight or slightly rounded 
while the under surface is shaped to fit the sunken bridge of the 
nose. If the incision made at the side of the nose for the insertion 
of the celluloid is a small one and made obliquely through the skin, 
the resulting scar will be quite invisible. jSTecrosis of bone will not 
be produced as the periosteum is not disturbed. Before the cellu- 
loid is inserted, a bed is made for its reception by separating the 
skin from the cartilage with an appropriate instrument, a favorite 
one being made like a minute ax upon a very long handle. The 
bed should be so prepared that the celluloid may lie in it easily, 
and no attempt should be made to hold it in position by a bandage 



DEVIATION OF THE SEPTUM OF THE NOSE 



100 



or plaster. If the result is to be satisfactory, the support must rest 
easily in the cavity prepared for it. 

Deviation of the Septum of the Nose. The septum of 
the nose may be deviated to one side, usually as a result of trau- 
matism. One air-passage may be closed thereby. 

TREATMENT. A number of operations have been proposed to 
establish free passage of air through both nasal fossse. The sim- 
plest of all is to punch out a large opening in the septum at its 
most projecting point. The practical result of this is good, but it 
is a permanent deformity, and as such has not appealed to the 
minds of either surgeons or patients. 

Of the many operations which have been devised to straighten 
the septum, two may be mentioned as comparatively simple in 
technic, and likely to yield a good result. A tongue-shaped flap 
of the whole thickness of the septum may be cut from the convex 
side. While it is still attached posteriorly, it should be pushed 




FIG. 66. DIAGRAM OF THE SEPTUM OF THE NOSE, SHOWING THE PORTION' NECESSARY 
TO RESECT SUBMUCOUSLY TO CURE DEVIATION OF THE SEPTUM. 

through the opening in the septum until it lies in the other nos- 
tril. A hollow rubber cone may be placed in the nostril to prevent 
the flap from resuming its original position until healing has taken 
place. 

A newer method is submucous excision. Anesthesia and 
ischemia are produced by the surface application of cocain and 



110 TUMORS AND DEFORMITIES OF THE HEAD 

adrenalin for twenty minutes or more. An incision is made on 
the convex side about a third of an inch posterior to the junction 
of skin and mucous membrane. This incision extends through the 
perichondrium. Through this incision the mucous membrane and 
perichondrium are peeled from the convex surface of the septum. 
The anterior incision is next carried through the cartilage of the 
septum, and the perichondrium is peeled from the concave sur- 
face of the septum. The denuded portion of cartilage is then ex- 
cised with a special knife and scissors. It is usually necessary to 
excise with a small chisel a portion of the nasal spine of the supe- 
rior maxilla, and a portion of the vomer (Fig. 66). In any event 
the resection should be continued until the septum hangs straight 
in .the middle line. The incision is closed with two or three 
sutures. No after treatment is required ; or a little gauze may 
be kept in each nostril for forty -eight hours. It is important to 
preserve both layers of perichondrium, so that a certain amount 
of rigidity may be retained, and in order to avoid subsequent per- 
foration of the septum through atrophv. 

Elongation of the Uvula. A catarrh of the naso-pharynx 
sometimes leads to enlargement and elongation of the uvula. Such 
elongation is a common accompaniment of acute inflammation of 
the throat, and disappears as soon as the inflammation subsides. 
No treatment of the uvula itself is necessary in such cases. It is 
quite another matter when the uvula is chronically so elongated 
that its tip rests constantly on the base of the tongue or even 
reaches to the epiglottis, causing the patient to gag and cough, 
particularly when he lies upon his back. The possibility that a 
persistent dry cough is due solely to uvular irritation should be 
borne in mind. 

Inspection of the throat will show at once whether the 
uvula is long enough to cause irritation. If acute inflamma- 
tion is present one should, of course, wait until this has passed 
over before condoning the uvula, as the elongation may be tem- 
porary. 

TREATMENT. When a uvula is elongated and the cause of 
irritative symptoms, it should be shortened by appropriate treat- 
ment. This means first of all attention to the general conditions 
of health of which the relaxation of the uvula may be only one 
manifestation. Such general causes are indigestion or constipa- 



ELONGATION OF THE UVULA 



111 



tion, too much tobacco or alcohol, over-exertion, bad air at work 
or during sleep, breathing through the mouth, etc. 

Astringent gargles and sprays, or the application directly to 
the uvula of stronger preparations than the patient should handle 
himself, will sometimes result in a cure. Tannic acid, alum, and 
the salts of silver are remedies worth trying. 

If local remedies and attention to the general health fail to 
shorten the uvula sufficiently to cause the disappearance of symp- 




FIG. 67. SCISSORS FOR AMPUTATION OF THE UVULA. 

toms, a portion of the little organ should be removed. This opera- 
tion is a simple one, but it is desirable that the excision should be 
exact, since the removal of too much or too little may subject the 
operator to a good deal of criticism, especially if some symptoms 
persist. The uvula should be anesthetized by the application of 
one per cent cocain on a cotton swab to its anterior and posterior 



112 TUMORS AND DEFORMITIES OF THE HEAD 

surfaces. The tip of the uvula should then be seized with mouse- 
tooth forceps and drawn somewhat forward. A sufficient part of 
the organ is then to be cut away with curved scissors. The part 
removed should extend higher posteriorly than in front. By this 
means the blunt appearance of the uvula is avoided, and the 
wound is placed on the posterior surface and so is less affected by 
swallowing. Unless the uvula is held by forceps during the section 
it is likely to slip from the scissors. A special instrument has been 
made for the purpose which combines the action of the forceps 
and scissors. It is called an uvula scissors (Fig. 67). If hemor- 
rhage follows, it is readily controlled by pressure with a swab wet 
with a solution of adrenalin, or peroxid of hydrogen, or one of 
the other styptics. 

No after-treatment is required other than the use of iced Do- 
bell's solution as a gargle, or some similar alkaline solution, and 
the avoidance of coarse or seasoned articles of diet for a few days. 

CONGENITAL DEFORMITIES 

Harelip and Cleft Palate are common congenital deformi- 
ties. There may be either one or two clefts of the lip and anterior 
portion of the mouth, but the posterior portion of the hard palate 
and the soft palate develop from right and left halves, so that a 
cleft due to imperfect development is invariably single. If the 
harelip is double its central portion is connected with the inter- 
maxillary bone and is attached to the septum of the nose. This 
deformity may be so extreme that even a successful operation pro- 
duces a most unsatisfactory result. The opening may -be closed, 
but the scar and disfigurement which persist are most unsightly. 
If, on the other hand, the development of tissue both of the central 
portion and margins of the clefts has been abundant, it is possible 
to produce something like a normal appearance, even though the 
clefts open into the anterior nares. If the cleft is unilateral and 
exists in the lip only (Fig. 68), a perfect result may be obtained, 
so that it is scarcely possible in after-years to perceive that a hare- 
lip existed. The time for operation has been the occasion of much 
dispute among surgeons, but it is now pretty generally admitted 
that a cleft palate should not be operated upon until the child is 
six or eight years old, whereas a better result is obtained if a 



HARELIP AND CLEFT PALATE 



113 



harelip is operated upon in early infancy, say from the third to 
the sixth month, or even earlier if the cleft in the lip interferes 
with the proper nutrition of the child or causes deviation of the 
nasal septum (Fig. 69). Sometimes, when the child cannot nurse 
from the breast it may take milk from the bottle, or, if not, life 
may still be preserved by pouring milk into its mouth from a 





FIG. 68. HARELIP, THE CLEFT NOT EN- 
TERING THE NOSTRIL. The vermilion 
of the lip extends into the cleft, but is 
much narrower there. 



FIG. 69. HARELIP, THE CLEFT ENTERING 
THE NOSTRIL. Note the deviation of 
the septum, even in this comparatively 
simple case. 



teaspoon, or the feeding may be accomplished by the passage of a 
soft rubber catheter into the esophagus. 

TREATMENT. Jn operating for harelip it is of the first im- 
portance that the vermilion border be accurately approximated, 
and, secondly, that a slight excess of tissue at the suture-line be 
provided; otherwise the contraction which follows in every scar 
will draw the lip upward at the line of suture and a slight notch 
will result. To overcome this, it has been found best to make an 
oblique incision through the vermilion portion of the lip and to 
leave a little fulness at this point. If the power of contraction 
is overestimated it is very easy to reduce this excess at a later 
period of life. The edges of the cleft must be pared so that they 
shall be even, and enough tissue must be removed to make the 
edges to be sutured equal in thickness to the rest of the lip. 

The suturing is very important. Fine black silk is the best 

material for the purpose. There may be a number of stitches 
10 



TUMORS AND DEFORMITIES OF THE HEAD 



which approximate separately the mucous membrane and the skin. 
Or fewer stitches may be employed and passed through the whole 
thickness, or nearly the whole thickness, of the lip. In any case 
the strain should be evenly distributed upon the stitches. Some 
operators employ one or two additional stitches set well back from 
the wound, in order to take the strain off the suture-line. This 
can, however, be accomplished with less disfigurement by placing 
a narrow strip of strong gauze, such as bolting silk, across the lip 
from cheek to cheek, fastening its ends to the cheeks by collodion. 
Another method is to carry two strips of adhesive plaster from the 
cheeks to the forehead. These two strips make an X, crossing over 
the bridge of the nose, and fully relieve tension upon the upper lip. 

The stitches should be removed as early as possible, say in 
three or five days, in order to avoid a prominent scar, but the strain 
on the lip must be prevented for a longer period by one of the 
methods mentioned. In infants operation for simple harelip may 
be done without any anesthetic, or with a very little chloroform. 

Cleft of the Lower Lip. A rare deformity, and one which is 
always single in the median line, is the cleft of the lower lip (Fig. 




FIG. 70. CONGENITAL CLEFT OF LOWER LIP. 

TO). It is easily cured by a V-shaped excision of the cleft fol- 
lowed by suture (p. 101). 

TREATMENT FOB CLEFT PALATE. If the cleft in the palate 
involves only the soft palate, the operation for its relief is very 



TONGUE-TIE 115 

si in | ilc. It consists in paring the edges of the cleft and carefully 
approximating them with many fine black silk sutures. If the 
deft extends also into the bony portion and is not too wide, it 
mav IK- closed by suture of the mucous membrane alone. To make 
this possible, however, it is necessary to make preliminary inci- 
>ions about luil I' ;in inch from the cleft on either side and separate 
the strips of mucous membrane from the hard palate. These two 
strips, right and left, may then be sutured in the middle without 
great tension. 

To close a larger cleft a strip of bone and mucous membrane 
may IK- chiseled from either side and sutured together in the mid- 
dle. If this operation is successful, two small clefts remain which 
can lie closed by subsequent operation. The details of these opera- 
tions will be found in books on major surgery. Complete anes- 
thesia is necessary. 

If it is decided to wait some years before operating for cleft 
palate-, ji plate of rubber should be fitted and worn. This can IHJ 
done as soon as the child has double teeth to which the plate can 
be fastened generally at two years of age. Such a plate facili- 
tates swallowing and is a great help to the child in its efforts to 
talk. 

Thick Lips. Persons with very thick lips sometimes become 
dissatisfied with their appearance and seek surgical aid. An im- 
provement can be accomplished by the removal of an elliptical 
shaped piece, the incisions for which should lie fully within the 
vermilion portion of the lip and should run on either side to a 
very fine point, in order to produce a smooth appearance. 

Tongue-tie. Parents often think their child's tongue is tied 
if he does not learn to talk as soon as the average child. If the 
tongue can be protruded beyond the incisor teeth it is sufficiently 
free for all purposes. If the frenum of the tongue is really short 
it will pull upon the tip of the tongue and produce a cleft in the 
tip when an attempt is made to extend the tongue. If this is the 
case, the tongue should be lifted and the frenum snipped with scis- 
sors. The reverse end of the surgical instrument called a grooved 
director is often made with a notch, so that when one uses it to 
lift the tongue, the frenum may slip into it and be firmly held 
while the surgeon makes the necessary division. Backwardness 
in acquiring speech is, of course, dependent on other causes. 



116 



TUMORS AND DEFORMITIES OF THE HEAD 



Deformities of the Ear. The lobe of the ear may be cleft 
(Fig. 71). A rather commoner deformity is reduplication of 
some portion of the auricle (Fig. 72). The occurrence of sinuses 





FIG. 71. CONGENITAL, CLEFT OF LOBE 
OF AURICLE. 



FIG. 72. CONGENITAL DEFORMITY OF 
EAR. 



in front of the meatus has been spoken of on page 76. Many of 
the deformities of the auricle may be remedied by plastic opera- 
tions. 



SECTION II 
AFFECTIONS OF THE NECK 



CHAPTER IV 
INJURIES AND INFLAMMATIONS OF THE NECK 

Contusions. Contusions of the neck, if serious, are so be- 
cause of the injury to the deeper structures. They are usually the 
result of accidental or attempted strangling. The skin of the neck 
is tough and freely movable, and if it is pressed against any un- 
derlying bone, it may escape injury, even though some deeper 
structure such as the hyoid bone or larynx be broken. An example 
of this is seen in cases of wheel injury. The wheel of a vehicle, 
especially if rubber-tired, may pass over the neck and even break 
one or more of the vertebra? without leaving any mark externally. 

Foreign Bodies. A foreign body, such as a morsel of food 
or some harder substance, may lodge in the larynx, trachea, or 
esophagus. (For foreign bodies in mouth and pharynx see page 
12.) The symptoms vary all the way from a slight irritation 
and discomfort on swallowing, to complete strangulation and in- 
tense pain, depending on the shape and characteristics of the for- 
eign body and the particular position which it occupies. 

TREATMENT. Even when the symptoms are not alarming the 
foreign body should be removed as promptly as possible, in order 
to save the patient from the inflammation which is likely to follow 
its presence, and which may by its swelling completely occlude 
the air-passages. The patient's efforts coughing, gagging, and 
vomiting may expel the foreign body, or it may be extracted by 
a finger passed well down the throat. If these simpler means do 
not suffice, the pharynx and larynx should be inspected with a 
laryngeal mirror in a good light, and the foreign body extracted 
with forceps. If the patient lies on his back, with the head lower 
than the shoulders, extraction is facilitated. A child may be 

117 



118 INJURIES AND INFLAMMATIONS OF THE NECK 

turned upside down in an effort to shake out the foreign body, but 
only for a few moments. If respiration is seriously interfered 
with and does not improve, tracheotomy is indicated (p. 119). 

If the foreign body has entered the esophagus, it is likely to 
be arrested by the projection of the cricoid cartilage. In this case 
it may still be extracted by forceps introduced through the mouth. 
If it is of such a nature that it is safe to allow it to enter the 
stomach, the patient should try to crowd it forward by swallowing 
pultaceous material, such as well chewed bread. If the foreign 
body passes the cricoid it may be arrested at the cardiac orifice of 
the stomach. This has happened a number of times when artificial 
teeth have been swallowed. This condition will usually require a 
gastrotomy. Time may be taken for this, however, as the imme- 
diate distress ends with the passage of the foreign body to the 
lower portion of the esophagus. 

If the foreign body is in the trachea or still lower in one of 
the bronchi, it may be extracted through the natural passages 
through an opening made in the trachea (tracheotomy, see p. 119), 
or through an opening made directly into the bronchus. This last 
will, of course, not be attempted unless the body has been exactly 
located by means of the X-ray. It will always remain one of the 
rare major operations, the details of which need not be here dis- 
cussed. After the foreign body has been removed, the patient 
should gargle with normal saline solution, or use an alkaline throat 
spray (Dobell's solution, glycothymolin, etc.). 

Wounds. Wounds of the neck, especially stab-wounds, are 
relatively common. Their interest, too, centers in the injury to 
the deep structures which may coexist. The jugular vein may be 
opened by a stab-wound or by a cut, as with a razor. Edema of 
the lax tissues may speedily become distressing. Death from hem- 
orrhage is easily possible. Attempts at suicide with a razor often 
extend no deeper than the jugular vein, although there are in- 
stances in which an individual has succeeded in dividing most of 
the structures of the neck as far back as the vertebra?. A cut, even 
though much less extensive, may open the air-passages, usually 
between the hyoid bone and the thyroid cartilage. 

TREATMENT. Experience has shown that an incised vein may 
be sutured and its continuity restored, but it is scarcely worth 
while to attempt this with the external jugular, as interruption of 



WOUNDS 119 

its blood current has no significance. In general the decision 
should he to ligate all the large vessels, to suture with catgut any 
opening into the air-passages, and to provide for the subsequent 
performance of tracheotomy should the breathing become difficult 
through swelling of the larynx. These steps may all be performed 
under the influence of a local anesthetic unless the patient, very 
likely insane, refuses to remain quiet. 

It is better not to trust to pressure to control hemorrhage ex- 
cept in the most superficial wounds. Pressure may stop the flow of 
blood at the surface, while allowing it to continue in the deeper 
planes of tissue. This is especially true in the case of irregular 
or punctured wounds, which should be immediately explored to 
their depths, even though it is necessary to enlarge the wound in 
the skin. Veins as well as arteries should be ligated with fine 
catgut. 

Wounds of the Esophagus. A stab-wound of the neck, without 
giving rise to serious symptoms, may penetrate the esophagus. 
l T n<ler such circumstances there will be a slight mucous discharge 
to which may be added milk, water, etc., when the patient swal- 
lows these fluids. Such a wound, if it has good drainage, will 
generally close spontaneously in the course of two or three weeks ; 
but one should be on his guard against infiltration of the deeper 
tissues or a burrowing of pus and food along some fascial plane. 
If necessary the external wound must be enlarged to afford free 
drainage. 

If the opening into the esophagus cannot be satisfactorily 
sutured, a soft rubber tube should be passed into the lower por- 
tion, through which the patient can be fed temporarily until the 
wound has time to close by granulation, or permanently, if the loss 
of the wall of the esophagus is permanent. 

Tracheotomy. Tracheotomy performed upon a normal adult 
is ;i simple operation. A vertical incision is made in the median 
line from the cricoid cartilage downward for a distance of an 
inch or more. This wound is deepened until the surface of the 
trachea has been bared in the median line for about an inch. A 
scalpel is then passed through the anterior wall of the trachea. 
The sides of the incision are separated by means of sharp hooks 
or an especially devised dilator, and the tracheotomy tube is in- 
serted. The whole procedure may be performed without an assist- 



120 INJURIES AND INFLAMMATIONS OF THE NECK 

ant, and in case of need an opening has been made with a jack- 
knife and death from strangulation thus averted. In an infant 
struggling for air and violently moving its larynx up and down, 
the operation is far more difficult. The principles are the same, 
but the neck is so short that exposure of the trachea for a sufficient 
distance and its division in the median line are by no means easy. 
In adults, under circumstances in which an emergency opera- 
tion is necessary, the distance from the skin to the trachea is often 
greatly increased by edema, extravasation of blood, and venous 
congestion. 

The instruments which are essential for this operation are a 
dissecting and mouse-tooth forceps, scalpel, scissors, artery clamps, 
small, sharp and blunt retractors, a curved dressing forceps or 
a specially constructed tracheal dilator, and a tracheotomy tube 
(Fig. 73). The patient lies upon his back with the neck fully 
.extended over a hard pillow or sandbag. An incision is made in 
the median line from the cricoid cartilage downward for an inch 
and a half. Veins as they appear should be divided between 
clamps, of clamped as they are cut, until the trachea is reached. 
The isthmus of the thyroid should be drawn upward. If time per- 
mits, all hemorrhage should be controlled before the trachea is 
opened. This is done by a median vertical incision for a distance 
of three-quarters of an inch. The walls of the trachea are held 
apart by two narrow blunt retractors or by the tracheal dilator. 
Mucus or a possible foreign body is sponged away or removed by 
means of a curved dressing forceps, and the tracheotomy tube is 
inserted. The wound in the soft parts, if unnecessarily large, 
should be partly closed by suture. A flat collar of gauze, impreg- 
nated with some antiseptic, should be placed between the shield 
of the tube and the wound, while the tube itself is held in position 
by two tapes tied at the back of the neck. A moist sponge should 
be kept over the mouth of the tube in order to keep the inhaled 
air warm and moist. 

Upon the care of a tracheotomy tube depends in no small meas- 
ure the early cure of the patient. Mucus may be removed from 
the tube by a small wisp of wet cotton on a bent probe. If the 
tube is a single one, it should be removed and cleaned at least once 
a day. The wound should be frequently cleansed. Only the mild- 
est antiseptics are permissible in such a situation. A double tube, 




s 5 



121 



122 INJURIES AND INFLAMMATIONS OF THE NECK 

while leaving less space for the air, has the advantage that the 
inner tube can be removed at any time without disturbing the 
wound, and it can always be replaced without difficulty. Tubes 
are also made in such a manner that either the outer or inner tube 
can be removed and replaced without disturbing the other. Thus 
the tube left in place acts as a guide for the insertion of the 
other. 

Intubation. This little operation consists in the introduc- 
tion into the larynx of a rigid tube so as to permit respiration to 
go on in spite of swelling, or an accumulation of mucus or mem- 
brane, which might close the glottis. It is chiefly performed in 
cases of diphtheria. With the ingenious instrument devised by 
O'Dwyer, the introduction of the tube is comparatively simple. 
The patient is held firmly in an upright position, the mouth gag 
is inserted, and the forefinger of one hand is passed into the throat 
until the tip of the epiglottis can be felt. With this finger as a 
guide, the tube is passed into the larynx. The instrument with 
which the tube was introduced is then released and withdrawn, 
the finger holding the tube in position meanwhile. As a precau- 
tion against mishaps, the tube may be threaded on a long loop, 
and the thread removed only when the operator is sure the tube is 
in position. 

In removing the tube, the patient is again placed in an upright 
position, the mouth gag is inserted, and the forefinger passed into 
the throat until the tube can be felt. It acts as a guide to the 
extracting instrument. The withdrawal of the tube is more diffi- 
cult than its insertion, so that if a tube is inserted merely as a 
temporary measure, it is well to leave the loop of thread in posi- 
tion to facilitate extraction. If this is done the loop ma^ be fas- 
tened over the patient's ear. 

Sprain of the Cervical Spine. The lower portion of the 
spine is more often the seat of sprain than is the upper portion. 
This may be due to the greater flexibility of the Cervical* spine. 
However, sprain of the neck is by no means uncommon. It: may 
follow falls or blows of various sorts. ,' 

The symptoms are pain and tenderness, especially when' certain 
movements are made, against which the patient often protects him- 
self by muscular contraction. External signs, such as. edema and 
ecchymosis, are usually wanting. There is no true deformity) al- 



FRACTURES 123 

though the patient for his own comfort may keep the head out 
ef the median line. Thus an injury of this sort, if not properly 
treated, may lead to wryneck. Symptoms of shock may be pres- 
ent, but are usually wanting in cases of simple sprain. 

DIAGNOSIS. The essential point in the diagnosis is not to over- 
look a more serious injury, such as fracture, or injury of the cord, 
received at the time of accident, or due to pressure of the hema- 
toma. Hence the patient should be carefully examined, the ex- 
tent of the various normal motions of the neck tested and recorded 
(for the method see p. 162), possible paralysis, either sensory or 
motor, investigated, and any other symptoms noted. This is the 
more important in cases of spinal injury, out of which damage 
suits may arise. 

The possibility that a dislocation has occurred and has been 
spontaneously reduced should also be borne in mind. The chief 
significance of this is the damage to the cord which may have 
occurred through undue pressure. Another possibility to be 
thought of is commencing tuberculosis. 

TREATMENT. Treatment consists in rest in a correct position, 
with hot or cold applications to relieve pain. Later, massage and 
passive and active motions should be instituted in order to regain 
the full range of motion. If the patient has a tendency to hold 
the head in an abnormal attitude, this should be corrected, even 
though it is necessary to give an anesthetic and to apply a plaster 
of Paris bandage to the head, neck, and chest. This should not 
be continued very long, lest stiffness result. It is therefore better 
to remove it in a week, and to begin treatment by manipulation. 

Fractures. Fracture of the Hyoid Attempts at strangula- 
tion may cause fracture of the hyoid bone. The usual symptoms 
of fracture, pain on motion, swelling, and ecchymosis, are present 
but may be rather slight. In case of the hyoid bone, crepitus will 
probably be obtainable. To these ordinary symptoms there may 
be added pain on swallowing, or cough, or swelling of the larynx 
so great that tracheotomy becomes necessary. If no displacement 
is present, the parts will unite without treatment. If there is 
displacement, it is better to make an incision and suture the 
fractured cartilage or bone with catgut, so as to avoid deformity. 
No apparatus is required to hold the fractured ends in normal 
position if there is no tendency to displacement, but a few strips 



124 INJURIES AND INFLAMMATIONS OF THE NECK 

of adhesive plaster or immobilization of the head will give the 
patient comfort. 

Fracture of the Larynx. In fractures of the larynx the thyroid 
cartilage is usually involved; the fracture may or may not he 
complete. As the mucous membrane of the larynx is often rup- 
tured, blood flows into the trachea and excites a most painful 
cough. Swallowing and talking are also painful. The thyroid 
is flattened; there is marked edema, and frequently emphysema. 
If the fracture is complete, crepitus is easily obtained. 

This is a very dangerous injury, statistics showing that more 
than one-third of the. patients who suffer from it die. As death 
usually comes during an attack of dyspnea, tracheotomy should be 
immediately performed, except possibly in simple cases when the 
patient is so situated that tracheotomy can be performed at a 
moment's notice. Subsequent treatment should be directed toward 
keeping the fracture aseptic, controlling hemorrhage, and prevent- 
ing stenosis. To accomplish these measures it is often necessary 
to perform laryngotomy. 

Fracture of the Trachea. This injury occurs less often than 
fracture of the larynx. The symptoms in general are similar. 
Dyspnea and emphysema are the most alarming ones, and are fre- 
quently the cause of death ; or death may follow at a later period 
from inhalation pneumonia. 

The treatment is similar to that recommended for fracture of 
the larynx. If there is no dyspnea and no emphysema, trache- 
otomy may be deferred, but the patient should be kept under strict 
observation for several days. 

Fracture of the Cervical Spine. Fracture of the cervical ver- 
tebras may be due to direct violence, but it is generally the result 
of blows or falls upon the head. It is not necessarily fatal, but is 
often accompanied by injury of the cord sufficient to terminate 
life either immediately or after the lapse of a few weeks. The 
symptoms are the usual ones of fracture, namely, pain on pres- 
sure and on manipulation, abnormal mobility and crepitus, pos- 
sibly swelling and ecchymosis. Some of these symptoms may be 
masked by the numerous strong muscles which surround the ver- 
tebrae, and which are kept contracted to prevent the pain due to 
motion of the neck. 

The cord is usually injured, either pressed upon, or partly or 



CELLULITIS AND ERYSIPELAS 125 

wholly crushed. There is, therefore, almost always more or less 
paralysis, sensory or motor, or both. 

Prognosis, on account of the injury to the cord, is bad, worse 
than when the lumbar spine is fractured. 

TREATMENT. If no cord symptoms are present, treatment con- 
sists in the immobilization of the spine, possibly with extension 
and counterextension. If there is a partial or complete paralysis, 
the spinal canal should be opened posteriorly (laminectomy), and 
depressed fragments of bone or compressing blood-clots removed. 
Unfortunately the paralysis is usually due to crushing of the cord 
at the time of the accident, and not to pressure. Hence it is only 
occasionally that an operation benefits the patient. 

Dislocation of Vertebrae. This injury may be due either 
to direct violence or to a fall. If the dislocation is complete, it is 
often found to be associated with fracture and to have produced 
fatal lesions of the cord. There are instances, however, in which 
dislocation is only partial and in which the cord escapes serious in- 
jury. This is especially true when a partial dislocation takes 
place betw r een the axis and atlas. Such a patient may escape 
paralytic symptoms and may live with the dislocation unreduced. 

TREATMENT. If the head and body are pulled strongly apart 
and the neck is manipulated, the dislocation may be reduced. 
This procedure is not without risk of sudden death. It should 
be performed with the greatest steadiness and gentleness, prefer- 
ably under an anesthetic. Otherwise the treatment consists in 
in i mobilization of the neck, followed by massage and manipula- 
tions (compare the treatment for Sprain, page 123). 

INFLAMMATIONS 

Burns. The neck is often the seat of severe burns, especially 
when the clothing catches fire. Such burns, if deep, are likely 
to result in deforming contractures, even to the extent of draw- 
ing the chin down upon the chest (Fig. 87, p. 148). For the 
treatment of burns see page 26. Contraction should be prevented 
by keeping the burned area extended during healing by means of 
a plaster of Paris splint fitted to the opposite side of the neck. 

Cellulitis and Erysipelas. Superficial cellulitis and ery- 
sipelas occurring in the neck present no peculiar features. For 



126 INJURIES AND INFLAMMATIONS OF THE NECK 

description and treatment of these disorders see pages 33 
and 35. 

Boil. The back of the neck is a favorite seat for boils. A 
furuncle or boil is a local suppuration due to staphylococci. The 
inflammation begins in the skin usually at the root of a hair. 
There is a purulent center, surrounded by a red, edematous area. 
The swelling and pain vary. Sometimes the inflammation is so 
intense that necrosis of the deeper portion of the skin takes place. 
This necrotic slough is called the " core " of the boil. If the 
boil forms where the skin is delicate, the pus very soon breaks 
through to the surface. In the back of the neck, where the skin 
is often a quarter of an inch thick, it is sometimes several days 
before the necrotic center of the boil, popularly called the core, 
becomes softened and separated from the surrounding skin, so that 
the contents of the boil are able to discharge themselves spon- 
taneously; and sometimes, instead of discharging on the surface, 
the pus finds its way into the subcutaneous fatty tissue, forming 
an abscess there. A boil does not tend to spread beyond its 
immediate vicinity, and after its discharge it usually goes on to 
recovery without giving rise to other than a local cellulitis. The 
process, however, is apt to be repeated, often many times, in the 
vicinity of the first lesion, each new boil developing separately as 
if it were the only one, from infection through the hair-follicles, 
due to the smearing of pus on the surface. 

TREATMENT. The best treatment is to evacuate the abnormal 
products already formed and to hasten or cut short the patho- 
logical process. At the back of the neck the skin is thick and the 
inflamed area is proportionately great, so that the introduction 
of a drop of carbolic acid will not usually stop the infection, as it 
often will in case of a small boil of the face (p. 36). Most sur- 
geons still follow the domestic plan of poulticing such a lesion for 
a couple of days until there is a well marked center to the suppura- 
tion. This poultice treatment is generally continued too long. To 
keep up the poultices until there is simply a soft pus-sac to be 
opened simplifies the operation, but it prolongs unnecessarily the 
sufferings of the patient, and by increasing the size of the cavity, 
which has to be closed in healing, it delays ultimate recovery. In 
most instances, as early as the second day, it is possible to say 
where the center of the boil is located, and if a short incisiou 



CARBUNCLE 127 

is made clear through the skin at this point and a wet dressing 
is applied, not only will the patient be saved one or more days 
of intense suffering, but the inflammatory process will rapidly 
subside and there will be very little necrosis of the skin to be 
made good by the growth of the new tissue. Any violent attempts 
at curetting or squeezing out the necrotic tissue or pathological 
products are to be condemned, as these substances will come out 
of themselves in a few hours, while the violence adds somewhat 
to the sum total of injured tissue and may set up a severe cellu- 
litis. A strip of rubber tissue or gauze should be inserted to favor 
the escape of pus. 

An injection of cocain or eucain directly into the inflamed 
skin over a boil is a very painful proceeding. It is therefore bet- 
ter to begin the anesthetization at a little distance from the in- 
flamed area, so that as new punctures are made nearer the center 
they shall enter tissue in which sensation has been benumbed. It 
is in operations of this character that a freezing spray of ethyl 
chlorid proves satisfactory. For other details of treatment see 
Chapter XX. 

The after-treatment of a boil is simple. The wet dressings 
should be continued for a couple of days, until the discharge is at 
u minimum, when an ointment, such as balsam of Peru, one 
part, vaseline, eight parts, may be substituted. 

The advantages of the poultice may be obtained without its 
disadvantages by applying heat to the outside of the wet dress- 
ing. For this purpose a hot-water bag or bottle, or a hot brick 
or flat-iron, may be used. It is easy to produce and maintain as 
high a temperature as the patient can stand, by changing the^ 
bottle as soon as its temperature falls. In this manner the gradual 
cooling of the poultice and discomfort and trouble of its renewal 
are avoided. 

Carbuncle. A carbuncle is a suppuration which, unlike that 
of a boil, has a tendency to spread laterally through the cutane- 
ous tissues. Local abscesses are formed in the various hair-folli- 
cles, and the interstices of the skin become saturated with pus, and 
there is an extensive cellulitis with necrosis of more or less of 
the true skin, besides the usual symptoms of infection (Fig. 74). 
A carbuncle also extends downward, and the subcutaneous fat is 
usually involved in all except very mild cases. From this brief 



128 

description it appears that an extensive carbuncle is a serious 
trouble which not infrequently terminates fatally. 

TREATMENT.' It is important that incisions should be made 
through the skin before the process has extended widely. As 
many as possible of the small abscesses should be opened by the 
incisions, which may be made at intervals of one-fourth or one- 




FIQ. 74. CARBUNCLE OF NECK. Note the flat top, and several points of 

suppuration. 

third of an inch, both vertically and horizontally; or they may 
radiate from a central point (Fig. 75). Some few surgeons ad- 
vocate the complete excision of a carbuncle, but this causes the 
loss of an unnecessary amount of tissue. A compress wet with 
a strong antiseptic solution should be applied and kept hot in 
the manner "described above. It may be necessary on the follow- 
ing day or at a later period to make other incisions to permit the 
escape of newly formed collections of pus. Figure 76 shows the 
outcome of a very bad case. 




FIG. 75. CARBUNCLE OF NECK. Duration, four weeks; incised three times, gangrene 
of one flap. Scar from similar operation for carbuncle twenty years previous. 
Patient aged fifty-two years. 




FIG. 7G. SAME PATIENT AS SHOWN IN Fi<;. 7 it, iinr ELEVEN WEEKS LATER. 
11 129 



130 INJURIES AND INFLAMMATIONS OF THE NECK. 

Abscess. Abscesses may also form in the neck as the result 
of infection in some other situation. This is notably the case in 
neglected children, who scratch their heads to find relief from the 
itching set up by pediculi. The epidermis is broken, a slight 
cellulitis results in the scalp, and the infection follows the lym- 
phatics to a cervical gland and produces an abscess in the neck 
(Fig. 77). It is usually possible to find the starting-point of 
the infection under STich circumstances. Such an abscess is 
wholly subcutaneous and is not possessed of the virulence either 
of the boil or the carbuncle. It should be opened and treated 
according to the plan laid down for abscesses of the scalp (p. 34). 




FIG. 77. ABSCESSES OF NECK. Duration two weeks, secondary to pediculosis capitis, 
occurring in a child of two years. 

The pediculi should be removed to prevent recurrence of the 
trouble. Applications of benzin, or kerosene, or tincture of 
delphinium and ether, followed by a shampoo, will accomplish this. 

Deep suppuration of the neck, due presumably to infection 
from the mouth, sometimes develops rapidly. In a day or two 



ABSCESS 131 

the whole front or side of the neck may be swollen, brawny, 
:unl, later, saturated with pus, while chills and fever show the 
<f the affection. This trouble has often been called 
Linlor'n-'i, It deserves early radical treatment or it may 




FIG. 78. ABSCESS UNDER STERNOMASTOID MUSCLE. Six months' duration; 
probably tubercular. Patient aged fifty-six years. 

speedily lead to a fatal termination. The tension should be re- 
lieved by incisions sufficiently numerous and deep to open any 
pockets of pus and allow the escape of the greater part of the 
exuded fluid. If operation is delayed until the whole front of the 
neck is involved, the prognosis is decidedly unfavorable. 

A slowly forming deep abscess of the neck may be due to 
breaking down of a tuberculous gland (Fig. 78), or to a mixed 
infection in case of syphilitic ulcerated throat. Abscess of the 
cervical lymphatic glands secondary to alveolar abscess, is spoken 
of on page 42. 



132 INJURIES AND INFLAMMATIONS OF THE NECK 

Anthrax. Anthrax or malignant pustule is a disease not 
common in this country. It usually develops in a man who has- 
been handling infected hides. The first lesion appears upon the 
hand or some part of the body that the hand has touched. It 
is a hard, raised, flattened, reddish nodule, with a surrounding 
zone of more or less indurated cellulitis (Fig. 79). It shows little 




FIG. 79. THE PRIMARY LESION OF ANTHRAX. Diagnosis confirmed by microscopical 
examination of discharge from the ulcer, and of the blood. 

tendency to necrose in the central portion. The constitutional 
symptoms are severe and out of proportion to the local mani- 
festations, although they may not become so until several days 
after the infection has taken place. The diagnosis can only be 
made with certainty by an examination of the serum and blood 
obtained from the pustule. The anthrax bacillus is large and 
has square ends, like the segments of a mature tapeworm, so that 
it is readily recognized in a stained smear by a simple micro- 
scopical examination. As confirmatory evidence, cultures should 



CERVICAL TUBERCULOSIS 133 

he made. The bacillus grows readily upon any of the common 
en It u re media. If a positive diagnosis is made, the local lesion 
should he immediately excised. Further operative measures are 
i:enerally useless, as the disease spreads through the blood as well 
us through the lymphatic system. A fatal termination is common, 
hut. is by no means invariable, so that life should not be despaired 
of at once. 

Cervical Tuberculosis. Tuberculosis in the neck is situ- 
ated either ill the lymph-glands or in the spine. Tubercular 
lymphadenitis is described, with other enlargements of the glands, 
on page 142. 

Tuberculosis of the bones of ilia neck or cervical Pott's dis- 
ease, as it is called, is a condition which in its early stages is apt 
not to he recognized. fKvmg to the fact that the spines of the 
yertehra- are not so plainly to be felt as those in the back and in 
the lumbar region, the diagnosis is not so simple as it is in the 
latter situations. The first symptoms noticed are pain, stiffness, 
and rigidity of the neck. Later there is swelling of a diffuse 
character, making the neck somewhat thicker than before. There 
is great pain when the neck is bent, either by the patient or by 
the examiner. The trouble may be differentiated from acute sup- 
puration by the gradual onset of the disease, by the low fever, and 
the iibsenee of surface heat, edema, and redness. From wryneck 
and the acute myositis which precedes wryneck, it can be differen- 
tiated by the situation of the swelling. In cervical Pott's the 
swelling is in variably in the median line, though it may extend 
more to one side or the other. In myositis or wryneck the swelling 
is lateral or well to the front. In wryneck the chin is directed 
away from the side on which the sternomastoid muscle is prom- 
inent. In cervical Pott's the chin is directed toward the affected 
side. In wryneck correction of the deformity is prevented by the 
bauds which spring into marked relief when correction is at- 
tempted. In cervical Pott's an attempt to correct the deformity 
is painful, and will be resisted by the hands of the patient. 

TREATMENT. The object of treatment is to obtain relief 
from the weight of the head and to keep the parts at rest. This 
is accomplished by an apparatus known as a jury-mast which lifts 
the weight of the head by a strap placed under the occiput and 
under the chin. The instrument rests upon the back and shoul- 



134 INJURIES AND INFLAMMATIONS OF THE NECK 

ders and is secured in place either by straps or by a plaster of 
Paris bandage. Whether the disease will be arrested or progress- 
to an unfavorable termination will depend upon the age of the 
patient, the hygienic surroundings, etc., more than upon local 
treatment. 



CHAPTER V 
TUMORS AND DEFORMITIES OF THE NECK 

TUMORS 

Sebaceous Cyst. This variety of tumor is found in the 
skin of the front and back of the neck, but with less frequency 
than upon the head. It presents no peculiarities on account of its 
situation, so that what has been said of the diagnosis and treat- 
ment of sebaceous cysts of the head is applicable here (see p. 66). 

Thyroid Cyst. (See Goiter, p. 145.) 

Thyreoglossal Cyst. The region of the larynx is a favor- 
able site for congenital cysts and sinuses developing from some 
remains of the thyreoglossal duct, which at an embryological pe- 
riod extends from the base of the tongue through the hyoid to the 
thyroid cartilage. If the remains of such a duct open externally, 
one or more sinuses will persist and will discharge mucus. If the 
remains of the duct do not open externally or into the mouth, the 
secretion may give rise to a cyst containing mucus. Such a cyst is 
easily opened and its contents evacuated, and the sutured skin will 
heal per primam. In the course of a few days or weeks, however, 
the fluid will reaccumnlate and the tumor will reappear. In order 
to avoid this unpleasant result the treatment should be thorough. 
The scar following an unsuccessful attempt to remove a thyreo- 
glossal cyst is shown in Fig. 80. This also shows the situation of 
the original sinus or cyst. If a sinus exists, it is invariably in the 
median line. 

TREATMENT. The only successful treatment is the complete 
removal of the cyst and its duct. The situation is a conspicuous 
one and it is desirable to leave as small a scar as possible, yet the 
dissection must be deep enough to expose the abnormal tissue, both 
above and below the hyoid bone if need be. The skin should be 
cocainized or the patient given a general anesthetic. The incision 

135 



136 



TUMORS AND DEFORMITIES OF THE NECK 



should be made directly in the median line and more above than 
below the center of the tumor, as it is necessary to follow it up-' 
ward. The dissection and removal of a rounded cyst is easy ; that 
of a narrow sinus is more difficult, since it is often impossible to 
recognize it when it becomes attenuated. Even when there is a 




FIG. 80. THYREOGLOSSAL, CYST; OPERATION; RECURRENCE. Note the position of 
the cyst in the median line just below the hyoid bone. . 

well marked cyst, an inconspicuous sinus often leads from its 
upper part. It has been suggested that such a sinus be injected 
with a solution of methyl blue, so that the operator may follow 
it more readily. 

When the congenital tissue has been followed to the hyoid 
bone there will often be found a perforation of the bone. The 
lining of this should be curetted away, and if the sinus exists 
above the hyoid it should be followed and removed. When this 
has been done, the patient will have been given the best chance 
against recurrence, but a guarded prognosis should be given. The 
wound should be sutured entirely, or over a minute drain in its 
lower angle. 



LiroMA 137 

Branchiogenic Cysts and Sinuses. Other 0.1 ig< -iiiial cysts 
and sinuses may IK- found in the sides of the neck, having de- 
veloped from the remains of the branchiogenic clefts, or at tlie 
base of the ear and posterior to it. These tumors are some- 
limes made up of a few larger cysts and innumerable smaller 
ones, and contain either a clear serous fluid or one made tliieker 
by the presence of muehi and other albuminous substances. They 
are benign in character, but on account of the deformity and their 
tendency to keep on growing they should be removed as thoroughly 
as possible. 

In making a diagnosis of a lateral cervical cystic tumor, 
aneurism of the carotid or one of its branches should always be 
considered. One thinks at once of expansile pulsation as a means 
of differential diagnosis. It should be borne in mind that if a 
tumor, cystic or solid, lies upon the carotid artery it receives an 
impulse from the arterial beat. This impulse may be mistaken 
for expansile pulsation unless a careful examination is made. 

Lipoina. A fatty tumor or lipoma is probably the com- 
monest solid tumor of the neck. It occurs in three forms: simple, 
diffuse, and intermuscular. 

A simple lipoma is a well encapsulated tumor lying in the 
subcutaneous plane of fascia. It seems to form a part of the sub- 
en taneous fat, but it soon exceeds this fat in thickness and is usu- 
ally covered by a thin layer of this fat. It may be found in any 
portion of the neck (Fig. 81). It tends to grow larger, and this 
causes an ever-increasing deformity. This is the one reason for 
its removal. 

TREATMENT. A local anesthetic is sufficient unless the pa- 
tient is very sensitive. The incision in the skin should usually 
be parallel to or lie in one of the circular wrinkles of the neck. 
A transverse incision is also preferable if the tumor is situated 
at the back of the neck. The incision should be deepened until 
the capsule of the tumor is plainly seen. This is usually covered 
by some normal subcutaneous fat, and if the operator attempts to 
dissect out the tumor before the true capsule is reached, the diffi- 
culties are unnecessarily increased and a ragged cavity will result. 
When the correct plane is reached the whole tumor can be quickly 
shelled out with blunt dissection either with the fingers or with 
closed, blunt-pointed, curved scissors. There is scarcely any bleed- 




FIG. 81. SIMPLE LIPOMA OF THE NECK OF Two YEARS' DURATION. 




Fio. 82. DIFFUSE LIPOMA OF THE NECK. This tumor was symmetrically bilateral. 
One portion was removed five days before the photograph was taken. 
138 



139 

ing, but the wound should he inspected for it, and if any Weeding 
vessel exists, it should be ligated with fine catgut lest a hematoraa 
fill the cavity left by the removal of the lipoma, and for a time 
continue the deformity. The wound should be completely sutured 
with horsehair or fine black silk and elastic pressure applied by 
means of a gauze and cotton dressing and a firm bandage. This 
may be removed in three days and any small dry dressing be 




FIG. 83. FIBROMA OF NINE YEARS' DURATION, APPARENTLY STARTING IN THE 
FASCIA ABOUT THE STERNOMASTOID MUSCLE. 



reapplied. The stitches should be removed one-half on tin- 
fourth day and one-half on the sixth day, or sooner if the wound 
is a small one. 

Diffuse Lipoma. The second variety of lipoma develops in con 
nection with the deep fascia. It is not encapsulated ; it contains 
more fibrous tissue than the other two varieties, and its removal 



140 



TUMORS AND DEFORMITIES OF THE NECK 



is difficult and unsatisfactory. It usually develops symmetrically 
on both sides of the neck (Fig. 82). Fortunately it is rare. 

Intermuscular Lipoma. The third variety of lipoma develops 
in the fascia between the muscles. It is found in the neck, trunk, 
and extremities. In structure it resembles the simple lipoma, 
being made up of lobules of almost pure fat, each surrounded by 
a complete delicate capsule. The dissection for its removal is 
therefore easy, but the extensive ramification of the tumor between 
the various muscles sometimes makes necessary a pretty long 
wound. 

Fibroma. A pure fibroma, wholly subcutaneous, is not a 
very common tumor in any portion of the body. Such a ono de- 
veloping slowly in 
connection with the 
left Bternomaatoid 
muscle is shown iu 
Figure 83. It wns 
removed without, dif- 
ficulty, being fully <>n- 
r;i]isiihited (Fig. 84). 
Enlarged Lym- 
phatic Glands. - 
Acute Lymphadenitis. 
The most common 
tumor of the neck is 
n swollen lymph- 
gland. In the strict 
use of the term this 
is not a tumor at all 
but an inflammation, 
a lymphadenitis. But 
for clinical reasons it 
is well to class these 
enlarged glands with 
the tumors. The cer- 
vical glands are especially liable to swell on account of infection 
from bad teeth, or from throat troubles, such as ulcerated tonsil, 
or from inflammation in or about the ear, as well as from infected 
wounds of the skin. A very common source of lymphadenitis of 




FIG. 84. SAME SUBJECT AS FIG. 83, SHOWING THE 
TUMOR AFTER REMOVAL. It was fully encapsu- 
lated and easily removed. 



ENLARGED LYMPHATIC GLANDS 141 

the posterior cervical glands in children is pediculosis capitis. The 
child scratches the scalp to relieve itself of the intolerable itching, 
the scratches become infected, and the glands swell. An extreme 
case in which the glands have broken down and two large abscesses 
have resulted is shown in Figure 77, page 130. 

Whatever the source of infection, the glands lying in the 
path of the afferent lymph-vessels will become inflamed. One or 
more of them swells until it presents itself as a smooth, round, 
movable tumor, above which the skin is also freely movable. If 
the severity of the inflammation causes the gland to break down, 
fluctuation is obtainable and the inflammation extending to the 
skin will prevent movement of the latter over the gland. Later 
the abscess may break through the skin. Often, however, the 
infection, being of a milder character, does not extend beyond 
the capsule of the gland, and the acute symptoms of infection are 
wanting in the periglandular tissue; or the inflammation in the 
glands themselves may be of a more chronic form. In such a 
case the swelling of the gland wall be painless, and there will be 
little tenderness even on pressure. 

One should never be satisfied with a diagnosis of simple 
lymphadenitis. The source of the infection should also be de- 
termined. If no 'cause for the swelling of the gland can be 
ascertained, the possibility of tuberculosis should be kept in 
mind. 

TREATMENT. If the infection of the gland has not proceeded 
to demonstrable suppuration, the attention may be directed to the 
prevention of further infection by the treatment of the infected 
teeth, or sore throat, or w r ound of the skin. When the source of 
infection has been shut off, acute lymphadenitis will take care of. 
itself in many cases. 

If fluctuation can be made out in a gland, the process will 
rarely undergo resorption without a discharge of pus. In such 
cases it is better therefore either to drain the gland or to remove 
it entirely if this can be readily done. For if the glandular tissue 
is riddled with pus and germs, but has not necrosed, the relief of 
tension, when the abscess is incised, will give it a new lease of life, 
so that this glandular tissue may remain a long time in the wound, 
discharging constantly a purulent secretion and delaying wound- 
healing in an aggravating manner. If the whole gland is removed 



142 TUMORS AND DEFORMITIES OF THE NECK 

with its capsule, union of the sides of the wound will be prompt 
and often primary. 

If the infection comes from the front teeth, so that the tumor 
forms in the situation of the submaxillary gland, this gland is ex- 
posed first in making the incision. It ought not to be sacrificed, 
however, because the source of the pus is not in its substance, but 
in that of one or more lymphatic glands lying just under it. If 
this caution is not borne in mind, the salivary gland may be need- 
lessly excised. 

Chronic Lymphadenitis, or Tuberculous Glands. The lymphatic; 
glands of the neck are also suliject to inflammatory processes .>f 
a chronic character. Many times the process is distinctly tuber- 
cular, and can be shown to be such by the presence of tubercle 
bacilli in the excised gland. At other times, however, the tumor 
develops in a similar manner and presents the same clinical appear- 
ances, although no tubercle bacilli can be made out. Such patients 
are anemic, have a poor digestion, suffer from cold feet and bands, 
and have an appearance of malnutrition although the subcutaneous 
fatty tissue may be abundant. 

TREATMENT. The treatment in tuberculosis is primarily liy- 
gienic. Such treatment should precede and follow the local treat 
ment. Just what the local treatment should be must be determined 
in each particular case. If a single large gland exists, causing a 
deformity and suggesting the possibility of enlargement of other 
glands, its removal is absolutely indicated. If there are many 
slightly enlarged glands operation can be deferred. If there are 
numerous large glands, some of which are plainly suppurating, 
removal is necessary both to reduce the number of foci from 
which the disease may spread as well as to save the patient from 
abscess formation with resulting sinuses and disfiguring cicatrices. 

If a single movable gland is to be removed, a local anesthetic 
suffices in many cases. If many glands are enlarged, and espe- 
cially if one or more are adherent, the operation is a more formi- 
dable one and had better not be undertaken except with general 
anesthesia; for although the enlarged glands may seem to lie 
close to the surface, they invariably extend deeper than they ap- 
pear to do, and almost always there are others still deeper which 
are concealed by the more superficial ones. A thorough opera- 
tion in such cases means a free incision of the skin and superficial 



ENLARGED LYMPHATIC GLANDS 143 

muscles and wide exposure of the cervical vessels. Such glands 
often lie just in front of the sternomastoid muscle and close to 
the internal jugular vein; others are usually found just behind 
the muscle or beneath it. Hence the division of this muscle 
greatly facilitates their removal. A transverse or U-shaped or 
Z-shaped incision through the skin is advocated on account of 
the splendid exposure it gives. The resulting scar is prominent, 
and should be avoided when possible, even though two separate 
incisions are required one in front of the sternomastoid and one 
behind it. In cases of extensive involvement of the glands, it is 
well to remove as much of the gland-bearing fascia as possible. 
This requires a long and difficult dissection, which is fully de- 
scribed in good text-books on major surgery. 

The cases which may properly be considered here are those 
in which there are one or more enlarged glands, freely movable 
and easily accessible. In such a case it is better to make the in- 
cision directly over the glands and parallel to the edge of the 
sternomastoid muscle. When the various planes of tissue, skin, 
subcutaneous, and deep fascia have been divided, there will be ex- 
posed the outer capsule of the gland. If this is also divided, the 
gland may sometimes be shelled out like the pulp of a grape from 
its skin, especially if it is still solid and the inflammation has not 
set up adhesions between the gland substance and the outer cap- 
sule. In that case the dissection may be tedious, but should be 
persisted in until the gland is removed. The rule should always 
be to keep close to the gland in removing it. If a little of the 
gland substance remains, it is easy to remove it after the gland 
itself has been excised ; whereas if the line of incision strays from 
the gland itself, serious damage may be done to some important 
vessel or nerve. 

The important structures to be kept in mind during the dis- 
section are the internal jugular vein and pneumogastric nerve in 
front of the sternomastoid muscle, and the spinal accessory nerve 
posterior to it. 

When the enlarged glands have been removed the wound 
should be cleansed and sutured. Even though necrotic material 
has been smeared over the wound by the rupture of a softened 
gland, primary union is still attainable in most cases if all dis- 
eased glands are removed. The finest of black silk sutures should 



144 TUMORS AND DEFORMITIES OF THE NECK 

be placed through the skin wound, thus allowing the deeper parts 
to collapse and assume their normal relation. Light pressure ob- 
tained by a piece of sterile gauze placed on the wound and cov- 
ered with cotton and a gauze bandage will suffice to keep the 
deeper parts of the wound in apposition. If the wound is dry 
before it is sutured no hemorrhage need be feared. Even if the 
dissection is a limited one, it is better to confine the movements 
of the head for two or 'three days by the application outside of the 
gauze bandage of a starch bandage, made by tearing heavy crin- 
olin into strips two or three inches wide. These strips are rolled and 
immediately before being used they are wrung out of hot water, 
care being taken not to squeeze out more of the contained starch 
than is necessary. In the case of a child, or of a restless adult, 
the bandage should run around the neck, up the back of the head 
and around the forehead, and should also extend under one or 
both arms (No. 22, Chapter XXI). This may seem like a very 
extensive dressing for a simple wound, but only in this manner can 
# wound in the neck be properly protected and the head kept quiet. 
In a day or two, when the starch has thoroughly dried, the parts 
of the bandage which extend under the arms may be cut away, 
as by that time the molding of the bandage to the shape of the 
neck and shoulders will be sufficiently firm. The wound should 
be dressed in four days, and half of the stitches removed, the rest 
being left in three or four days longer. From this time on a 
cotton-collodion dressing will sufficiently protect the wound from 
outside contamination. If the adult is quiet and the' incision does 
not extend to the upper third of the neck, the bandage around 
the head may be omitted. 

Suppurating Tuberculous Glands. Unfortunately the clean 
operations above described are often impossible because the pa- 
tient will not allow any operation until the pus has burst through 
the skin or at least has ruptured the capsule of the gland and has 
infiltrated the surrounding tissues. Under such circumstances the 
abscess-cavity must be drained through a suitable incision, but the 
operator should not content himself with this alone, but should 
make an attempt to remove all of the affected gland, either by 
means of a curette or, what is better, by means of forceps and 
scissors. If this dissection does not extend beyond the original 
capsule of the broken-down gland, the risk of spreading the infec- 



TUMORS OF THE THYROID GLAND 145 

tion by this treatment is not worth considering, and the period of 
recovery will be materially shortened if one does not leave behind 
a half disintegrated gland, which will keep a sinus discharging a 
small amount of pus daily for weeks afterward. If, on the other 
hand, the gland is wholly removed, and free drainage is given 
to the wound, it may be able to close by granulation in a week 
or two. 

In Syphilis. The cervical glands may be enlarged in syphilis 
either as an accompaniment of an ulcerated throat or as a later 
manifestation of the disease. In the former case, on account of 
the presence of pus, an incision may be necessary. Glandular 
enlargement due to syphilis will subside rapidly under antisyph- 
ilitic treatment, so that removal of the glands is not usually 
necessary. 

In Leukemia, Pseudoleukemia, Sarcoma, Carcinoma. Other 
causes of chronic lymphadenitis are leukemia, Hodgkin's disease, 
and the malignant tumors. It is well worth remembering that 
the cervical glands above the left clavicle have connection with the 
abdominal organs through the lymphatics which accompany the 
thoracic duct; and they may enlarge so as to be easily palpable, 
before the patient seeks advice for a gastric or hepatic cancer. 

Tumors of ,the Thyroid Gland, or Goiter. The thy- 
roid gland is frequently the seat of hypertrophy and new growth. 
There may be a diffuse enlargement of a part or the whole of the 
gland, or there may be well marked nodules, either cystic (Fig. 
85) or parenchymatous in structure. Any such benign swelling 
of the thyroid gland is known as a goiter. This is a common 
affection in certain mountainous districts in Europe, but it is by 
no means confined to them, and seems to be increasing in fre- 
quency in New York City, possibly on account of immigration 
from such regions. The larger swellings, involving the whole 
gland if of parenchymatous nature, are sometimes associated with 
protrusion of the eyeballs and certain nervous symptoms. Such 
a goiter is called exophthalmic goiter (Fig. 86). 

DIAGNOSIS. Tumor of the thyroid may be recognized by the 
fact that it is drawn strongly upward when the patient swallows, 
on account of the close attachment of the thyroid gland to the 
larynx. It is not so easy to tell a cystic from a discrete parenchy- 
matous swelling. A diffuse swelling of even elastic consistence 
12 




n 




146 



CICATRICES 147 

throughout is invariably parenchymatous. A large cyst will yield 
a fluctuation wave when tapped upon or compressed. A small 
cyst and a small parenchymatous nodule react about alike in this 
respect. An aspirating needle will distinguish the two. 

TREATMENT. The removal of a cystic or a parenchymatous 
nodule is not a difficult procedure if the surgeon is careful to con- 
trol hemorrhage step by step. Local anesthesia is sufficient. The 
best incision is parallel to the transverse wrinkles of the neck. 
The deep fascia is divided, any intervening muscle freed and 
pulled to one side, and the gland exposed. Its capsule and usually 
a thin layer of its substance must be divided before the nodule 
is reached. Hemorrhage is readily controlled by clainp and liga- 
ture. The nodule is shelled out of its bed. The divided gland is 
sutured with fine, catgut sutures which pass through its capsule; 
and the deep fascia is similarly sutured, while the wound in the 
skin is sutured with fine black silk. Only when there is oozing 
from the gland should a small drain be employed. 

The removal of a part of a diffusely enlarged thyroid gland 
is a much more serious matter and should be undertaken only after 
all precautions for a major operation have been made, and yet 
some of the most experienced operators use a local anesthetic in 
all cases of goiter. In no case should the whole gland be removed, 
as myxedema or other nervous disturbances are apt to lead to a 
speedy fatality. 

ACQUIRED DEFORMITIES 

Cicatrices. Burns of the neck (p. 125) are often followed 
by annoying cicatricial contractions. Besides the disfigurement 
so caused, the force of the fibrous bands may keep the head twisted 
to one side or may bring the chin close down to the sternum 
(Fig. 87). 

TREATMENT. Such a condition of affairs may be greatly im- 
proved by a suitable plastic operation in some cases and in others 
by extensive skin-grafting (Chapter XX). If possible, the offend- 
ing bands should be partially or wholly excised, as their presence 
will seriously interfere with the result of the operation. The exact 
details of such an operation cannot be given, as they must be 'made 
to correspond to the necessities of each particular case. It is well, 
however, for both the patient and the surgeon to recognize that 



148 



TUMORS AND DEFORMITIES OF THE NECK 



the best results under such circumstances are obtained, not by a 
single extensive operation but by several lesser ones, repeated at 




FIG. 87. CICATRICIAL CONTRACTIONS FOLLOWING BURN OF THE NECK. 

intervals sufficiently long to reveal the gain made by each opera- 
tive attempt. 

Torticollis, or Wryneck. Wryneck, or torticollis, is the 
shortening of one or more of the cervical muscles, so that the 
head is held in an abnormal position. There may or may not 
be a spasm of these muscles. The sternomastoid is the muscle 
most , affected, although the posterior cervical muscles are usually 
involved to a certain extent (Fig. 88). The condition is thought 
to be due to a unilateral myositis of infancy, secondary possibly 
to traumatism at birth, or developing as one of the lesions of con- 
genital syphilis. As the child grows, the lack of exercise of certain 
muscles from the cramped position in which the head is con- 
stantly held, adds to the deformity and increases the muscular 
changes. If nothing is done to relieve the condition, the cervical 



TORTICOLLIS, OR WRYNECK 



149 



spine will become much curved, and there will be compensatory 
curves in both the dorsal and lumbar spine. Even the develop- 
ment of the head may be affected (Figs. 89 and 90). 

Strictly speaking, cases of torticollis may be divided into acute 
and chronic. Usually, however, the acute symptoms will have 
subsided before the child is brought to the doctor. 

DIAGNOSIS. In many cases the parent has already recognized 
the nature of the deformity. Inspection shows that the mastoid 
process on the affected side is nearer to the sternum than it should 
be. This means that the face is turned toward the opposite side 
and the chin slightly elevated, although the head may be bent 
toward the shoulder of the affected side. If the contraction is 
of long standing, the 
whole head will seem 
to have slipped over 
toward the unaffected 
side. This is due to 
the curvature of the 
neck. But the most 
reliable method by 
which to ascertain 
what muscles are af- 
fected is to make pal- 
pation and manipula- 
tion of the head and 
neck. When the head 
is flexed and extended, 
and abducted to the 
right and left and ro- 
tated, the difference in 
the muscles of the two 
sides of the neck is at 
once apparent. Such 
manipulation is usu- 
ally not painful unless 
carried to an extreme 
degree. 

A differential diagnosis between torticollis and tuberculosis of 
the cervical spine has sometimes to be made. In tuberculosis there 




FIG. 88. WRYNECK OF RIGHT SIDE OF MODERATE 
DEGREE. The position of the head is typical. 
This patient was made absolutely straight by an 
operation performed with cocain, and subsequent 
manipulation. 



150 TUMORS AND DEFORMITIES OF THE NECK 

is extreme tenderness, inability to move the head in any direction 
without pain, spasm of the cervical muscles when an attempt is 
made to do so. Moreover, there is a daily slight fever. 




FIG. 89. EXTREME DEGREE OF TORTICOLLIS, SAID BY PATIENT TO HI; CONGENITAL. 
Note the deformity of face, as well as of spine. The ulcer of the nose was due 
to recent tniumuti.sm. 

TREATMENT. The first treatment of acute torticollis is the 
treatment of the traumatism or acute myositis in which it origi- 
nates. This consists in the application of heat, and tin; niainte- 




FIG. 90. BACK VIEW OF SAME PATIENT. 



TORTICOLLIS, OR WRYNECK 151 

nance of the head in a correct position, or at least the prevention of 
an increase in the deformity. If the condition is considered to 
be rheumatic, salicylate of soda should be administered. 

As soon as the pain subsides, treatment by manipulation should 
be commenced to correct existing deformity. The effort should be 
to overcorrect the deformity which exists. Therefore the face should 
be rotated in the opposite direction until the affected sternomas- 
toid is tight. The chin should then be tilted downward and the 
head bent away from the affected shoulder. These manipulations 
should be made a number of times, and the treatment repeated 
each day until the deformity is overcome. Even then it is better 
for the physician to see the child once a week for a few weeks. 

If the patient is an infant, manipulation described may be 
carried out upon the mother's lap. If it is an older child, it- 
should sit upright during the treatment. In either case it is an 
advantage if a second person holds the shoulders while the ma- 
nipulations are made, so that the manipulator can make traction 
upon the head while twisting it and bending it. 

During sleep the pillow should be so arranged that the position 
of the body will tend to correct the deformity, or at least will not 
tend to increase it. 

In chronic cases, treatment by manipulation will succeed only 
if the affected muscles are still elastic ; otherwise operative treat- 
ment is indicated. In slight cases, division of the sternomastoid 
muscle is necessary, whereas in the severer cases the trapezius sple- 
nius and other muscles will also require division. 

The incision may be made parallel to the edge of the sterno- 
mastoid or parallel to the clavicle. The former leaves a slighter 
scar. The incision should be at least an inch long. Usually, 
when the most prominent bands have been divided and tension 
has separated their cut ends, it will be found that other deeper ones 
still hold the head to a lesser degree in an abnormal position. 
Such bands should in turn be divided until motion of the head 
is free. The restraining muscular bands lie a little outside the 
sheath of the great vessels, and the latter could be injured only 
by careless cutting. No deep suture is necessary. Hemorrhage 
should be stopped and the skin-wound entirely closed with fine 
black silk sutures. A firm dressing should be applied, and the 
head put up in an overcorrected position and held so by a plaster 



152 TUMORS AND DEFORMITIES OF THE NECK 

of Paris bandage placed around the neck, over the head, and under 
both arms (No. 22, Chapter XXI). If there is no rise of tem- 
perature or pain, the dressing need not be changed for a week or 
ten days. As soon as the wound has healed, gentle passive rota- 
tion and other motions of the head should be commenced :ml 
repeated every other day for several weeks. As the time goes on 
the force with which this is done may be increased, and in addition 
the patient should practise active motion daily to correct the de- 
formity and increase the mobility of the neck. 




CHAPTEE VI 
INJURIES AND INFLAMMATIONS OF THE TRUNK 

INJURIES 

Contusions of the Chest and Back. Blows upon the 
chest and back on account of the firm underlying bones usually 
produce little injury. General directions for treatment of such 
injuries are given on page 2. 

Contusion of the Breast. A blow on the mammary gland may 
produce a partial rupture with the formation of a hematoma (Fig. 




FIG. 91. LARGE HEMATOMA OF MAMMARY REGION, FIVE WEEKS AFTER A BLOW. 

91 ; see p. 3 for treatment) or an inflammation, mastitis, or 
even abscess. It may also be followed by a malignant growth. 

Hence the importance of immediate intelligent treatment. 

153 



154 INJURIES AND INFLAMMATIONS OF THE TRUNK 

Hot, moist applications should be applied to the breast, or the 
surface may be covered with gauze thickly spread with ichthyol 
ointment, and outside of this a layer of non-absorbent cotton or 
lamb's wool. Moderate, even pressure is to be maintained by a 
breast bandage, which should be so applied that the breast is sup- 
ported from the shoulder (No. 28, Chapter XXI). After a few 
days gentle massage should be administered. 

Contusion of the Back and Ribs. Contusion of the back is con- 
sidered under the heading Sprain (p. 158), and contusion of a 
rib under the heading Fracture (p. 167). 

Contusion of the Abdomen. Blows or undue pressure 
upon the abdomen are important less for their effect upon the 
abdominal wall than upon the abdominal organs, one or more of 
which may be ruptured or seriously injured by violence which 
leaves no mark upon the skin. 

A sharp unexpected blow upon the abdomen is apt to produce 
a condition of shock which is familiar to every boy under the 
phrase " it knocked the wind out of him." The abdominal muscles 
being off their guard, the force of the blow is received upon the 
sensitive structures beneath, especially upon the sympathetic gan- 
glia in the region of the solar plexus, and faintness and nausea 
and possibly vomiting and unconsciousness follow. Such a blow 
may even produce death, although this is not common in an animal 
the size of man. When the muscles are forewarned and have time 
to contract, they can protect the abdominal organs against a very 
heavy pressure. For instance, a man weighing, say, 170 pounds, 
can lie face downward bearing his whole weight on a horizontal 
bar which crosses his abdomen. The rigidity of the recti and other 
muscles prevents the bar from pressing backward enough to pincJi 
the intestine or mesentery against the spinal column. This ex- 
plains how so many persons escape serious injury from the wheel 
of a moving vehicle, even though it passes directly across the 
abdomen. Such escapes have been frequently noted, even when 
the vehicle has weighed more than 3,000 pounds (750 pounds 
weight on each of four wheels). When the wheel is broad and 
rubber-tired, the possibility of escape from serious injury is natu- 
rally much greater than with a wheel having a narrow steel tire. 

DIAGNOSIS. The principal symptoms of contusion of the abdo- 
men are general. They are the symptoms which, grouped together, 



CONTUSIONS OF THE ABDOMEN 155 

are spoken of as shock namely, feeble pulse, pallor, cold, pos- 
sibly clammy skin, and frequent respiration. These are also the 
symptoms of internal hemorrhage and of rupture of the stomach 
or intestine, which are often the result of undue force applied to 
the abdomen. It is important to separate simple contusion from 
these other conditions, if possible, since their respective treatments 
are opposites. Often the progress of the case will alone decide. If 
there is uncomplicated contusion, the symptoms will rapidly dis- 
appear. If there is an accompanying internal hemorrhage or rup- 
ture, the pulse and respiration will increase in rate, the patient 
will become more restless, and the symptoms of shock will become 
more marked. Vomiting usually accompanies rupture of an intra- 
abdominal organ. The vomitus should be examined microscopi- 
cally to determine the possible presence of blood. 

There is usually pain at the seat of rupture, extending thence 
in the direction in which the escaped intestinal contents would be 
likely to gravitate. If the amount of escaped fluid is large, its 
presence as free abdominal fluid may be shown by percussion with 
the patient lying first on his back and then on his side, or in 
other positions. Abdominal rigidity on palpation is a sign of great 
importance. It may exist in simple contusion, but it is less 
marked than it is in more serious conditions and tends to de- 
crease. 

In all cases of abdominal injury the whole abdomen should be 
carefully examined with the stethoscope. By this means one can 
determine whether the normal peristaltic action of the intestines 
is going on, whether normal peristalsis is at a standstill, and, 
roughly, the shape of the air-spaces which distend the abdomen, 
and the presence of free fluid or gas. All of these factors have their 
weight in determining the question of operation. If perforation of 
stomach or intestines is present, immediate operation and suture 
gives the patient the only chance of recovery. Under such circum- 
stances the delay of a few hours will reduce such chance by at 
least one-half, as the successful cases are almost exclusively those 
operated upon within sixteen or twenty-four hours after the acci- 
dent. The character of the urine, and the patient's ability to 
pass it, and the state of the bowels must also be considered, as 
rupture of the bladder or of one kidney is as urgent an indication 
for operation as is that of the stomach or intestines. 



156 INJURIES AND INFLAMMATIONS OF THE TRUNK 

NON-OPERATIVE TREATMENT. If it is decided that no serious 
internal injury exists, and in all cases, before a complete diagnosis 
can be made, the patient should be kept absolutely quiet in a hori- 
zontal position. An ice-bag or heat applied to the abdomen usu- 
ally helps toward this end. It is desirable to avoid morphine until 
the diagnosis is clear. If this is not possible, the doses given 
should be small, and should be administered hypodermically. Ab- 
solutely nothing should be given by mouth. If the skin is broken 
a light, moist, antiseptic dressing should be applied. The symp- 
toms of the patient should be noted every hour. If they all im- 
prove steadily, it may be safely inferred that there is a simple 
contusion. If they grow worse, and particularly if local muscular 
rigidity is noted or increases, laparotomy should be performed. 
It should be the aim of the surgeon to decide definitely for or 
against operation in less than twelve hours from the injury. This 
gives the patient the best chance of recovery after operation, what- 
ever the character of the injury. 

If the contusion is uncomplicated, the patient may be allowed 
water after twelve hours, fluid nourishment on the following day, 
and solid food after the bowels have been moved. 

It is well worth remembering that a contusion of the abdomi- 
nal wall may be accompanied by a contusion of the intestine with- 
out immediate hemorrhage or rupture. This is particularly apt 
to be the case after wheel injury. The slough of intestine may 
give way and allow the intestinal contents to escape into the abdo- 
men as late as two weeks after the injury. The warning sign is 
a localized contraction of the muscles of the abdominal wall. The 
patient should be kept in bed and on the simplest fluid diet until 
this disappears. 

Wounds. Uncomplicated wounds of the trunk should be 
treated in accordance with the rules given on page 13. 

Hemorrhage from the Umbilicus. This occurs in the infant, 
due to premature separation of the cord. The hemorrhage should 
be controlled by solution of adrenalin (1: 2,000) and pressure, or 
by application of peroxide of hydrogen full strength or diluted 
one-half, or if necessary by ligature. Asepsis should be observed 
in the dressing. 

Gunshot Wound of the Back. Gunshot wound of the back- 
as met with in civil life is frequently not serious, as the bullets 



WOUNDS 157 

of small caliber fired from cheap revolvers do not penetrate through 
the thick muscles in this region. A bullet fired into the back may 
be deflected by the strong fascial planes or by some vertebra ; it 
is therefore difficult to make out its exact location or to follow 
its track with the probe. Unless its situation is easily determin- 
able, the surgeon should recognize that the operation for its re- 
moval may be a protracted one, and should make preparation 
accordingly. If the bullet is within easy reach it may be extracted 
and the wound properly treated without a general anesthetic. The 
position of the bullet may be shown in a radiograph if the patient 
is not too stout. 

Penetrating Wound of the Pleural Cavity. A bullet or the 
point of a knife may pass between two ribs and open the pleural 
cavity. Air or blood may then occupy the pleural space. There 
may be more or less shock. If there is no wound of exit, an at- 
tempt should be made to locate the bullet by means of the X-ray. 
If the lung is injured there is usually a certain amount of cough 
and hemoptysis and an effusion of blood into the pleural cavity, 
revealed by an area of dulness on percussion ; but even these symp- 
toms may be very slight. If a large artery is broken, death fol- 
lows rapidly, partly from hemorrhage and partly from suffocation, 
as the blood which pours into the bronchi is imperfectly coughed 
out. 

TREATMENT. Air or a small quantity of blood is readily re- 
sorbcd from the healthy pleural cavity. Even a foreign body 
such as a bullet may give no trouble. It is best, therefore, not to 
explore a penetrating wound of the chest unless there is some 
definite reason for interference, such as the known accessibility of 
the bullet, continued hemorrhage, or the existence of suppuration 
(p. 175). Drainage is secured by the resection of two inches of 
one rib as described on page 177. 

Penetrating Wound of the Pericardial Cavity. A penetrating 
wound of the pericardium alone may be sutured under cocain 
after the excision of an inch or two of one rib, or the wound may 
be left to unite of itself. The danger in such a case is not from 
the extent of the injury, but from the possibility of subsequent in- 
flammation. Drainage is inadvisable in a recent case, but if pus 
forms in the sac, extensive drainage will of course be required. 
If the heart is injured the case is by no means hopeless. Instances 



158 INJURIES AND INFLAMMATIONS OF THE TRUNK 

are on record in which after the resection of a portion of one or 
more ribs, the pericardial sac has been opened and the wound 
in the heart successfully closed by suture. 

Penetrating Wound of the Abdomen. Every wound of the ab- 
domen should be explored until the surgeon can either see its bot- 
tom or can assure himself that it has entered the abdominal cav- 
ity. Whether it should be explored still further will depend on 
circumstances. It is generally agreed that the abdomen should be 
opened after every gunshot wound, and after every stab wound ac- 
companied by symptoms of hemorrhage or intestinal injury. As to 
penetrating wounds without symptoms of complication, it may !>< 
said that the risk of opening the abdomen with suitable facilities 
is less than the risk of allowing the injury to go without explora- 
tion. The younger surgeons at least are acting on this principle. 

Sprains. Sprain of Back. As a result of twists and falls, 
and less often of blows, the back is sprained, almost always at the 
junction of the lumbar and sacral regions. Often under such cir- 
cumstances there is little or no change in its appearance; the usual 
symptoms are those of stiffness, and pain at the pelvic attachment 
of on'e or both lumbosacral muscles, noticed especially when the 
position is changed after a short period of quiet or when an 
attempt is made to bend the body in certain directions. Some- 
times it is almost impossible to stand erect. In the simpler cases 
the symptoms are due to stretching or bruising of the muscles or 
of the intermuscular cellular tissue. In the severer cases it is 
probable that some of the muscular or fibrous threads are broken ; 
at any rate, the symptoms often persist for a .provokingly long 
period, sometimes for several weeks. 

It is not always possible to differentiate a sprain of the back 
from lumbago. The latter is technically a neuralgia in the mus- 
cles of the back, and usually comes on after exposure to cold. If 
such exposure is combined with overexertion it may be impossible 
to tell whether the symptoms are due to sprain or to lumbago. As 
the treatment is similar in some respects, the doubt is less impor- 
tant than it would be otherwise. 

TKEATMENT. The first indication for treatment is the relief 
of the pain. This may be constant, or occur only when the mus- 
cles of the back are contracted. There may be a partial spasm of 
the muscles which greatly aggravates the pain. The patient should 



SPRAINS 159 

remain in bed while the symptoms are acute, and external heat 
should be applied. This may be moist or dry. A hot-water bag 
filled with boiling water is a convenient form of application. Hot 
moist compresses may be applied, covered with flannel, and still 
further heated by a flat-iron. 

Massage is indicated, especially around the origin of the 
strong muscles of the back from the sacrum and ileum. The 
massage to be effectual must be given with a good deal of force; 
hence mechanical vibration with a good machine is most service- 
able in these cases. 

Dry-cupping is another means of relieving pain in this region 
which is not used nearly as often as it should be. 

The various counter-irritants may be employed. JsTo one is 
better, and none so cleanly, as the thermocautery. The point of 
the cautery, preferably a round one, should be kept at a pale red 
heat, and should be swung in circles which just touch the back 
tangentially. In this manner the cauterization can be performed 
with a delicacy quite impossible if a forward and backward 
movement be given to the point. The pain of this treatment is 
very slight if the point passes swiftly over the skin, so that the 
cauterization can be continued until the whole painful area has 
been thoroughly gone over. The treatment may be repeated the 
following day, if necessary. Sometimes a single application will 
effect a cure. 

It is rarely necessary to give morphin. Acetanilid, or one 
of the other coal-tar products, is sufficiently powerful if an anal- 
gesic is necessary. 

There is one other remedy which is said to stop the pain in 
lumbago almost instantly, and that is the injection of from four 
to twelve ounces of sterile normal salt solution into the muscles 
of the back. 

In cases of sprain it is important to support the back and to 
keep the injured parts at rest. For this purpose a proper strap- 
ping with adhesive plaster is excellent. The use of a porous plas- 
ter is too well known to require mention. A far more efficient 
support can be obtained as follows: two strips of adhesive, three 
inches broad, are applied on either side of the spine from the 
lower angle of the scapula nearly to the tuberosities of the ischia. 
There should be a space of a half inch between them. Six trans- 



160 INJURIES AND INFLAMMATIONS OF THE TRUNK 



verse strips, each two inches broad, and long enough to reach a 
little more than half-way around the body, should cross these ver- 
tical strips at right angles (Fig. 92). There should be a space 






FIG. 92. STRIPS OF ADHESIVK PLASTKR 
APPLIED TO GIVE SUPPORT TO A 
SPRAINED BACK; GRIDIRON STRAP- 
PING. 



FIG. 93. STRIPS OK ADHESIVE PLASTER 
Ai'iM.iKD DIAGONALLY TO (livi; SUP- 
PORT TO A SPRAINED BACK. 



of half an inch to an inch between each one of those to allow the 
perspiration to evaporate and to lessen the itching which follows 
the application of a broad, unventilated strip of adhesive plaster. 

Another method of strapping is to apply the strips of adhesive 
plaster diagonally. It is easier to make the plaster fit a hollow 
back when it is applied in this manner (Fig. 93). 

Whatever the method of strapping chosen, the patient should 
stand upright or lie prone on his face when the strips are applied, 
so that the back may be fully extended at the time. He should 



SPRAINS 



161 



subsequently avoid bending forward, as that loosens the plaster 
and lessens its usefulness. The strapping should be repeated every 
two or three days, or as often as it loosens. The old plaster can 
be peeled off, or washed off with ether or benzin or " carbona." 

In some cases the administration of the salicylates seems to 
hasten recovery. This is especially true in cases of lumbago. 

Railroad Spine. The effects of a severe contusion of the back 
or sprain of the spinal column are sometimes felt for months or 
years. It is important for the surgeon to know whether the symp- 
toms complained of are real or are kept in the mind of the patient 
by an expected suit for damages. This doubt has earned for this 




I''i<;. 94. TESTS FOR INJURY OF THE 
SPINE. The patient bends forward. 
Note the full normal curve of the 
spine. 



FKJ. !)">. - TESTS FOR INJURY OF THE 
SPINE. The patient bends backward. 
Note the concavity of the dorsolum- 
bar region. This attitude is impos- 
sible in sprain. 



type of injury the name " railroad spine." Without going into 
the remote details of this subject, it is worth while emphasizing 
one point. Whoever examines one of these patients should inspect 



13 



162 INJURIES AND INFLAMMATIONS OF THE TRUNK 



and palpate the back from the skull to the sacrum, and should 
then test the functions of the spine in the following manner : The 
patient should be stripped to the hips and stand erect with his 
back toward the surgeon. 1. He should bend forward and back- 
ward several times, keeping the knees straight, while the surgeon 
notes the flexibility of the different portions of the spine (Figs. 
94 and 95). If any portion has been injured the muscles will 





FIG. 96. TESTS FOR INJURY OF THE SPINE. FIG. 97. TESTS FOR INJURY OF THE 

The patient bends to the left, keep- SPINE. The patient twists to the right 

ing the knees straight. The same mo- and then to the left without moving 

tion should be made to the right. the feet. 

hold it rigid while the other parts are bending. This is especially 
striking if one side is involved more than the other. This con- 
traction of a part of the muscles of the back is something which 
cannot be imitated, and if present represents real injury. 2. The 
patient stands erect as before, and then, without flexing the knees, 
he bends his body toward the right and then toward the left, while 
the range of motion of the spine and possible irregular muscular 
action is noted as before (Fig. 96). 3. The patient, without mov- 



FRACTURES 163 

ing his feet on the floor, twists his shoulders around to the right 
as far as possible, and then around to the left (Fig. 97). The 
limit of motion in these various directions, and any other points 
observed, should be recorded for future comparison. 

TREATMENT. The treatment in these cases must be long con- 
tinued to produce permanent results If tenderness is marked, the 
spine should be supported by a plaster of Paris jacket (Chapter 
XXII). In most cases it is better to obtain the support by a re- 
movable corset, so that there may be daily massage and exercises. 
Mechanical vibration is of great service. Out-of-door life and 
other hygienic measures are of the greatest importance. There 
is a strong tendency to hysteria in these patients, and the -regu- 
lation of the daily life should be such as will lessen rather than 
increase this tendency. 

Fractures. Fracture of Clavicle. Sometimes by direct vio- 
lence, or more often as a result of falls upon the arm or shoulder, 




FIG. 98. FRACTURE OF LEFT CLAVICLE IN THE USUAL SITUATION OF ONE WEEK'S 

DURATION. 

the clavicle is fractured. Any portion of the bone may be broken, 
but the line of fracture is in the great majority of instances within 
an inch of the center of the bone (Fig. 98). The normal outline 
is changed, due to edema and the irregularity of the broken bone. 
The amount of deformity varies greatly. The line of fracture 



164 INJURIES AND INFLAMMATIONS OF THE TRUNK 

is usually an oblique one, and either the outer or inner fragment 
is displaced backward. 

There is more or less disability of the arm, extreme motions 
being limited by pain. In some cases measurement from the ster- 
nal to the scapular end of the bone will show a shortening, but this 
is not always the case. There is a swelling and tenderness at the 
site of fracture, and crepitus can usually be obtained, unless the 
fracture is near the outer extremity of the bone. In that case 
motion between the fragments may be prevented by the various 
ligarnentous attachments to the coracoid and acromion processes. 
Ecchymosis is usually present, but is often slight. 

TKEATMENT. On account of the impossibility of applying :my 
form of apparatus on both sides of the bone, treatment of a frac- 
tured clavicle, aiming to reduce the misplaced fragments and to 
keep them in position, is eminently unsatisfactory. This does not 
mean that a bad result is to be anticipated. On the contrary, in 
most cases the bone unites speedily, with little deformity, if the 
arm is merely kept in a sling. Many times some child's mother 
has brought it for treatment two weeks or more after the fall 
occurred, with not the slightest idea that any bone had been 
broken. The pain disappeared a day or two after the accident, 
and she only sought medical advice on account of the slight swell- 
ing at the seat of fracture, or because the child still cried when 
lifted by that arm. In these absolutely untreated cases there is 
often union with a minimum of deformity. 

If no deformity exists, or if it is slight, the patient should 
not be tortured with unnecessary apparatus. The arm should 
merely be supported in a sling, or if the patient is restless, or is 
a child, a simple bandage of the arm to the chest should be applied. 
A good bandage for this purpose is the Velpeau (Xo. 30, Chapter 
XXI). This method of treatment is adapted not only to fracture 
of the outer portion of the clavicle, but to many fractures in the 
central portion. Sometimes existing deformity may be lessened by 
pressure directly upon the projecting fragment, obtained by a com- 
press of gauze and two strips of adhesive plaster crossed over it 
in an X. This is only advisable in those cases in which slight 
digital pressure has been found efficacious in replacing a fragment. 

There remain for consideration those cases in which deformity 
is considerable. The fracture is usually oblique and the fragments 



FRACTURES 



165 



have overlapped. If the fracture is recent, one can usually reduce 
the overlapping by grasping the upper part of the arm and pulling 
the shoulder outward and backward. But while this can be accom- 
plished manually, and for a few minutes without pain, attempts 
to keep up this extension for two or three weeks are sometimes 
very painful, so that the patient wriggles until the pull is less- 
ened, or, if he fails to do so, the skin where pressure is greatest 
may become excoriated. I have repeatedly seen instances of this 
in cases in which a Sayre's dressing has been applied. 

Extension upon the Principle of the Lever. There are two 
ways in which the shoulder may be pried out and backward by 
means of bandages alone. A pad may be placed in the axilla, and 
upon this as a fulcrum the humerus may be used as a lever. When 
the elbow is brought to the side the shoulder is pried outward. 
This is the principle of the antiquated Desault bandage (Xo. 31, 






FIG. 99. SAYRE DRESSING FOR FRAC- FIG. 100. SAYRE DRESSING FOR FRAC- 
TURE OF CLAVICLE. Rear view. Show- TURE OF CLAVICLE. Front view, 
ing application of first strip of adhe- Showing application of second strip 
sive plaster. of adhesive plaster. 

Chapter XXI). Gradual flattening of the pad relieves the patient 
and does away with the extension upon the clavicle. The other 
method is that of the Sayre dressing and the Moore bandage. In the 
Sayre dressing the upper part of the humerus is fixed well back- 



166 INJURIES AND INFLAMMATIONS OF THE TRUNK 

ward by a loop of adhesive plaster about the arm and a continua- 
tion of the same around the back and side of the chest, until it 
is fastened to itself. The elbow is then pulled well forward and 
fixed by a second str.ip of adhesive plaster. The first loop acts 
as a fulcrum and the shoulder is carried backward (Figs. 99 and 
100). 

Moore's bandage acts on a similar principle, by pushing up- 
ward the shoulder and drawing backward the arm by means of a 
strip of cotton cloth twisted around the elbow in two directions. 

Direct Extension by Means of Rigid Apparatus. If a prop- 
erly padded splint is placed across the back of the shoulders they 
may be bandaged or strapped to it, and thus extension of a broken 
clavicle be obtained with a minimum of pressure upon the soft 
parts. A board used for this purpose is likely to slip unless it 
is fixed by an upright piece. This makes a veritable cross, and 
few patients will consent to be bound to such an apparatus for 
two or three weeks. It is, however, very efficient in reducing de- 
formity to a minimum. 

Another plan which often succeeds is the application of the 
posterior figure of eight bandage of the chest (No. 26, Chapter 
XXI) in plaster of Paris. The bandage should be reenforced with 
a molded strip across the back of the shoulders, or a light wooden 
splint may be incorporated in it. 

Reduction by Operation. Of course none of the methods of 
extension above described is applicable unless reduction can be 
accomplished manually without the employment of much force. 
In other cases, unless one is willing to allow union to take place 
with deformity, it will be necessary to make an incision over the 
site of fracture to bring the ends of the bone into a correct posi- 
tion, and to keep them there by means of a suture of chromicized 
catgut or kangaroo tendon. It may seem like an unwarrantable 
procedure to convert a simple into a compound fracture, but in 
the experience of the writer the result obtained often justifies the 
operation, as the bone will unite without deformity, and the scar 
in a few weeks can scarcely be made out. Such an operation can 
be performed with cocain if the patient is old enough to appre- 
ciate the advantages of local anesthesia. The suture material em- 
ployed should be capable of resisting disintegration for at least 
four weeks. 



FRACTURES 167 

Fracture of the scapula is far less common than that of the 
clavicle. If the fracture is of the body of the scapula or of its 
acromioii process it is easily made out, crepitus usually being ob- 
tained by direct manipulation. No treatment is required other 
than limitation of the motion of the arm. Fracture of the neck 
of the scapula is a rare accident, whose exact diagnosis, like that 
of other fractures about joints, is most surely made by a good 
radiograph. The arm should be kept at rest for four or six weeks 
by a shoulder cap and sling (cf. No. 34, Chapter XXI). 

Fracture of Sternum A severe blow is required to break the 
sternum. Even if this occurs, displacement of the fragments is 
unlikely. So that diagnosis depends upon the history, tenderness 
on pressure, and also on pressure at a distance, and in some cases 
on crepitus. If displacement has occurred, the displaced frag- 
ment may be lifted by boring into it with a coarse gimlet or a 
slender corkscrew. Once in place it will remain so without assist- 
ance. The front of the chest should be strapped with adhesive 
plaster to limit motion. 

Fracture of the Ribs. Fracture of a single rib is an extremely 
common accident. It usually is the result of a fall upon a sharp 
edge or corner. The ribs most exposed are oftenest broken. That 
is to say, the patient falls upon his side, striking upon the seventh, 
eighth, ninth, or tenth rib ; and one of them is broken, usually in 
the posterior or anterior axillary line. Sometimes the rib is broken 
in two places two or three inches apart. There is usually little 
or no displacement of the broken ends. Pain, after the first feel- 
ing of injury has passed off, is not great, unless the patient coughs, 
laughs, or sneezes. The pain is apt to increase for a few days, 
since respiration constantly moves one broken end upon the other. 
To avoid this the patient breathes as much as possible with his 
sound side. He often loses some sleep, and is incapacitated for 
hard work for three or four weeks. 

The symptoms due to fracture of the ribs are simulated by 
those which follow a blow from some sharp object. This may in- 
jure the periosteum, and possibly crack the bone, although definite 
signs of this are wanting. There is tenderness on pressure, and 
perhaps pain, although the pain will not be greatly increased by 
respiration nor by pressure upon the rib at a distance from the 
point of injury, as is the case in complete fracture. There is, 



168 INJURIES AND INFLAMMATIONS OF THE TRUNK 

after a few days, a slight, hard swelling close to the bone which 
simulates a callus, but is of less extent, and the deformity is less 
than if the rib were fractured. The symptoms usually last from 
one to three weeks. 

TREATMENT. The pain can be materially lessened by apply- 
ing a broad strip of adhesive plaster directly over the broken rib. 
A strip five or six inches wide and long enough to reach half-way 
around the body, should be fastened posteriorly first and then be 
drawn strongly and slowly forward to the front of the chest ami 
made fast by pressing it close to the skin. The more tight and 
smooth the fit of the plaster, the greater will be the relief to the 
patient. It is sometimes recommended that when one end of the 
plaster has been fastened, the patient shall expire vigorously while 
the surgeon quickly draws the plaster tight and sticks it to the 
skin; but on the whole a more satisfactory result can be obtained 
by a slower and more careful application in the manner described. 
It is better that the plaster should cover only the affected side. 
This leaves the well side free to expand without pulling upon the 
injured side, as is the case if the plaster extends all the way 
around the body. If the skin is hairy it should be shaved before 
the plaster is put on; otherwise the patient will hold the one who 
removes the plaster in lasting remembrance, as most of the hairs 
will be so firmly embedded in the gum that they will be pulled 
out by the roots with the removal of the plaster. 

Fractures of the Vertebrae. Owing to the closeness of their 
articulations to one another and to the ribs, the dorsal vertebra?, 
except the lower two or three, are rarely fractured by indirect vio- 
lence. Fracture of the lower dorsal vertebra? and of the lumbar 
vertebrae may follow a severe fall or blow or be caused by a bullet 
or sharp instrument. In most cases the fracture of the bone is 
overshadowed by the injury to the cord. As this does not extend 
below the first lumbar vertebra the prognosis is more favorable 
the lower down the seat of fracture. Life may be prolonged almost 
indefinitely even though the cord be seriously injured, but sooner 
or later, in spite of the greatest care, the patient dies from sepsis 
due to the extensive ulcers of the back or legs, or to purulent 
cystitis, or to pyelitis, caused by the unavoidable catheterization. 

The immediate symptoms of fracture of a vertebra are pain, 
tenderness, edema, and at least partial loss of motion and sensa- 



DISLOCATIONS 169 

tion. Ecchymosis is usually slow in making its appearance. All 
of these symptoms may be present in severe cases of contusion 
without fracture. Signs due only to fracture are crepitus, the dis- 
placement of a spinous process, and angular deformity produced 
when the spine is flexed or extended. In cases in which there is 
great pressure upon the cord or destruction of the same, there will 
be inability to urinate or defecate, and loss of sensation and motion. 

TREATMENT. In a doubtful case of fracture the patient 
should remain in bed until tenderness has disappeared. After that 
the treatment given on page 158 is applicable. If there is a frac- 
ture without injury to the cord, a plaster of Paris jacket should 
be applied in an extended position. The patient may be allowed 
to get up in two or three weeks, but should wear the jacket for 
two months. After its removal he should be treated by massage 
and exercise, with plenty of rest in a horizontal position. 

The treatment of fracture accompanied by injury to the cord 
is beyond the scope of this book. 

Dislocations. Dislocation of Clavicle. The clavicle may be 
dislocated from the sternum. The tendency to displacement is not 
marked, and a pad upon the overriding bone, with light pressure 
obtained by adhesive plaster strips and a bandage, will usually 
prevent its recurrence. If this is not successful, a periosteal 
suture should be performed. Fixation by either method should 
be maintained for several weeks. 

Dislocation of the outer end of the clavicle also occurs. The 
symptoms are usually slight. The end of the clavicle projects up- 
ward. It is easily reduced by direct pressure or by drawing the 
shoulder outward. This, together with absence of crepitus and 
the absence of shortening of the clavicle when measured from the 
sternum to the outer projecting end, will differentiate this injury 
from fracture ; though fracture of the clavicle sometimes occurs 
without shortening. It may be treated in the same manner as dis- 
location of the inner end, but any form of apparatus usually fails 
to keep the end of the clavicle firmly down on the acromion. This 
can be accomplished by passing a long fine drill through the acro- 
mion and well into the clavicle, and leaving it in place for eighteen 
days. The operation should be carried out. aseptically. 

Dislocation of Costal Cartilage. Sometimes the cartilage of the 
tenth rib may be separated from that of the ninth at its anterior 

./ 



170 INJURIES AND INFLAMMATIONS OF THE TRUNK 

end, and by its occasional slipping forward and backward give rise 
to a little pain. The radical treatment is the amputation of the 
anterior tip of the cartilage; or counter-irritants may be applied 
until the acute symptoms subside and the patient grows accustomed 
to the sensation. 

Dislocation of Vertebrae. Dislocation of either dorsal or lum- 
bar vertebra? without fracture rarely occurs, and when it does so 
it is a partial dislocation in most cases. Attempts at reduction 
should be made under general anesthesia with great care (see p. 
125). If successful, a plaster of Paris jacket should be applied. 

ACUTE INFLAMMATIONS 

Burns. The burns which occur on the body or trunk present 
no especial characteristics. As the body is protected by the cloth- 
ing, the heat applied, whether of flame, fluid, or vapor, usually 

affects a consider- 
able area. An ex- 
ceptional case is 
shown in Figure 
101. This man 
was working in an 
iron foundry, with 
scanty clothing, 
when the steam in 
a wet mold explod- 
ed and spattered 
him with small 
drops of liquid 
iron. 

TREATMENT. 
Directions for the 
treatment of burns 
have been given on 
page 26. The im- 
mediate discomfort 
from burns of the 
body is less in pro- 

FIG. 101. MULTIPLE BURNS OF BODY OF FIVE DAYS' . r . 

DURATION PRODUCED BY SPATTERING LIQUID IRON. portion to their 




INSECT BITES 171 

area than it is in burns of the head and neck, and on this account 
one may be misled into making an unduly favorable prognosis. 
When the destroyed skin begins to slough the gravity of the situ- 
ation will be more clear. Hence the importance of saving the 
strength of these patients in every way from the very first. 

Insect Bites. Pediculi. By the marks of the nails one can 
usually make a diagnosis of pediculosis corporis. These body lice, 
which are vulgarly called " graybacks," live not upon the person 
of an individual, but upon his clothing. The marks of their 
bites are insignificant. The itching produced is extreme, and the 
patient has the habit of drawing his nails across the affected part 
of the skin in long sweeps. Minute excoriations of the skin often 
mark the track of these long scratches, many of which become 
infected, so that shallow ulcers result, which heal slowly, often 
with pigmentation. The diagnosis of the trouble can generally 
be made from the appearance of the skin. A search in the under- 
clothing will result in the finding of pediculi. Essential treatment 
consists in the destruction of the parasites by. baking or boiling 
the clothing, and observance of personal cleanliness. The -itching 
often persists for days, so that an antipruritic may be indicated. 

Fleas and Bedbugs. The bites of fleas and bedbugs can usu- 
ally be distinguished by their distribution. A flea travels quickly 
from one place to another, so that the bites of a single insect, from 
six to twelve or more in number, will often be scattered over half 
the body. A bedbug, on the other hand, makes numerous bites in 
one locality. These are often strung out in a row like the splashes 
made by a flat stone when it is skipped over smooth water. It is 
sometimes difficult to distinguish a bite from the lesions of urti- 
caria. If the latter have not been scratched, the skin involved 
will not show any break; whereas the skin of a bite made by a 
flea or a bedbug will invariably show in its center a small puncture. 

TREATMENT. As infection is often caused by scratching an 
insect bite, it is important to relieve the itching. A solution of 
camphor in alcohol, or some other cooling lotion, is good for this 
purpose. Another excellent method is to brush the involved skin 
lightly with a whisk-broom or a not too stiff hair-brush. This 
relieves the itching without breaking the epidermis. 

Scabies. Scabies is also accompanied by itching, so that the 
excoriations may obscure the burrows of the insect. A minute 



172 INJURIES AND INFLAMMATIONS OF THE TRUNK 

examination of the skin will usually reveal the characteristic link' 
row of brownish specks (the fecal masses of the insect) in the 
substance of the more or less inflamed skin. If the lesions are 
found on the hands, the differential diagnosis from pediculosis 
corporis is certain, as the body lice do not bite the exposed parts 
of the body. 

The treatment of scabies consists in the disinfection of the 
clothing, and a hot bath at night, followed by a thorough rub- 
bing of all suspected portions of the skin with sulfur ointment. 
In the morning another bath with soap and water should be taken. 
After three or four days, if patches of the disease remain, the skin 
should be treated again in the same manner. 

Herpes Zoster. This disease, on account of its predilection 
for the area of the intercostal nerves, may be here considered. It 
develops rather suddenly with pain and some fever, followed 
by an eruption of groups of small vesicles. Often the skin 
supplied by a single nerve is affected; sometimes that by two 
adjacent nerves; rarely that supplied by two opposite nerves, 
making it bilateral. It runs a natural course to termination 
with drying up of the vesicles in a few days, but in the mean- 
time, by the burning and pain, it may make the patient very 
uncomfortable. 

TREATMENT. The vesicles should be protected from rupture. 
The burning may be relieved by the frequent application of a 
solution of menthol in alcohol, twenty grains to the ounce. Mor- 
phin may be required to control the pain in some cases. 

Cellulitis and Dermatitis. Cellulitis, erysipelas, and the 
various local suppurative processes occur frequently upon the 
trunk. In so far as they have no peculiar characteristic due 
to their situation, the description of them and the treatment 
given on pages 33 et seq., must suffice. Only a few special 
forms of inflammation will be described in this section. 

Excoriation of the Breast. I n stout women the constant con- 
tact of the skin of a pendulous breast with that of the abdomen 
may lead to excoriation, ulcer, or even abscess. These conditions 
rapidly disappear under suitable treatment. As a preventive the 
parts should be bathed frequently, the skin rubbed with alcohol, 
and dusted with a talcum powder. If an ulcer has formed, wet 
dressings should be employed. 



MAMMARY ABSCESS 173 

Mammary Abscess. The common period for the occur- 
rence of an abscess of the breast is during early lactation, and 
especially the first lactation. The infection takes place through 
a crack or excoriation of a too tender nipple, and this can almost 
always be found upon search. The usual signs of suppuration 
are present. A portion of the mammary gland and the overlying 
skin are indurated and tender, and in the center of this affected 
area there can usually be made out a smaller area of fluctuation. 

TREATMENT. If the inflammation is seen at an early stage, 
wet applications should be made to the nipple and breast, either 
cold compresses, or flaxseed poultices, or wet compresses with heat 
applied externally, as spoken of in connection with abscess of the 
head (p. 38). A baby should not be put to the inflamed breast, 
although he may continue to nurse from the opposite one if the 
mother has only a slight degree of fever. The milk should be 
drawn, regularly from the affected breast, and if in a day or two it 
is seen that the inflammatory process is increasing, an incision 
should be made into the center of the indurated area, where, as 
above stated, a soft spot can usually be felt. If the softened area 
is plainly palpable, it is useless to further postpone operation. 
The incision may be made under local or general anesthesia. It 
should invariably be made in a line radiating from the nipple. 
Neglect to observe this rule has led to the division of milk ducts 
and the establishment of a mammary fistula. 

An abscess of the breast has a strong tendency toward recovery, 
and the incision therefore does not need to be much longer than 
the diameter of the suppurating area. The cavity should be thor- 
oughly washed out with a solution of bichlorid of mercury, 
1 : 2,000, and a dilute solution of peroxid of hydrogen, one part 
to five. A drain should be inserted in the abscess-cavity, but it 
should not greatly distend it. The hot, moist, gauze dressing 
should be continued. Under these circumstances any further se- 
cretion of pus quickly finds its way into the dressing, and the 
wound has an opportunity to heal just as rapidly as it is able to 
do so. Not until the repair has reached the subcutaneous fatty 
tissue should the drain be omitted. 

Often in an abscess of the breast which has lasted for some 
time, so that the zone of cellulitis about the pus cavity is not an 
excessive one, incision and cleansing will terminate the whole 



174 INJURIES AND INFLAMMATIONS OF THE TRUNK 

pathological proqess so that the sides of the cavity will adhere 
and almost primary union of the wound will follow. If this rapid 
method of cure be attempted, the dressing should be changed at 
least every day, and if there is any retained discharge, the cavity 
should be washed out again and the drain inserted to a greater 
depth. 

If the suppuration- is more excessive and has passed beyond 
the capsule of the gland and has lifted up, as is frequently the 
case, a portion of the gland from the underlying ribs, more than 
one incision may be necessary to provide suitable drainage. Under 
such circumstances, one incision should be made at the most de- 
pendent portion of the abscess-cavity as the patient lies in bed or 
as she sits up, according to circumstances. If she is up most of 
the time, the most favorable point for drainage is immediately 
below the breast, whereas if she is lying in bed the outer edge 
of the breast or a point between this and the lower edge will be 
found most serviceable. If the pus shows a tendency to approach 
the surface at any point, that place should be selected for one of the 
incisions, as there are other factors connected with perfect drain- 
age besides the force of gravity, and unless there are plain contra- 
indications the point chosen by nature for the discharge of jms 
had best be accepted by the surgeon as the most suitable one. 

The best drain for these cases is made by cutting the tip from 
a rubber finger cot and passing through it a wick of gauze. In 
this manner the gauze will be prevented from sticking to the sides 
of the wound. The rubber is more flexible and stronger than the 
gutta percha tissue usually employed in a " cigarette " drain. 

PREVENTIVE TREATMENT. The physician who has charge of 
a pregnant woman should give her directions for the enlargement 
and toughening of the nipples by daily massage, applications of 
alcohol, alum, etc., and if they are retracted they should be drawn 
out with a breast-pump. In this manner they can be prepared for 
nursing two or three months before the birth of the child, and 
cracked nipples and mammary abscesses can almost invariably be 
avoided. 

Axillary adenitis and suppuration are described in Chap- 
ter XV. 

Inguinal adenitis and suppuration are described in Chap- 
ter VIII. 



EMPYEMA 175 

Umbilical Suppuration. The skin of the umbilicus may 
ulcerate or an abscess may form as a result of the irritation which 
is produced in a deep umbilicus by the dirt and secretions which 
may collect there, and even form a hard ball. Cleanliness and 
moist antiseptic dressings will speedily effect a cure. Umbilical 
sinus, which may also suppurate, is described on page 181. 

Bed-sores. An ulcer of the skin of a bedridden patient 
caused by pressure upon some one point is called a bed-sore. 
The sacral region is the commonest situation, both on account 
of its poor blood-supply and the habit many patients have of 
lying the whole time upon their back. There is first a dusky 
redness over the area about the size of a quarter of a dollar, then 
the epithelium gives way at the center and a sore is started which 
gradually involves the whole thickness of the skin, or possibly the 
whole thickness of the skin is at once involved and becomes dark 
and gangrenous and sloughs leaving a large ulcer. The skin over 
the great trochanter is also often the seat of a bed-sore. The rapid- 
ity with which a bed-sore may form, especially in a patient weak- 
ened by long disease, is truly amazing. 

TREATMENT. Frequent massage and the use of alcohol will 
usually prevent the formation of an ulcer if the weight of the 
body is supported upon soft pillows or an air-ring, so that the 
pressure upon the bony prominences is avoided. When an ulcer 
has formed, it should be washed frequently with mild antiseptics 
and dressed with a mildly stimulating preparation. Compare the 
treatment of ulcers of the leg, given in Chapter X\ T III. 

Empyema. Pus in the pleural cavity, or empyema, is a con- 
dition demanding surgical treatment. The signs of empyema are 
fever, increased pulse and respiration, dulness or flatness in the 
lower portion of the affected side of the chest, above which is 
usually a zone of bronchophony with pleuritic rales. The diag- 
nosis is not always an easy one to make, and the importance of 
prompt drainage is great, so that in a doubtful case it is better to 
make one or more exploratory punctures in order to be certain of 
the presence and the location of the pus. These punctures should 
be made with a large hypodermic needle. The needle used by 
veterinary surgeons for hypodermic injection is just right for the 
purpose. The syringe need not be a large one; an ordinary hypo- 
dermic syringe is large enough. 




176 



SYPHILIS 177 

TREATMENT. When pus has been shown to be present in the 
pleural cavity, drainage should be accomplished by the removal 
of an inch and a half of the eighth or ninth rib in the posterior 
axillary line. The operation may be performed under a general 
anesthetic, but if the respiration is embarrassed by the amount of 
fluid in the pleura, a local anesthetic is safer. The instruments 
required are shown in Figure 102. The soft parts overlying the 
rib are cut through parallel to its long axis for a distance of two 
or three inches, the scalpel being 1 pressed firmly against the rib 
so as to split its periosteum. This is then reflected above and 
below, and bone shears passed between the inner portion of peri- 
osteum and the rib. An inch of the rib is removed and its cut 
edges trimmed if rough. The pleural cavity is then opened in 
the long axis of the rib, and when most of the pus has escaped two 
soft-rubber tubes pierced by the same safety pin are inserted. A 
stitch at either end of the wound is an advantage. A dry creolin 
gauze dressing is applied and changed as often as it becomes mois- 
tened by pus. . Forced expiration should be practised as soon as the 
soreness of the wound has somewhat subsided, say by the fifth 
day. The patient is shown how to blow colored water from one 
Wolff bottle to another. This exercise should be kept up for five 
minutes, and repeated several times a day. It is of the greatest 
service in stretching the collapsed lung so as to make it resume its 
normal space in the pleural cavity. The force of expiration can 
be increased by elevating the second bottle a few inches. 

Drainage with two tubes should be continued until granula- 
tions have shut off the pleural cavity from the wound. The tubes 
may be shortened a half inch at a time as the cavity grows smaller, 
but they should not be removed as long as they enter the pleural 
cavity; nor should they be replaced by tubes of smaller caliber. 
Neglect of this rule has turned acute cases into chronic ones and 
made secondary operations necessary to reestablish drainage. 

. CHRONIC INFLAMMATIONS 

Syphilis. The trunk has its full share of the secondary and 
tertiary lesions of syphilis. An isolated minima, appearing long 
after all other manifestations of the disease have disappeared, is 

often a puzzle in diagnosis. A common seat for the same is the 
14 



178 INJURIES AND INFLAMMATIONS OF THE TRUNK 

region of the sternum. The constitutional treatment is important. 
Any protective dressing will answer locally. 

Tuberculosis. Tuberculosis involves the skin of the trunk, 
and especially of the back (lupus). Its essential characteristics 
are the same as those of the disease when seated in the skin of 
the face (see p. 63). Because of the concealed situation, more 
radical excision and skin-grafting are permissible. 

Tuberculosis of the bones and joints of the trunk is so fully dis- 
cussed in larger works upon surgery and orthopedic surgery that it 
will be considered here chiefly for the sake of early diagnosis. 

Tuberculosis of the Sternoclavicular Articulation. This' joint 
is attacked by tuberculosis as well as by syphilis. In either case 
the periarticular tissues are swollen. In tuberculosis, one or more 
tender spots in the end of the clavicle can usually be made out. 
Later an abscess may form and rupture. 

If treatment by fixation is determined upon, it is easily secured 
by keeping the arm bandaged to the chest and carrying the fore- 
arm in a sling. 

Costal Tuberculosis. One or more ribs may be attacked by 
tuberculosis. The general health of the patient suffers little, so 
that the disease may be disregarded for some time. When the 
patient first comes for examination, there may be an abscess or a 
sinus, the pus having already broken through the skin. A probe 
will follow such a sinus obliquely to the eroded bone. The fingers 
will recognize that beyond the abscess-cavity the periosteum is 
thickened. More than one rib is often involved, the extent of the 
disease being greater in one than in the other. Erosion of the 
inner surface of the rib is usually more extensive than that of its 
outer surface. 

Operative treatment is strictly indicated, and should be car- 
ried out under general anesthesia. An incision should be made 
over the affected rib parallel to its long axis, and the diseased bone, 
periosteum, and other tissues fully removed. This can usually 
be accomplished without opening the pleural cavity, so that the 
shock of operation is slight. The wound should be fully drained. 
Recovery from the operation is prompt, but the patient should lie 
kept under observation for a considerable time, as extension of 
the process along the same or adjacent ribs is the rule rather than 
the exception. 



TUBERCULOSIS 179 

Tuberculosis of the Vertebrae The symptoms of tuberculosis 
of the cervical vertebne have been given on page 133. When the 
disease is situated in the dorsal or lumbar vertebrae, the symp- 
toms elicited vary somewhat according to the accessibility of the 
parts to palpation, and the varying degrees of motion that are 
their normal possession. An essential to diagnosis in every case 
is a thorough examination of the whole back, stripped to the skin 
for the purpose. Such an examination will almost always enable 
the surgeon to state positively, even in the early stages of the dis- 
ease, not only that the spine is affected, but that the disease is situ- 
ated in certain vertebrae. The various symptoms to be observed 
are: Slight edema along the spinous processes, slight deformity 
(which often disappears entirely in some positions), tenderness 
when the affected vertebra? are pressed upon (a sign often absent 
in children who cannot or will not differentiate pressure upon one 
vertebra from that on another), and rigidity or a lack of freedom 
in using the affected part of the spine. Compare the tests for 
sprain of the back given on page 162. A symptom which is 
chronologically a late one, but which is sometimes the first thing 
a patient notices, is the swelling due to an abscess. This may be 
situated near the spine posteriorly or it may come to the surface 
at the side of the trunk, or following down the front of the spine it 
may appear above or below Poupart's ligament. 

TREATMENT. As is well known, the treatment for a tubercu- 
lous focus which cannot be removed is immobilization, and relief 
from pressure. In the case of the spine these objects are partially 
obtained by a plaster jacket or a brace, and more perfectly ob- 
tained by a stretcher frame, a form of apparatus especially adapted 
to a child of four years or less. 

Sacroiliac Tuberculosis. Another common seat for tuberculosis 
is the sacroiliac synchondrosis. The difficulty of recognizing the 
disease in this situation is great, so that a correct diagnosis is often 
not made for a long time. A history of traumatism is apt to 
be confusing; the traumatism may have caused the trouble or be 
entirely independent of it. In either case it is apt to mislead the 
surgeon into thinking that he has to do with a severe sprain. The 
early symptoms are pain, slight fever, and a disinclination to 
exertion. As there is practically no motion between the ilium 
and sacrum, the best sign of tubercular joint disease, namely, limi- 



180 INJURIES AND INFLAMMATIONS OF THE TRUNK 

tation of motion, is in this case wanting; yet the patient moves 
with awkwardness and unusual care when he is asked to stoop, rise, 
sit, squat, etc. If there is no history of injury the diagnosis of 
rheumatism is apt to be made. The age of the patient, the limi- 
tation of the trouble to a joint to which rheumatism is rarely if 
ever confined, and the slight but constant afternoon fever, serve 
to differentiate the two 'diseases. 

TREATMENT. In tuberculosis, of course, no benefit follows the 
administration of salicylates. Treatment is eminently unsatis- 
factory. Cases have been recorded in which an early resection of 
the joint has led to recovery, but owing to the fact that a diagnosis 
is usually not made until pus appears either in the groin or in 
the buttock, the most favorable period for radical treatment has 
already passed, so that operations are usually palliative, to alVord 
a more direct exit for the pus and so to relieve the patient of pain 
and some fever. The usual course is a steady decline through some 
years to death, unless the resisting power of the patient can he- 
raised by hygienic measures. 

Tuberculosis of the Mammary Gland. One of the less common 
situations for tuberculosis is the mammary gland. Because of its 
rarity, and because of the similarity of the lesion in its general 
outline to carcinoma of the breast, this mistaken diagnosis is often 
made. There will generally be a history of tuberculosis in the 
patient, or examination of the corresponding lung may show that 
the primary trouble was located within the chest and has worked 
outward. If an ulcer or sinus exists its appearance will keep an 
observant man from making a wrong diagnosis. There will be in 
the edges of the tubercular ulcer none of the active growth which 
is always seen in the edges of a carcinomatous ulcer. The axil- 
lary glands are usually enlarged if an ulcer exists. 

TREATMENT. In tuberculosis of the breast it is quite unneces- 
sary to remove more than the affected part. Usually the whole 
gland is diseased at the time of operation, but unless the axillary 
glands are plainly diseased it is wrong to subject the patient to 
the e,xtra shock of an axillary dissection. On account of the pos- 
sible involvement of an underlying rib, a general anesthetic is 
preferable. If the disease is plainly limited to the freely movable 
breast-gland, a complete removal can be satisfactorily effected 
under local anesthesia if the patient's temperament warrants it. 



CTTAPTETC YTT 
TUMORS AND DEFORMITIES OF THE TRUNK 

TUMORS 
CYSTIC TUMORS OF THE TRUNK 

Sebaceous Cysts. These cysts occur less often upon the 
Irmik lluin upon the head. They are very rare below the waist 
line. They have the same characteristics as those of the head 
(p. GO) and require the; same treatment. 

Umbilical Cysts and Sinuses. Tt sometimes happens that 
the duct which in fetal life leads from the umbilicus to the blad- 
der, and which is called the nraehns, is not completely closed at 
hirlh. Or it may be closed in part. As a result there may be a 
sinus discharging urine, or a short sinus with a slight discharge 
of sebaceous material, or a cyst lined with epithelium and contain- 
ing sebaceous material. Or it may have no external orifice and 
may first manifest itself as a tumor situated below the umbilicus 
and containing sebaceous material. 

TREATMENT. The cyst or sinus should be removed by dissec- 
tion through an elliptical incision made close around it. In some 
cases this is very easy; in others it is necessary to open the peri- 
toneum for a short distance. As it is impossible to know this 
beforehand, the operation should be performed with extreme asep- 
tic precautions. When the cyst or sinus has been removed, the 
abdominal wall should be closed in three layers peritoneum, deep 
Fascia, and skin in order to prevent hernia. As the condition is 
an annoying one, rather than one which interferes with healthy 
development, the operation may be safely postponed if the patient 
is an infant, until it is some years old. 

Coccygeal Cysts and Sinuses. These formations are 
congenital in origin, but they may not be noticeable until adult. 

life. In their simplest form the skin at the lower end of the 

181 



182 TUMORS AND DEFORMITIES OF THE TRUNK 

spine is so folded in upon itself that it forms an isolated cyst, 
lined with epithelium, or a sinus also lined with epithelium, one 
or both ends of which reach the surface of the skin. As the epi- 
thelium contains hair-roots, such a cyst or sinus is likely to fill up 
with sebaceous material and short hairs. If near the surface the 
contents may discharge from time to time. Such a cyst or sinus 
is usually situated low down in the median line over the coccyx 
or sacrum. It is likely to become inflamed from time to time. 
With the discharge of a mixture of sebaceous material and pus, 
the acute signs of inflammation subside. 

TREATMENT. To rid the patient of this annoying condition 
the cyst or sinus should be fully exposed by a median incision and 
all traces of an epithelial structure removed. The wound may 
then be closed by suture, and primary union be anticipated even 
if acute infection is present; although, if the infection is marked, 
it is advisable to drain with a wick of rubber tissue some portion 
of the wound. At the change of dressing on the first or second 
day this should be removed, and if the inflammation has subsided 
it should not be reinserted. The operation is readily performed 
under local anesthesia. 

Dermoid Cysts. There are other dermoid tumors in the 
region of the coccyx which may contain, in addition to sebaceous 
material and hair, fragments of bone and other structures, or even 
fairly well developed portions of another fetus or twin. They 
should be removed and the gap closed by a plastic operation or 
by skin grafts. 

CYSTIC TUMORS OF THE BREAST 

Retention Cysts of Infancy. An infant's breast some- 
times secretes a milky fluid, which collects in the larger ducts 
about the nipple, and forms a soft fluctuating swelling. If the 
secretion is forcibly expressed from the nipple once or twice the 
swelling will disappear. 

Retention cyst in the adult may be due to scar tissue, fol- 
lowing abscess of the breast, or perhaps a misdirected incision. 
It will usually not be necessary to excise such a cyst. If it 
is split open and drained the normal granulations will obliter- 
ate its cavity. (Compare the description of a salivary cyst on 
page 71.) 



GRANULOMA OF THE UMBILICUS 183 

Simple Cysts and Cystic Adenomata. Cysts of the 

mammary gland apparently due to disordered secretion are very 
common in young women. Such a tumor is freely movable, 
rounded, and elastic; but it is very difficult to obtain fluctuation 
in it on account of its small size. It cannot always be differ- 
entiated from a solid tumor, except by aspiration. Moreover, 
the withdrawal of fluid does not absolutely distinguish the two, 
as many adenomata and some malignant tumors contain cysts. 
Naturally, in such a case, the withdrawal of the fluid will not so 
collapse the tumor as it will a simple cyst. The fluid may be like 
serum, straw-colored, or it may have a pink, red, or brown tint. 

TREATMENT. Aspiration as a means of diagnosis has been 
spoken of. It sometimes cures the patient, the fluid not again 
accumulating. Should this happy result not follow, or should the 
withdrawal of fluid not cause the immediate collapse of the tumor, 
operation is indicated. Small tumors can be removed from the 
breast under cocain; but on account of the sensitiveness of the 
part, and of the patient, a general anesthetic is better in most 
cases. If the operation is a short one the patient can rise and go 
home in a few minutes. It is well to bear in mind that a small, 
easily movable tumor seems much nearer the surface during pal- 
pation than it does when one is cutting through skin, fat, and 
fascia and an outer layer of the mammary gland in the search for 
it. It is a help to have the assistant seize the gland on either side 
and stretch the skin tightly over the tumor while the incision is 
being made. 

The incision itself should radiate from the nipple. So much 
of the mammary gland as contains the cyst should be removed by 
an elliptical or a pie-shaped incision. The wound in the gland 
should be closed by catgut sutures, and the wound in the skin 
should be closed by silk sutures. No drainage should be used, or 
at most a small wick of gutta percha tissue introduced through 
the skin to provide for the escape of blood. 

SOLID BENIGN TUMORS OF THE TRUNK 

Granuloma of the Umbilicus. Excessive granulation 
sometimes follows the removal of the stump of the umbilical cord. 
Owing to the confined situation the mass of granulations gradu- 
ally assumes a polypoid shape. 



184 TUMORS AND DEFORMITIES OF THE TRUNK 

TREATMENT. This condition is easily cured by the applica- 
tion of a drop of pure carbolic acid on a wooden toothpick. A 
slower but safer and no less certain method is the daily applica- 
tion of undiluted hydrogen peroxid upon a minute cotton swab. 
This method is preferable if the point from which the granula- 
tions spring is so hidden by folds of fat that it is not readily 
brought into view. 

ITSTTRA-ABDOMINAL COMPLICATIONS. In rare cases a poly- 
poid tumor of the umbilicus is covered with mucous membrane; 
or it may be lined with mucous membrane and communicate 
with the intestine. It should be removed, but not until tun- 
has at hand sutures to close a possible opening into the in- 
testine, and others to close a gap in the abdominal wall if 
necessary. 

Keloid. This firm, smooth tumor occurs in scars, especially 
in those of the trunk. It is made up of fibrous tissue, is inti- 
mately connected witli tlie curium, projects a quarter of an inch 
more or less above the level of the skin, and is covered with a 
shiny epithelium of poor qua'lity, in which dilated vessels are 
often seen. At an early stage of its development it cannot be 
told from a hypertrophied scar. As time goes on, however, the 
hypertrophied scar tends to shrink and lose its pink color, while 
the keloid maintains its size or continues to grow, exceeding the 
original limits of the scar, and sometimes sending out prolonga- 
tions into the skin around, which have been compared to crabs' 
claws, hence the name keloid. When a keloid develops in a wound 
which has been sutured, the scars of the individual stitches some- 
times give rise to a greater growth than the line of incision itself. 
The skin of the negro is peculiarly susceptible to the formation 
of keloids. 

TREATMENT. Surgical ingenuity has not yet succeeded in 
evolving a generally successful cure of keloid. Individual cures 
by various means have been reported, by dissection, by caustics, 
by long-continued elastic pressure, and by the X-ray. If the orig- 
inal scar was a bad one, and the surplus skin in the vicinity per- 
mits of a complete dissection, with suture of the wound and prob- 
able primary union, this plan is worth trying. The suture should 
be an intracuticular one, or the interrupted stitches of fine silk 
should be removed at the earliest possible moment, about four 



L1PUMA 185 

days. Tension upon the new scar should be prevented by cross 
strips of adhesive plaster for several weeks. But even when all 
these precautions are taken recurrence often follows. 

Papilloma : Fibroma : Fibrolipoma. These names are 
given to pedunculated tumors of fat and fibrous tissue covered 
with essentially normal skin. They vary in size from that of a 
pin-head to one inch or more in diameter. Frequently the tumors 
are multiple. The pedicle is usually small, but always contains 




FIG. 103. FIBROLIPOMATA OF THE BACK, OF FIVE YEARS' DURATION. Patient a 

girl aged nineteen years. 

an artery of a size corresponding to the size of the tumor. In this 
respect they differ from lipoma in which the blood-supply is very 
scanty (Fig. 103). A papilloma is a strictly benign growth, but 
<>n account of the annoyance caused by it, and its tendency to in- 
crease in size, it had best be removed. 

TREATMENT. A small papilloma may be snipped off even with 
the surface of the skin with a pair of scissors. A larger one should 
be removed by an elliptical incision close to the base of the pedicle, 
made through the whole thickness of the skin. Such a wound 
when sutured will give the minimum of deformity. 

Lipoma. Lipoma of the trunk is relatively common, espe- 
cially upon the shoulders. Such a tumor is lobulated, and while 
growing in the layer of subcutaneous fat its septa are intimately 
adherent to the skin. Hence the skin is dimpled when an attempt 
is made to lift it from the tumor. This is one of the diagnostic 



186 TUMORS AND DEFORMITIES OF THE TRUNK 

signs of lipoma of the simple subcutaneous type. It is well en- 
capsulated by thin planes of connective tissue, so that it is easily 
shelled out. 

TREATMENT. On account of the insensitiveness of the parts 
involved below the skin the removal of even a large lipoma of the 
trunk can readily be accomplished with a local anesthetic (Figs. 
104 and 105). This applies only to the simple or usual type of 
lipoma. For a description of the diffuse lipoma and of the inter- 
muscular lipoma, both of which varieties are found in the trunk, 




FIG. 104. LIPOMA OF BACK. Two years' duration; removed without pain, with an 
injection of 40 minims of 2 per cent, cocain solution. Another view of tumor is 
shown in the upper corner. 

see page 139. The skin is incised for a distance equal to one-half 
or more of the diameter of the tumor. If the tumor is covered 
by a layer of the subcutaneous fat, this is also divided so that 
the capsule of the tumor shall be exposed. This capsule is next 



ADENOMA 



divided, and then the 
fatty tumor can be 
readily peeled out of 
its compartments in 
the fascia, by a blunt 
and generally blood- 
less dissection, with 
the fingers or blunt- 
pointed curved scis- 
sors. With the remov- 
al of the tumor the 
edges of the wound 
are to be fully retract- 
ed and any bleeding 
points secured and 
compressed or ligated 
with fine catgut. The 
skin is sutured with- 
out drainage or over 
a wick of gutta- 
percha tissue. 




FIG. 105, LIPOMA SHOWN IN Ficfino 1()4 AKTKK RE- 
MOVAL. The scale of inches shows its length. Its 
weight was 25 ounces. 



SOLID TUMORS OF THE BREAST 

Hypertrophy. Sometimes during adolescence one of the 
breasts will become abnormally firm and larger than its fellow 
and rather more sensitive to pressure, but without acute pain. 
The enlargement is diffuse and uniform, and there is no adhesion 
of the breast to the structures either beneath or superficial to it. 
Such a condition has a tendency to resolve in the course of time. 
This return to the normal state may be hastened by an applica- 
tion of ichthyol ointment. 

Adenoma. An adenoma or an adenofibroma of the breast is 
a tumor which is composed of a localized increased growth of 
glandular and fibrous tissue. There are several types of such 
tumors distinguishable microscopically, but as no adenoma is com- 
posed only of glandular tissue and no fibroma is without a certain 
increase in glandular tissue, and as both of these often contain 
cysts, an exact differential diagnosis between them is not always 
possible, nor has it more than a pathological significance. The 



188 TUMORS AND DEFORMITIES OF THE TRUNK 

tumor is generally painless and is first noticed by the patient 
during a bath or by accident. In other cases there is a little pain 
in the tumor. 

TREATMENT. Such tumors are essentially benign, but they 
may also change their type of growth into one which has a ten- 
dency to spread into the surrounding tissues. Hence they should 
be removed, or at least carefully watched from month to mouth 
in order to bo sure that they are not growing. Puncture with a 
hypodermic needle, and aspiration, will differentiate between a 
cystic and a solid tumor if fluid is obtained. A negative aspira- 
tion is not conclusive (p. 183). If the tumor is small and freely 
movable, a local anesthetic will often suffice; but otherwise, and 
especially if the patient is more than thirty years of age, she 
should be told beforehand of the possibility of a major opera- 
tion and should be given a general anestheiie. If the growth is 
found to be malignant, the operation should be continued until 
it includes the removal of the breast and dissection of the axillary 
and clavicular regions, and the excision of one or both pectoral 
muscles, according to the judgment of the surgeon. It is of great 
assistance at such times to have a pathologist present, who, by ma- 
king frozen sections of the excised tumor, can determine whether 
or not it is of a malignant character. In general, one should be 
very suspicious of even a small, freely movable tumor which has 
been growing but a few months and is painful. This is especially 
the case if the patient is a woman more than thirty years of age. 

The Early Diagnosis of Malignant Tumors of the 
Breast. The treatment of malignant tumors of the breast is 
quite out of the range of minor surgery, but the importance of a 
correct diagnosis in the early stages is so great and these tumors 
are so often first seen in ambulatory practise, that the diagnostic 
points should be emphasized. 

In examining a patient's breast these points should be observed : 

Palpation. The patient should lie flat on the back with both 
breasts exposed for the sake of comparison. Some examiners pre- 
fer to have the patient sit upright, but the recumbent position is 
better for a thorough examination. Each breast should then be 
thoroughly examined by rolling its substance between the palmar 
surface of the fingers and the wall of the thorax. The aim of the 
examination is to determine the presence of any nodules or other 



EARLY DIAGNOSIS OF MALIGNANT TUMORS OF THE BREAST 189 

irregularities. If there are multiple nodules in both breasts, the 
case is probably one of chronic mastitis. The same is probably 
true of multiple nodules in one breast, for if these are cancerous, 
the disease will of necessity be far advanced, and some of the other 
symptoms will be present. A single nodule in one breast, or in 
each breast, may or may not be cancer. It should be further 
examined. 

Retraction of the Skin. This is best shown by pushing the 
breast, but not the tumor, toward the suspected part of the skin. 
Retraction of the skin, under these circumstances, is one of the 
most reliable signs of cancer. 

A Flattening of the Normal Curve of the Breast Over the 
Tumor. This is determined by sighting across it with the eye 
on the same level. If present it is an indication of malignancy. 

The Presence of One or More Enlarged Glands in the Axilla 
or Between the Breast and Axilla. This is not one of the earliest 
signs. Both axilla? should be palpated. If the glands in each are 
equally enlarged, and only one breast contains a nodule, the axil- 
lary glands are presumably non-cancerous. 

Palpation of the axilla is best performed as follows: If the 
left axilla is to be palpated, the surgeon stands to the right side 
of the patient. He lifts her left arm away from the body, and 
places the fingers of his right hand well up in the left axilla. The 
arm is then lowered, or brought to the chest, until the muscles are 
relaxed. The surgeon is then able to draw his fingers with the 
skin of the axilla back and forth over the axillary contents, and 
to feel any glands which are present. 

Retraction of the Nipple. This is an early sign of cancer 
only when the disease begins under or near the nipple. In other 
cases the growth may be well advanced before retracting the nipple. 

Hemorrhage from the nipple, either spontaneous or occurring 
\vhen the nipple is gently squeezed, is a symptom of value if there 
is no inflammation or other obvious explanation of its occurrence. 

Failure to Withdraw Fluid through a Fine Aspirating Needle. 
A long hypodermic needle is sufficiently large. Fluid indicates 
cystadenoma in most cases, though some cancers contain fluid. 

The importance of carcinoma of the breast is so great that, 
unless the examiner can be sure that the tumor is of a benign char- 
acter, he had better assume it to be malignant. In doubtful cases 



190 



TUMORS AND DEFORMITIES OF THE TRUNK 



a section should be removed for microscopical examination. This 
may be successfully done with cocain, unless the patient is of a 
nervous disposition. If the tumor is malignant, an extensive re- 
moval of breast and axillary gland and pectoral muscles and fascia 
is indicated. 

Carcinoma beginning in the nipple, so-called Paget's disease, 
may be mistaken for eczema. There is redness and scaliness, fol- 
lowed by a shallow ulceration with a slightly indurated base and 
narrow indurated margin. It is inexcusable to neglect such a con- 
dition, since the microscopic examination of a small section of 
the affected skin will reveal the true nature of the disease." 

Sarcoma. Sarcoma of the breast differs somewhat from car- 
cinoma in its gross characteristics inasmuch as it usually develops 

at a greater dislmirr 
from the nipple and 
forms a diffuse swelling 
deeply situated beneath 
the skin, and often ex- 
tending beyond the mar- 
gin of the breast in one 
or more broad lobules 
before the surgeon's 
advice is sought in re- 
gard to it. It grows 
rapidly, without pain, 
and forms new nodules 
by continuity rather 
than through the lym- 
phatic system; hence 
the axilla may be en- 
tirely free although the 
tumor has grown to a 
diameter of two inches 
or more. Such a free- 
dom of the axilla is 




FIG. 106. EPITHELIOMA OF THE BACK AT AN 
EARLY STAGE. The drawing was made from 
the tumor after removal. Note the margin of 
healthy skin on all sides of the epithelioma. 



never seen in carcinoma 
of the breast of a similar 

size. Sarcoma grows more rapidly than carcinoma, and a thor- 
ough and early removal is, therefore, not less important. 



CARCINOMA AND SARCOMA 



191 



Tuberculosis may be mistaken for a malignant tumor (see 
p. 180). 

Tumors of the Male Breast. The male breast, as has al- 
ready been said, suffers from the same diseases as the female 




Fir,. 107. Cnoss-SECTioN OF THE TUMOR SHOWN IN FIGURE 106. Note that the 
tumor has not yet invaded the subcutaneous tissue. 

breast. As the fear of disfigurement is not so strong, the male 
patient will usually seek surgical advice soon after he has discov- 
ered the tumor of the breast. Hence the prognosis along opera- 
tive lines is fairly good. If neg- 
lected, however, cancer of the male 
breast develops in fully as virulent 
a manner as that of the female 
breast, forming metastases, extend- 
ing inward into the chest, and 
causing the death of the patient 
from exhaustion. 



MALIGNANT TUMORS OF THE 
TRUNK 

Carcinoma and Sarcoma. 

The skin of the trunk may be 
the seat of malignant tumors. 
They have no especial character- 
istics due to their situation (Figs. 
106 and 107). If seen early, 
the prognosis after removal is un- 
usually good, since the surrounding 




FIG. 108. MELANOSARCOMA OF 
LOWER ABDOMEN OF FOUR 
MONTHS' DURATION GROWING 
FROM A MOLE OR SOFT WART. 
Patient a woman aged fifty-four 
years. 



192 



TUMORS AND DEFORMITIES OF THE TRUNK 



tissues may be 
sacrificed with 
much freedom, and 
hence the incision 
is usually earned 
wide of the growth 
(Fig. IDS)/ 

An instructive 
mistake in diag- 
nosis is connected 
with the patient 
shown in Figure 
109. A fluctuat- 
ing swelling devcl- 
o|H d soon after an 
injury. Aspiration 
produced a bloody 
fluid, and the needle 
touched abnormal 
bone. A diagnosis 
of sarcoma of the 
scapula was made. 
When the patient 
was operated upon 
it was found that 
there was an osteoma of the scapula, which had so irritated an 
adjacent bursa as to cause an accumulation of bloody fluid. 




FIG. 109. CYST UNDER SCAPULA. One week's duration. 
Due to subscapular osteoma and traumatism. 



ACQUIRED DEFORMITIES 

Displaced Coccyx : Goccygodynia. Falls upon the base 
of the spine may bend the coccyx backward or forward, or otherwise 
injure it. It may then become the seat of annoying and persistent 
pain, called coccygodynia. The projection forward of the bone 
may interfere with defecation and prevent its easy performance. 

The history given by the patient of a severe fall, followed by 
pain and tenderness which have never entirely disappeared, should 
lead at once to a physical examination. The patient either stands 
or lies upon his side with knees drawn up. The surgeon passes 



DISPLACED COCCYX: COCCYGODYNIA 



193 



the well lubricated finger high up into the ivHimi, I ho palmar 
surface of the finger being directed backward. The lower part 
of the sacrum and the coccyx can then be grasped between the 
forefinger and the thumb. The size and direction of the coccyx 
and the possible range of motion in the joint between it and the 
sacrum should be noted ; also the existence of any tender spots. 

TREATMENT. If there is reason to attribute the existing pain 
to the coccyx, or if it is ankylosed or is badly deflected and 
cannot be brought 
into normal relation 
to the sacrum with- 
out pain, the coccyx, 
or a portion of it, 
should be removed. 
A two inch median 
incision is sufficient 
for the purpose. 
The patient's bowels 
should be thorough- 
ly emptied on the 
previous day. At 
the time of 1 opera- 
tion the skin in the 
vicinity should be 
thoroughly cleansed, 
but no enema given 
nor rectal examina- 
tion made just before 
operation. Either 
local or general an- 
esthesia is satisfac- 
tory. The incision 
is started at the level 
of the joint between 
sacrum and coccyx 
and extended a dis- 
tance of not more 
than two inches toward the anus. Skin and fat are divided and 
the coccyx cut down upon. The soft tissues are dissected from it 
15 




FIG. 110. REMOVAL OF A DISPLACED COCCYX. The 
wound necessary for its removal has been closed by 
four sutures. Photograph taken four days after 
operation, and retouched only to make the stitches 
and wound more prominent. The coccyx is laid on 
the patient's buttock. 



194 TUMORS AND DEFORMITIES OF THE TRUNK 

posteriorly and along both sides. The joint between sacrum and 
coccyx -is opened and the ligaments divided. If the bones are 
aukylosed they must be separated with bone shears or a chisel. 
The upper end of the coccyx is then seized and pulled backward. 
The soft tissues in front of the coccyx are then pushed and cut 
away from its anterior surface and the bone is withdrawn from 
the. wound. In this manner it is easy to avoid wounding even 
the outer coats of the rectum. Bleeding is controlled by pressure 
or ligation, the cavity is obliterated by buried sutures of catgut, 
and the skin is sutured with horsehair or fine black silk (Fig. 110). 
If any drain is employed it should be a small gutta percha one, 
to be removed in two days. Primary union should be obtained. 
The patient should lie in bed for two days, and should avoid for 
some days longer any sitting or other posture which will tend to 
separate the edges of the wound. 

Hernia. A hernial sac is a protrusion of a part of the peri- 
toneum through an opening in the abdominal wall. In this sac 
there may or may not be found portions of the abdominal organs. 
If they can be " replaced " in the abdominal cavity the hernia is 
called " reducible." Otherwise it is an " irreducible " hernia. 
Such reduction may be impossible on account of altered shape of 
the organs in the sac, its " contents," so-called, or on account of ad- 
hesions which have formed around the sac and its contents. The 
hernia may become inflamed as a result of traumatism, etc. This 
rarely leads to suppuration. It may produce so much swelling of 
the hernial contents that the blood-vessels which supply them are 
occluded, and strangulation results (Strangulated Hernia, p. 198). 

A hernia may exist at birth or develop soon afterward in an 
abnormally weak spot in the abdominal wall. It may also appear 
in later life, either suddenly, following some crush or severe strain, 
or gradually, as the result of oft repeated lesser strains. 

The subject of hernia, and especially its operative treatment, 
is exhaustively discussed in works upon major surgery. Still, the 
general means of correct diagnosis and the ambulant treatment of 
patients who, for one reason or another, cannot be operated upon, 
are here in place. 

GENERAL PRINCIPLES or DIAGNOSIS. A patient suspected to 
have a hernia should be examined in both standing and recumbent 
postures. 



HERNIA 195 

Inspection may show variation iu size at different times if the 
hernia is reducible. Peristaltic movements are often visible in 
large intestinal hernia?. 

Palpation may reveal the presence of intestinal coils, of gurg- 
ling gas and fluid, of lumpy omentum, or of pasty fecal masses 
capable of being indented. 

Compression, when the patient is recumbent, may affect the 
reduction of the hernia. 

Percussion will bring out the resonance of intestinal coils con- 
taining gas. It will also give a thrill in case the swelling is due 
to a hydrocele or a cold abscess. 

Auscultation may reveal an intestinal gurgle or, in rare cases, 
an aneurysmal thrill. 

An impulse on coughing is obtained in case of most hernia'. 
It may also be obtained, though less marked, in case of a large 
varicocele or in case of a hydrocele which extends well up into 
the inguinal canal. 

Reduction of the swelling upon compression or spontaneously 
when the patient lies down is very significant of hernia, but may 
also occur with an imperfectly descended testis or a cold abscess. 

GENERAL PRINCIPLES OF TREATMENT. Operation for hernia, 
wherever situated, to be successful must accomplish these three 
steps: 1. The reduction of the hernial contents, either before or 
after the sac has been opened. 2. The closure of the peritoneal 
cavity at the normal level. The sac is usually tied at this point, 
its neck, and the surplus removed. 3. The approximation by firm 
sutures of the damaged wall of the abdomen, or at least of its 
strongest part, namely, the deep fascia. The various methods of 
accomplishing these three steps vary in different situations and in 
the hands of different operators. They are fully described in all 
surgical text-books. 

If the condition of the patient and the character of the hernia 
make it probable that the three steps above described can be car- 
ried out by operation, and primary union attained, operation 
should be advised. It is, of course, absolutely indicated in case 
of strangulated hernia as a relief of acute symptoms, even under 
circumstances in which a permanent cure of the hernia is not to 
be expected. 

A truss is to be recommended in all other cases of reducible 



196 TUMORS AND DEFORMITIES OF THE TRUNK 

hernia. A patient having an irreducible, inoperable hernia is in- 
deed in a bad state. Some of them gain relief by an operation 
which changes the hernia from an irreducible to a reducible one, 




FIG. 111. DORSAL HEUNIA FOLLOWING KRASKE'S OPERATION FOR CARCINOMA OF 
THE RECTUM. The hernia developing through the gap in the posterior pelvic 
wall caused by the removal of the sacrum, contained the greater part of the 
small intestine and the sigmoid flexure. 

so that a truss can be worn. An unusual type of partly reducible 
hernia is shown in Figure 111. 

The symptoms of hernia in different situations vary greatly. 
A brief description is therefore given of each. 

Umbilical Hernia. Hernia of the umbilicus in the new-born is 
extremely common. The sac is usually small and contains intes- 
tine or is empty. This hernia has a strong tendency toward 
recovery, but to facilitate this end it should be constantly kept 
pressed back by means of a cloth-covered, wooden button-mold 
and a short strip of adhesive plaster. This should be changed 
every day or every second day after the infant's bath, but before 
the old one is removed the new one should be prepared, and in 
the interval the hernia should be pressed back by the nurse's fin- 
ger until the new button is put in place. The plaster should extend 
in a different direction every day so that the skin may not become 
irritated. If treated in this manner the great majority of infan- 
tile umbilical hernia? can be cured in a few months. 

Umbilical hernia in the adult is especially common in stout 



HERNIA 197 

persons of middle age. It first appears as a flabby tumor as large 
as the terminal joint of the finger, covered with normal skin. It 
is usually irreducible. Its contents are omentum. As it grows 
the sac becomes more distended ; small intestine will often be added 
to the omental contents. This part of the hernia is usually re- 
ducible, at least for a considerable period. Such a hernia fre- 
quently becomes strangulated. 

A truss is an unsatisfactory appliance for umbilical hernia of 
tlie adult. An operation should be performed early, if possible 
before intestine is involved. 

Inguinal Hernia. Inguinal hernia is more common than femo- 
ral hernia both in the male (39 to 1) and female (3 to 2) ; or, to 
put it differently, for every 84 inguinal hernias in the male there 
are 8 inguinal hernias in the female, 6 femoral hernias in the 
female, and 2 femoral hernias in the male. It is usually indirect, 
that is to say, the omentum, intestine, etc., which fills its sac leaves 
the abdomen by the normal route of the inguinal canal, and does 
not burst through the posterior wall of the inguinal canal to the 
median side of the epigastric artery (direct inguinal hernia). 

Inguinal hernia may be congenital or acquired, and if acquired 
it may develop suddenly as the result of a crush or strain, or slowly. 

SYMPTOMS. These symptoms are usually present : normal 
movable skin; underlying tumor giving impulse on coughing, 
growing smaller or disappearing entirely under pressure or on 
lying down; enlarged ring and inguinal canal evident on reduc- 
tion of tumor; reduced tumor does not reappear when patient 
stands and coughs if the canal is blocked by the surgeon's finger ; 
no true fluctuation ; opacity to transmitted light. 

Possible additional symptoms of intestinal hernia are : reso- 
nance on percussion, gurgling on manipulation, indentation of 
doughy fecal masses in large intestine. 

TREATMENT. Treatment by operation entails only a slight 
risk, and is generally successful. It should therefore be advised 
in the case of all healthy children and active adults. Treatment 
by truss is advisable for feeble and aged persons and for those 
whose tissues in the inguinal region are so thinned by previous 
unsuccessful operation that they cannot be made to withstand the 
intra-abdominal pressure. 

A truss is a pad held firmly against the lower part of the 



198 TUMORS AND DEFORMITIES OF THE TRUNK 

inguinal canal to prevent the exit of the omentum, etc., from the 
abdominal cavity. It has been well compared to the stopper of a 
bottle. Opinions differ as to the best form of truss. A satisfac- 
tory truss is one which, with a minimum of pressure and without 
causing the patient any pain, prevents the hernial contents from 
entering the hernial sac. 

The hernia must be fully reduced before a truss is applied. 
This is best done when the patient lies on his back. A truss 
should never be applied to a hernia which is only partially re- 
ducible. It will rarely succeed in keeping back the rest of the 
hernial contents, and by its pressure on the part already in the 
sac it will cause pain and possibly serious inflammation, or even 
gangrene. 

A truss is rarely needed in case of a very young infant; but 
before the child is old enough to walk it should be fitted with a 
truss or should be operated upon. Operation is advisable for large 
congenital hernia, as cure is improbable when the neck of the sac 
is so wide. If the tunica vaginalis communicates with the peri- 
toneal cavity by a rather narrow passage, and the contents of the 
hernial sac can be reduced into the abdomen without dragging the 
testicle upward, a truss may cure the patient in the course of a 
few years. For this purpose it should be worn constantly day 
and night, as crying no less than walking will force the abdominal 
organs into the hernial sac. As the child grows older the truss 
may be left off at night, and if the neck of the sac becomes oblit- 
erated the truss need only be worn during exercise, and finally 
not at all. A cure is sometimes obtained from a truss in adult 
life, but is far less likely after the patient has attained his growl h. 

Femoral Hernia. In femoral hernia the protrusion of abdom- 
inal contents is under Poupart's ligament and through the femoral 
ring. Such a hernia is usually small, and this fact, added to the 
tortuous course of the canal, sometimes obscures the impulse on 
coughing and renders diagnosis difficult. An enlarged lymphatic 
gland, with which femoral hernia is often confounded, if unilat- 
eral has almost always an evident cause in some scratch or cut 
of the foot or leg. 

Femoral hernia should always be treated by operation. 

Strangulated hernia always requires treatment in bed or im- 
mediate operation, but most of the patients are seen by a physician 



ASCITES-PARACENTESIS 199 

while they are still walking about, so that the symptoms should 
be fixed clearly in mind, ready for instant service. They vary 
according to the character of the compressed organ. Omentum 
may become strangulated and give only moderate pain and dis- 
ability for days. Large intestine, and even small intestine if only 
a part of the circumference of the bowel is constricted, give the 
same symptoms in a more marked degree, plus vomiting and more 
or less distention. If the lumen of the small intestine is com- 
pletely obstructed there is repeated vomiting, becoming brown and 
foul-smelling (" fecal "), and absolute stoppage of the bowels even 
for gas. 

The various hernial orifices should be examined in all cases 
of intestinal obstruction. 

TREATMENT. Dorsal decubitus, the steady pressure of a pad 
of unbleached cotton and a spica bandage, and the cold of a big 
ice-bag will cause the reduction of many strangulated hernias. 
This treatment should be tried only in the early hours of strangu- 
lation, lest one succeed in reducing a loop of intestine already 
gangrenous. In most cases immediate operation is indicated. 

Ascites - Paracentesis. The causes of simple ascites are 
nie<lical, and its- treatment is essentially so, except in one respect, 
namely, paracentesis or the puncture of the abdomen for with- 
drawal of the extravasated serum, for the peritoneal cavity may 
become so distended with serum that it is desirable to withdraw 
the whole or a part of the fluid. This slight operation is almost 
free from risk. It is best performed in the following manner: A 
point is selected two or three inches below the umbilicus, either in 
or near the median line, or well to the outer edge of the rectus 
muscle. Thus one chooses the thinner parts of the abdominal wall 
and avoids the large vessels (deep epigastric) which lie beneath 
the outer part of the rectus muscle. In making the puncture one 
naturally avoids any visible veins. The patient should, if possible, 
be in a sitting posture, with the bladder empty. 

After cleansing the skin, the sensation may be dulled by ethyl 
chlorid or by the injection of a few drops of a two per cent solu- 
tion of cocain. A trocar and cannula is pushed quickly through 
the abdominal wall. If the peritoneal cavity is so distended with 
fluid that the wall is tense, the puncture is an easy one; if the 
distention is less, one must proceed with more care. It will then 



200 

be found of advantage to turn the instrument back and forth 
while pushing it forward, exactly as one uses an awl. In either 
case it is well to hold the forefinger against the side of the instru- 
ment as a guide to the depth to which it is plunged (Fig. 112). 




FIG. 112. METHOD OF HOLDING TROCAR AND CANNULA BEFORE PLUNGING IT THROUGH 
THE ABDOMINAL WALL. The forefinger acts as a guide to control the depth of 
puncture. A smaller trocar and cannula are also shown. 

The size of the cannula employed varies according to circum- 
stances. If the puncture is made merely for diagnostic purposes., 
or if the quantity of fluid to be removed is small, one naturally 
selects a small cannula, possibly as small as No. 6 French. If, 
on the other hand, several quarts are to be removed, as is fre- 
quently the case in hepatic cirrhosis, one should select an instru- 
ment not smaller than 12 or 14 French. The elasticity of the 
tissues will invariably close .the opening in a short time after the 
cannula is removed. 

When the trocar is withdrawn serus fluid should flow out in 
a stream. If it does not, the end of the cannula has not entered 
the ' peritoneal cavity, or else it is blocked by omentum or intes- 
tine. An attempt should be made to push the cannula further 
inward. If this is impossible its end is not within the peritoneal 
cavity. In this case the trocar should be reinserted, and the com- 
bined instrument pushed further inward, or a new site for the 
puncture may be selected. 



SPINA BIFIDA 201 

If fluid does not flow, although the cannula can be pushed 
further inward, or if a flow of fluid is suddenly stopped, it is 
evident that something has obstructed the inner end of the can- 
nula. This may be overcome by tilting the cannula, or by shift- 
ing the position of the patient, or by inserting a stiff wire, first 
sterilized, through the cannula to keep back the obstructing mass. 
Carmiilas have been made with lateral openings in order to pre- 
vent this annoyance, but it is rarely a troublesome one. 

The risk of wounding intestine or omentum is a very slight 
one. Indeed, this accident can scarcely occur unless there are firm 
adhesions at the point of puncture. In case of repeated puncture 
it is therefore well to select a new site each time. 

Some advise the incision of the skin with a narrow scalpel. 
This makes the puncture easier, but it is an unnecessary precau- 
tion unless the trocar is dull. 

Whether all the fluid should be removed at one sitting will 
depend on the general condition of the patient. In the majority 
of instances there is no objection to drawing it all off. 

Should the instrument puncture a vein or an artery in its 
passage through the abdominal wall, hemorrhage may follow the 
withdrawal of the cannula. It usually ceases in a minute or two, 
but if there is any doubt about it a little more cocain should be 
injected, a longitudinal incision made, the wound retracted, and 
the vessel ligated. This can be done without opening the peri- 
toneal cavity. 

The risk of infection following paracentesis is slight. It has 
doubtless been performed hundreds of times without any aseptic 
precaution, and yet without bad result ; but this is no warrant for 
negligence. When the cannula has been withdrawn the opening 
should be sealed with a little cotton and collodion, or if the serum 
continues to trickle from the wound, a pad of sterile gauze should 
be applied and changed as often as it becomes saturated. 

CONGENITAL DEFORMITY 

Spina Bifida. The only important congenital deformity of 
the trunk amenable to treatment is spina bifida. (For congenital 
cysts and sinuses, see p. 181.) 

Spina bifida is a failure of development in which the bony 



202 TUMORS AND DEFORMITIES OF THE TRUNK 

processes of one or more vertebrae are not united posteriorly, so 
that there is a protrusion of the membranes of the cord making a 
tumor, an inch or even inches in diameter, filled with serous fluid, 
and whose cavity is usually continuous with that of the membranes 
of the cord contained in the vertebral column. The essential fibers 
of the cord may be pressed against the front of this sac, or may 
be spread out over its inner surface. As such a condition termi- 
nates fatally if left to itself, operation is indicated, and numerous 
successes have been reported, although it is a serious undertaking 
and is often followed by death. 



SECTION IV 

AFFECTIONS OF THE GEETTO-URIIsARY 

ORGANS 



CHAPTER VIII 

INJURIES AND INFLAMMATIONS OF THE MALE 
GENITO-URINARY ORGANS 

INJURIES 

Contusion. Blows upon the penis and testicles are very com- 
mon. Owing to the sensitiveness of these structures they produce 
a degree of shock out of proportion to the local evidence of injury. 
The freedom of motion of these parts often saves them from severe 
injury. Swelling, especially of the testicle, may be considerable 
even after a slight injury. Deep injury may result in extensive 
extravasation of blood, with or without rupture of the erectile 
bodies or of the urethra, or it may be accompanied by hemorrhage 
into the tunica vaginalis, known as hematocele ; while a still 
deeper injury may cause rupture of the bladder, intraperitoneally 
or extraperitoneally. 

DIAGNOSIS. The diagnosis of the lighter forms of injury is 
usually not difficult. An inspection of the parts supplemented by 
palpation will usually reveal the extent of the trauma. Owing to 
the laxity of the tissues extravasated blood spreads rapidly, while 
edema finds little restraint and may quickly alter the normal ap- 
pearance of the penis. The diagnosis of the deeper injuries is 
considered under the separate titles. 

TREATMENT. This consists in rest, support of the parts, and 
cooling applications. Compresses wet with a mixture of alcohol 
and water or fluid extract of hamemelis, should be applied and 
kept moist. No impervious substance should be used to cover 
them, as the cooling effect of free evaporation adds greatly to the 
comfort of the patient in most cases. Or the wet compresses may 
be covered with flannel, oil silk, or gutta percha tissue, and the 

203 



204 INJURIES OF THE MALE GENITOURINARY ORGANS 

dressing kept cold by an ice-bag placed alongside of it. While 
the patient is in bed the testicles should be supported on a folded 
towel placed across the thighs. As soon as he is up the weight of 
a swollen testicle should be taken off of the cord by a suspensory 
bandage. If there is subcutaneous hemorrhage which is not con- 
trolled by these measures, or if an erectile body has been ruptured, 
an incision should be made and the bleeding vessel secured or the 
fibrous envelope sutured. 

Contusion of the testicle is apt to be followed by pain, more 
noticeable toward night or after exertion. An ointment contain- 
ing belladonna or ichthyol should be applied and the testicles sup- 
ported by a suspensory bandage. 

Hematoma: Hematocele. The blood from a ruptured ves- 
sel usually spreads quickly throughout the loose subcutaneous tis- 
sue. In this manner penis and scrotum may in a short time be- 
come a dark garnet or magenta in color. In other cases the blood 
may accumulate in one place and so form a hematoma. This is 
most likely to occur if the ruptured vessel empties into the tunica 
vaginalis. Such a condition is called a hematocele. It may exist 
without any discoloration of the skin. It gives rise to a smooth, 
tense fluctuating swelling, the size and shape of the distended 
tunica vaginalis. Often the swollen testicle is lost in the mass of 
clotted blood so that it cannot be distinguished. A hematocele 
can be differentiated from a hydrocele by its rapid formation, by 
its opacity to transmitted light ; from a hernia by its irreducibil- 
ity, by the absence of an impulse on coughing, and by the fact that 
the swelling does not extend into the inguinal canal. 

TREATMENT. Extensive hemorrhage in the tissues, if diffuse, 
will take care of itself. If, on the other hand, there is a large 
hematoma, an incision should be made into it and the blood clot 
taken out and the wound closed. The best time for the removal 
of the effused blood by aspiration is a few r days after the accident, 
when the cutaneous effects of contusion will have subsided and the 
blood clot will have softened somewhat. If operation is not per- 
formed the blood clot will remain for months before it is entirely 
absorbed, even if it does not act as a foreign body and cause necro- 
sis of the overlying skin. Such an operation is free from risk if 
asepsis is rigidly observed. The wound may be sealed with a cot- 
ton-collodion dressing. 



PARAPHIMOS1S 205 

" Fracture " of the Penis. A too violent effort in coitus, as 
well as some form of direct violence, may rupture one of the erec- 
tile bodies of the engorged penis. The result is the immediate 
escape of blood from the fibrous sheath in which the erector vessels 
are confined, producing a flabby and distorted penis. If there is 
also a wound in the skin the blood may escape externally. 

TREATMENT. The non-operative treatment consists in the ap- 
plication of cold and a firm bandage. The results are often unsat- 
isfactory, as is to be expected, when one considers the amount of 
the effused blood and the structure of the penis itself so ill 
adapted to a firm bandage. The blood clots are not fully absorbed 
for a long time, scar tissue forms, and the deformity is often per- 
manent. 

The modern surgical treatment in these cases is an immediate 
exposure of the ruptured tissues by a longitudinal incision, con- 
trol of the hemorrhage by ligature or otherwise, suture of the 
fibrous sheath with fine chromic catgut, and suture of the skin- 
wound with horsehair or fine silk. With reasonable care, wounds 
in the penis heal aseptically. The operation may be performed 
with a local or general anesthetic. The blood supply in the organ 
may be controlled during the operation by an elastic rubber band 
wound around the root of the penis. This will also facilitate local 
anesthesia by limiting the diffusion of the solution employed. 
The rubber bandage should be removed before the skin id sutured 
in order to test the control of deep hemorrhage. 

Paraphimosis. If a too tight foreskin is fully retracted 
over the corona of the glans, the head of the penis swells so that 
it is difficult to draw the foreskin down over it. The longer the 
condition lasts the more difficult it is to relieve it. Soon the fore- 
skin becomes edematous, and this adds to the difficulty of reduc- 
tion. The ability to urinate is usually not impaired. 

TREATMENT. To reduce a retracted foreskin it should be 
grasped with the thumb and finger of either hand at opposite 
points of its circumference, the thumbs being nearer the glans 
penis and firmly fixed upon the foreskin as close to the corona as 
possible. If the skin is slippery it should first be wiped dry and 
clean. Most of the obstruction to reduction is on the dorsal side 
of the penis, and hence the points at which the foreskin is seized 
should be situated a little more dorsally than ventrally. Steady 



206 INJURIES OF THE MALE GENITO-URINARY ORGANS 

tension should now be exerted, the two hands pulling in slightly 
divergent lines in order to assist in relieving the constriction of 
the foreskin over the corona. 

If the efforts at reduction are unsuccessful the surgeon may 
bandage the penis with a thin rubber bandage, and so reduce swell- 
ing, or he may use a gauze bandage and saturate it with an astrin- 
gent solution and leave it in place a few hours. This treatment 
may so reduce the swelling that the foreskin can be drawn over the 
glans. If the condition of the parts, such as marked congestion 
or threatened gangrene, forbids delay, the foreskin should be di- 
vided dorsally by an incision parallel to the long axis of the penis 
(see p. 246). Reduction will then be easy. The operation should 
be completed by suture, but the longitudinal incision should be 
sutured laterally, or a partial or complete circumcision may be 
at once performed. If a tight paraphimosis is left to itself a spon- 
taneous reduction may take place or the retracted skin may become 
adherent in its new relations so that reduction is impossible; or it 
may lead to gangrene of either the constricting skin or of the head 
of the penis. 

Neuralgia of Testicle. Violent coitus may produce neu- 
ralgia of the testicle, and even a swelling of the organ, which 
the patient calls a " strain." It is best treated by a suspensory 
bandage, by the application of cooling lotions, or of belladonna 
or ichthyol ointment, and by the avoidance of sexual excitement 
until the symptoms have disappeared. If the patient is troubled 
with erections during sleep, large doses of bromid of potash should 
be given during the afternoon and evening, and the bowels should 
be thoroughly emptied. In many cases of neuralgia of the testicle 
of sexual origin, relief follows the occasional passage of a steel 
sound through the deep urethra. 

Whenever possible, these patients should be encouraged to take 
up normal sexual life, for frequently and unjustly they mistrust 
their power to enter into a happy marriage. Experience has re- 
peatedly shown that all the neuralgic symptoms disappear in a few 
weeks after marriage. 

Foreign Bodies of the Penis and Urethra. A special 
form of injury of the penis is caused by slipping a ring over the 
end of the organ. The congestion which results swells the glans 
so that it is impossible to remove the ring. This congestion 



FOREIGN BODIES OF THE PENIS AND URETHRA 207 

increases as time goes by and if surgical aid is not sought gan- 
grene will follow. But before this occurs the ring may be so 
buried in the edematous skin as to be invisible unless a careful 
examination is made. 

Foreign bodies are also passed up into the urethra for pur- 
poses of sexual excitement. They sometimes slip from the grasp 
of the individual and pass wholly within the meatus. 

The symptoms vary according to the nature of the foreign 
body lodged in the urethra. If this is smooth there may be no 
serious symptoms until a calculus forms about it some weeks later, 
or infection of the urethra or bladder may be caused. This is 
more likely to follow the introduction of a sharp object such as a 
pin. If the urethra is torn, the swelling may make urination dif- 
ficult or impossible. 

TREATMENT. A ring which has been passed over the penis 
should be filed or cut in two places and removed. Usually a thin 
strip of steel can be passed under the ring at some point in its 
circumference in order to protect the penis from the file. 

The extraction of a foreign body from the urethra is often 
extremely difficult. If the body lies near the meatus it may be 
seized and drawn outward by a pair of thin forceps. Before at- 
tempting the seizure, firm pressure should be made upon the 
urethra near the base of the penis so as to prevent the foreign 
body from slipping upward into the bladder. If the object is 
sharp-pointed, as a pin, and the point is toward the meatus, it 
may be pushed out through the wall of the urethra and the penis, 
reversed, and pushed back into the urethra, so that the head is 
toward the meatus. The head can then be grasped with forceps 
and the pin extracted. If the foreign body is not sharp-pointed, 
as, for instance, a slate pencil, it may be extracted by pinching the 
urethra firmly above its upper end and crowding the penis upward 
past its lower end. The lower end is then grasped through the 
penis, and traction is made in order to stretch the urethra to its 
fullest extent. While thus stretched the urethra is again pinched 
above the upper end of the slate pencil, and the penis again 
crowded up from below. By this means the foreign body can be 
brought out of the meatus. This method can be easily demon- 
strated by slipping a slate pencil into a piece of rubber tubing 
whose caliber is great enough to receive it readily. 



208 INJURIES OF THE MALE GENITO-URINARY ORGANS 

If the foreign body cannot be extracted through the meatus, an 
incision should be made directly down upon it to permit of its 
prompt removal. The wound of the urethra should be sutured at 
once, and also the wound of the skin unless infection exists, in 
which case drainage may be advisable. 

Foreign Bodies in Bladder. A foreign body which finds 
its way into the male bladder, either through the urethra or by 
penetration of the wall of the bladder, usually becomes incrusted 
with urinary salts in a short time. 

The symptoms depend more or less on the nature of the object, 
whether it has sharp angles, etc. They are in general pain, espe- 
cially at the end of micturition; vesical irritability, as shown by 
pain when the body is jarred and by frequent micturition; and an 
admixture of blood with the urine, and perhaps the passage of a 
couple of drops of pure blood at the end of the act. The foreign 
body may cause a sudden stoppage of the urinary stream during 
micturition. If a foreign body remains in the bladder for some 
time, the urine may become ammoniacal. The symptoms given 
are also the symptoms of calculus. 

The diagnosis can be made from the symptoms; also by mm in 
of a short, sharply curved steel sound called a stone searcher; in 
some instances by the X-ray, and in some by tin- evstoseope. 

TREATMENT. The removal of the foreign body is the essential 
of treatment. This usually requires an incision into the bladder. 
The suprapubic route is the method of choice. 

Wounds. All wounds of the external genitals should be 
treated by thorough cleansing, control of hemorrhage by ligature, 
suture of both superficial and deep structures, and if necessary 
drainage. The tendency of contused wounds to bleed subcntane- 
ously is very marked, on account of the free blood-supply and 
lax tissues. All blood clots should be evacuated, and the spaces in 
which they lie should be suitably drained. 

Rupture of Urethra. This may be complete or partial. It 
is usually due to a fall astraddle of some hard object or to a kick 
in the perineum. By this violence the bulbous urethra is pressed 
against the edge of the pubis and divided. 

The symptoms are pain and swelling at the seat of injury, and 
usually bleeding from the meatus. There will be either inability 
to pass water or painful, dribbling micturition, the urine contain- 



RUPTURE OF URETHRA 209 

iiig blood, or, as is usually the case, the passage of a little urine 
from the meatus and the extravasation of a certain amount of 
urine about the point of rupture. If I here is ;m external wound 
the urine will escape from it. If not, the passage of an olive- 
tipped bougie will usually establish the diagnosis. If the urethra 
is torn clear across the bougie will fail to enter the vesical por- 
tion, or if it is only partially torn the rent in the membrane 
may be felt. Sometimes the break may be felt by external pal- 
pation. A doubtful diagnosis will usually exist only in those 
instances in which the urethra is divided without the skin being 
broken. 

TREATMENT. The treatment for all cases of partial or com- 
plete rupture of the urethra is immediate incision and suture. 
Only the simplest cases of rupture of the pendulous portion may 
be left to heal of themselves. If the divided ends are retracted, 
or if a portion of the urethra is so badly bruised that it has to 
be cut away, suture of the urethra is still possible by loosening it 
from its attachments a little distance in both directions. An inch 
of the urethra has been resected and the urethra sutured with com- 
plete success. For this purpose fine silk should be used, and only 
two or three of the sutures should pass clear through the mucous 
membrane. Unless the wound determines the site of the skin in- 
cision, it should be a longitudinal one made in the median line 
of the under surface of the penis. After operation has been com- 
pleted, a catheter should be left in the bladder for several days. 
This operation may be easily performed with the aid of a local 
anesthetic. The stitches should be removed in five days or a week 
and the catheter two or three days later. In most instances the 
deeper parts will heal with scarcely any leakage of urine. Should 
this occur the sinus will in a few days close of itself, since, unlike 
the condition when an inflammatory stricture is present, the tend- 
ency after traumatism is toward recovery. All silk sutures should 
be so placed that they can be removed, and for this purpose their 
ends should be left long; otherwise plain catgut should be em- 
ployed. If, in spite of all precautions, suppuration occurs, the 
catheter must be taken out of the bladder and the wound freely 
drained. After the inflammation has subsided, a second operation 
may be undertaken to close a persisting sinus. If the sinus is a 
large one or traumatic stricture exists, a section of the urethra 
16 



210 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

must be cut away so that clean fresh ends may be obtained for 
suture. 

Rupture of the Bladder. The rupture may be extraperi- 
toneal, but is usually intraperitoneal. In either case the accident 
is a serious one and follows a blow or fall, usually when the blad- 
der is full. When' it is overdistended a comparatively slight blow 
may rupture it. 

SYMPTOMS. Rupture of the bladder has some symptoms in 
common with rupture of the urethra ; but it may be differentiated 
by the history of the accident, by pelvic pain and shock, by the 
absence of visual injury in the perineum or along the penis, by the 
fact that blood in the urine is thoroughly mixed with it and does 
not appear simply at the beginning or the end of the urinary 
act, and possibly by the complete absence of urine, even after the 
passage.of a catheter. "Unless stricture is present there will be no 
difficulty in passing a catheter into a ruptured bladder. Extrava- 
sation of urine into the deeper parts of the pelvis, or its discharge 
into the peritoneal cavity, will also cause symptoms which will 
assist in the diagnosis of the injury. 

TREATMENT. An immediate suprapubic cystotomy is the best 
form of treatment. In many cases this must be combined with a 
laparotomy. 

Rupture of the bladder should be considered a possible com- 
plication in all eases of fracture of the pelvis. 

INFLAMMATIONS 

Burns. Burns of the external genitals may be of the usual 
kind, or they may be due to the application of too strong ointments 
or lotions. The symptoms and treatment are those of burns else- 
where in the body (see p. 26). On account of the great loose- 
ness of the skin and the relative firmness of the deep fascia of 
these parts, the edema resulting from even a slight burn may 
produce great distortion (Fig. 113). Such an edema is, of course, 
wholly temporary, and the patient should be so assured. 

Simple Balanitis. This is an inflammation of the mucous 
membrane covering the head of the penis, and the inner layer of 
the prepuce. It is common in cases of long prepuce, especially 
if the foreskin cannot be retracted. Under such circumstances the 



HERPES OF THE PENIS 



211 



secretions about the corona remain in a moist condition and un- 
dergo fermentations. Erosion of the delicate epithelial layers 
results, with foul smelling discharge. Diabetics are especially sub- 
ject to irritations of the foreskin. 

TREATMENT. Cleanliness, the application of a powder, such 
as stearate of zinc, or the application of a blan'd ointment such as 
cold cream, will heal the simplest cases. The.apposed surfaces 
may be kept apart by a wisp of cotton moistened with a dilute 
antiseptic. If the foreskin 
cannot be retracted, or if 
it is very long, so that the 
head of the (adult) penis 
is completely covered, cir- 
cumcision should be per- 
formed. The resulting ex- 
posure of the corona will 
stimulate the growth of a 
tougher epithelium, and 
will dry the secretions 
more rapidly. In operat- 
ing upon diabetics, one 
should remember the possi- 
bility of a failure to ob- 
tain primary union. 

Herpes of the Penis. 
The glans penis and the 
inner layer of the prepuce 
may break out with the 

characteristic groups of vesicles by which herpes is known in all 
portions of the body. In the case of the penis, however, the 
apposition of the two epithelial layers leads to the speedy macera- 
tion of the vesicles, so that if the patient is not promptly seen, 
only shallow ulcers may be found, together with more or less gen- 
eral inflammation. 

The treatment is similar to that advocated for balanitis. The 
apposed surfaces should be kept apart by a wisp of cotton or a 
layer of gauze moistened with some mild antiseptic, such as a 
dilute silver solution, or a drying powder may be employed, or a 
simple ointment. The parts should be frequently cleansed with 




FIG. 113. EDEMA OF THE PENIS AND SCRO- 
TUM IN BURN DUE TO THE APPLICATION OF 

MERCURIC OINTMENT. 



212 INFLAMMATIONS OF THE MALE GEN1TO-UK1NARY ORC1ANS 



hot saline solution to prevent irritation from accumulated secre- 
tion. If the digestion of the patient is faulty, it should be cor- 
rected. 

Simple Urethritis. Inflammation of the mucous mem- 
brane of the urethra, not due to the gonococcus, may follow trau- 
matism, such as the use of sounds, or excessive or unclean coitus, 
or the ingestion of drugs which, passing out through the kidneys, 
may irritate the urethra, etc. The symptoms are those of catarrh 
of mucous membrane everywhere namely, swelling, tenderness, 
redness, and an increase in the mucous secretion, which in some 
cases may be purulent. Micro-organisms may be found in the dis- 
charge, but they will not be gonococci. The lack of exposure to 
gonococcus infection, the absence of gonococci from the discharge, 
and the quick disappearance of symptoms, serve to differentiate 
simple urethritis from gonorrhea. 

TREATMENT. With the removal of the cause of irritation and 
dilution of the urine, the inflammation quickly subsides; usually 
in less than a week. The patient should drink as many as four 

large glasses of water, 
preferably hot, and 
taken an hour before 
meals and at bedtime. 
Sweet spirits of niter, 
or acetate of potash, 
or some other di- 
uretic should be given 
to reduce the acidity 
of the urine. 

Abscess. Most 
of the infections of 
the external genitals 
are of a venereal 
character, due to the 
organisms of gonor- 
rhea, chancroid, or 
syphilis. Cellulitis 
and abscess due to the 

FIG. IM.-ABSCESS OF SCROTUM OF FIVE DAYS' " Sllal PJOgenic organ- 
DURATION. Patient aged twenty-five. isms do OCCUr, how- 




SPECIFIC URETHRITIS, OR GONORRHEA 213 

ever, both in the penis and in the scrotum. A case of the latter 
character is shown in Figure 114. The symploni.-, ;m<l Irealnienl 
are similar 1<> those of abscess in oilier parts of (lie body. 

Specific Urethritis, or Gonorrhea. Gonorrhea as com- 
monly seen is an acute inflammation of the anterior urethra due 
to the presence of a specific microbe called the gonococcus. Ac- 
cording to the best authorities it can be obtained only by conflict 
with a person who has recently suffered from it, or with some of 
the discharges from such a person. In most cases it requires from 
two to four days for the germ to develop in the epithelium after 
its introduction into the urethra. After this interval free from 
symptoms, there is noticed an itching or burning, or pain greatly 
increased during micturition and during an erection, and a puru- 
lent discharge. The mucous membrane swells, and often pouts 
from the meatus. The inguinal glands swell and become tender, 
but rarely suppurate. These symptoms continue for two or three 
weeks and slowly subside. 

TREATMENT. The varieties of treatment advocated for this 
very common trouble are numerous indeed. None of them is 
able to cut short to any great extent the average duration of the 
disease. The discharge continues usually about six weeks. It is 
noticeable, however, that in succeeding attacks the disease pursues 
a briefer and milder course. As is the case in most acute inflam- 
mations, very hot water is grateful to the patient, who should soak 
his penis once or twice a day in a large tumbler filled with water 
as hot as he is able to bear it, with the idea of relieving the mucous 
membrane from the irritation of its own discharges, as well as in 
the hope of sterilizing the urethra and thus cutting short the attack. 
Many specialists upon genito-urinary diseases have advocated the 
use of irrigation. For this purpose a blunt pointed nozzle is pro- 
vided which contains tw r o openings side by side. With eacli of 
these a tube is connected, one coming from the reservoir of irri- 
gating fluid, the other leading to a waste pail. The nozzle should 
distend the meatus so as to prevent the escape of fluid around it. 
Irrigation may be carried out by allowing the stream to flow con- 
tinuously or by occasionally stopping the outflow in order slightly 
to distend the penis before the fluid flows out of it. Mild anti- 
septic solutions can be used for this purpose; permanganate of 
potash in water, 1 part to 2,000, is one of the favorites. 



214 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

It has been claimed that injections and irrigations have a tend- 
ency to spread the gonorrhea to the prostate, bladder, or testicles, 
but without injections of any sort being made these secondary in- 
flammations often develop, so that an injection in which no undue 
pressure is employed probably does not spread the disease to deeper 
parts. Nature has provided an irrigation for the urethra in the 
flow of urine through it at frequent intervals, so that the irriga- 
tions above described are not as necessary as they otherwise 
would be. 

The urine should be kept bland by causing the patient to drink 
large quantities of water, milk, weak tea, lemonade, etc. If it is 
desirable to reduce acidity still further, acetate of potash, ten 
grains every four hours, or some other diuretic may be given. 

Rest is another essential of treatment. The patient should lie 
down as much as possible, and should avoid exercise., tobacco, alco- 
hol, and sexual excitement of any kind. If troubled during sleep 
with erections of the penis, the patient should take during the 
afternoon and evening thirty or forty grains of potassium bromid. 
Constipation should be prevented, and the diet should be a simple, 
one. Such are the general principles of the treatment of acute 
gonorrhea upon which all writers agree. 

The specific treatment, that is, treatment which has in view 
the cure of the disease by the use of drugs, is by some writers 
asserted to be useless ; most specialists, however, administer drugs 
by the mouth or in injections into the urethra, or by both of these 
methods. The drugs given internally are chiefly copaiba, cubebs, 
sandalwood oil, and salol. These are all substances which are 
rapidly excreted by the kidneys, and give to the urine an aromatic 
odor and a certain degree of disinfecting power. A good prescrip- 
tion is as follows: 

3 Salol, ) . 

~, . , , > aa gr. iv ; 

Oleoresin cubeb, ) 

Balsam copaibne gr. viij ; 

Pepsin gr. j. 

One or two capsules, each containing the above, should be given 
after each meal. 

The other method of administering drugs namely, that of in- 
jecting solutions into the urethra opens a wide field for experi- 



SPECIFIC URETHRITIS, OR GONORRHEA 215 

mentation. Astringents of every sort, and most of the old and 
new disinfectants, have been repeatedly used for this purpose. 
Their efficacy in limiting an acute gonorrhea is open to grave 
doubt, though the astringent solutions are of undoubted benefit 
in the later stages of the disease when the purulent secretion has 
changed to a thin mucous secretion. The following solution is 
often employed: 

I? Argyrol 5iv ; 

Aquse destil oviij. 

Sig. : Use locally after urination. 

Or at a later stage, when the discharge becomes muco-purulent, 
the following mixture : 

1^ Zinc, sulphat gr. xv ; 

Plumbi acetatis gr. xx ; 

Tinct. opii, 



,. , aa .................. 011 ; 

Tmct. catechu, 



Aquae ad .......................... ovj. 

M. Sig. : To be injected after urination. 

COMPLICATIONS. The prostate, bladder, and testicle may all 
take part in the gonorrheal inflammation. It requires usually two 
or three weeks for the disease to spread to these localities, but 
when it has done so the same symptoms of heavy pain, heat, swell- 
ing, and tenderness to touch are present in these different locali- 
ties, and the patient has the constitutional symptom of fever of 
100-102 F. If the bladder is affected, micturition is frequent 
and urgent, extremely painful, and is often followed by the pas- 
sage of small quantities of blood. Blood may also be mixed with 
the urine. Inflammation is situated in the neck of the bladder 
as well as in the prostate, and most of the pain is referred to the 
base of the penis and to the perineum. Large doses of alkaline 
diluents, local application of heat in the form of hot compresses, 
or a hot sitz-bath and irrigation of the rectum with hot water, or 
heat applied through a closed rectal tube, will all relieve the pa- 
tient somewhat, but for a few days morphin will probably be 
required, and may be administered by the mouth or subcutane- 
ously or by rectal suppositories. If the inflammation does not 
subside in a few days the bladder should be irrigated daily through 



216 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

a soft rubber catheter with hot saturated solution of boric acid, 
or with very weak solutions of nitrate of silver (1: 4,000) at the 
beginning, or a solution of protargol (1: 2,000). 

If the disease extends to the testicles it usually attacks only 
one of them at a time, and involves chiefly the epididymis. This 
swells rapidly until it is several times the normal si/,o, and is 
exquisitely painful and tender. Rest in bed, support of the tes- 
ticle by folded towels placed upon the thighs, and the application 
of pounded ice or hot, moist compresses kept hot by a hot water 
bottle, will suffice to relieve the pain in a few days. Painting the 
overlying skin with a mixture of equal parts of guaiacol and olive 
oil will also relieve pain. Often the swelling persists for weeks, 
and the testicle should be carried in a suspensory bandage for a 
long time after the patient is up. Its return to the normal size 
can be hastened by the application of a mixture of mercurial and 
belladonna ointment. 

Chronic Gonorrhea: Posterior TJrethritis. By the 
treatment described, or even without treatment, the discharge 
in acute gonorrhea usually ceases in about six weeks. Occasion- 
ally, however, some few symptoms of the disease remain a little 
pain after urination, an occasional drop of clear mucus sufficient 
to keep the meatus moist and to disturb the mind of the patient, 
or a few shreds in the urine. The disease has passed into a chronic 
state and is known as chronic urethritis or gleet. In such a form 
it resists treatment most persistently. This is due sometimes to 
irregularities in the urethral canal, either natural or the result of 
the inflammation. Behind a small meatus there may be a little 
pouch in which the inflammation continues, and lights up from 
time to time after any slight irritation. Or there may be a stric- 
ture at any point in the urethra behind which the inflammation 
keeps up. Such a stricture is due to the contraction of scar tissue, 
which occurs everywhere in the body where healing has followed 
severe inflammation or loss of tissue. The persistence of the in- 
flammation may also be due to the fact that the gonococci have 
lodged in the prostatic ducts. In these narrow passages they are 
with difficulty reached by injections, and are not affected by the 
flow of urine. 

TREATMENT. A narrow meatus or a stricture should be di- 
vided. If posterior urethritis exists the most successful treatment 



STRICTURE OF URETHRA 217 

is the injection of a few drops of a strong solution of nitrate of 
silver by means of a deep urethral syringe. The solution first 
injected may have a strength of one per cent ; later, if necessary, 
stronger solutions may be employed. The instrument should be 
passed into the membranous urethra, i. e., about six inches from 
the meatus, before the fluid is injected. The injections should be 
repeated every two or three days. The effect of the treatment is 
heightened if the prostatic ducts be emptied once or twice a week 
by digital pressure applied .to the prostate gland through the 
rectum. 

Stricture of Urethra. This is a cicatricial narrowing of 
the canal, usually due to scar formation after gonorrhea. If the 
caliber is only slightly reduced, the symptoms are not severe. 
There is slight discomfort on urination, and the stream is irregular 
or interrupted. There may be a discharge of a few drops of clear 
mucus at times. If the stricture is very tight, the patient is con- 
stantly exposed to a complete obstruction (see Retention, p. 219). 

TREATMENT. The aim of treatment is to make and keep the 
caliber of the urethra sufficiently large, and also uniform, so that 
pouches may be done away with. A narrow meatus should be di- 
vided downward 'by a blunt pointed knife, after a little cocain 
has been injected hypodermically. When this has been done the 
urethra should be carefully examined with olive tipped bougies 
or with a urethrometer. These instruments should be sterilized 
and lubricated with a sterile medium such as boiled olive oil, or one 
of the manufactured preparations containing sea-moss. These are 
soluble in water, and in their other physical properties closely re- 
semble mucus. The meatus having been cleansed, the head of the 
penis is grasped lightly, and a small bougie is passed slowly in- 
ward until its point meets an obstruction or reaches the membra- 
nous portion of the urethra. If no obstruction is found, larger 
and larger sizes are employed until the limit of that particular 
urethra has been reached. 

If a stricture is present it may be dilated gradually or imme- 
diately, or it may be divided with special cutting instruments. 
All of these forms of treatment have often been carried out in the 
surgeon's office or in the dispensary, but sudden dilatation or 
divulsion, as it is called, is uncertain and is not now in vogue. 
Division of the stricture with a cutting instrument (internal ure- 



218 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

throtomy) is not without danger. There is some risk of hemor- 
rhage, but this is usually controlled without difficulty. A greater 
risk is due to the severe nervous symptoms which sometimes fol- 
low even a slight insult to the urethra. 

The choice between gradual dilatation and division of a stric- 
ture depends somewhat upon the condition of the patient and his 
circumstances, as well as upon the character of the stricture. If 
the latter is elastic, of not too small caliber, and gives only mod- 
erate symptoms, most surgeons are content with gradual dilata- 
tion. This should be carried on under strict aseptic precautions, 
steel sounds (Fig. 115) being passed every two or three days if 




FIG. 115. A GOOD TYPE OF STEEL SOUND. The shaft is smaller than the shoulder 
and does not therefore drag the meatus. It should be held as lightly as a pencil. 

the urethra does not react too violently. Later when a full sized 
sound is easily passed, the treatment may be performed only once 
in a week or two. The sound should be held as lightly as a pencil 
between the tips of the thumb and fingers. 

If the passage of the sound is too painful, a few drops of a 
one per cent solution of cocain may be injected into the urethra. 
A strong solution of cocain should never be used for this purpose, 
as death from absorption has more than once occurred. On each 
occasion two or three sounds, each one a little larger than the 
preceding one, may be passed ; but it is well to begin each time 
with a sound one or two numbers smaller (French scale) than the 
largest one passed at thefrprevious treatment. This gives the pa- 
tient confidence at the start, and reminds the surgeon of the par- 
ticular curves of the patient's urethra. The permanent cure of a 
stricture is often a matter of several months. 

Internal urethrotomy is not properly a minor surgical opera- 



RETENTION OF URINE 219 

tion, and need not be considered in detail. Suffice it to say that 

/ 

after the stricture is cut the caliber of the urethra should be at 
once tested by the passage of a full sized sound. This should 
be repeated again in four or five days, and every few days there- 
after for a month or so. 

Retention of Urine. If a stricture of the urethra is very 
tight, admitting only the smallest instruments (No. French or 
less), the symptoms mentioned above are more pronounced and 
at any time an acute swelling of the mucous membrane about the 
stricture may shut off the passage entirely. When this occurs, 
there is a complete retention of urine, one of the most painful con- 
ditions which can possibly be experienced. Sometimes the strain- 
ing bladder may force a little urine past the stricture, but without 
much relief of the symptoms of retention. There will then be a 
constant dribbling sufficient to keep the patient alive, but not to 
relieve him of his agony. This condition of affairs requires imme- 
diate treatment. 

Although stricture is the commonest cause of retention of 
urine, it is well to bear in mind that^it may be "Hue to a number 
of other causes, such as enlargement of the prostate gland, a con- 
dition not usually found before middle life ; or a stone in the blad- 
der ; or injury to the deep urethra or the bladder ; or a tumor ; or 
it may follow exposure to cold in persons of delicate constitution ; 
or accompany lesions of the spinal cord. The history of the pa- 
tient, together with the facts elicited by examination, should 
enable the surgeon to make a correct diagnosis in most cases. The 
necessity for immediate relief is equally great, whatever the cause 
of the retention. 

TREATMENT. The simplest measures should first be tried. 
Sometimes, to the great relief of patient and surgeon, a medium 
sized soft rubber catheter, if well lubricated and steadily pressed 
against the obstruction, will after a few minutes pass the stricture 
and bring the desired relief. When the bladder has been emptied, 
or partially emptied if its distention has been very great, and the 
patient has been put to bed on a light iliet and his bowels moved, 
the power to empty the bladder voluntarily often" returns; but 
should subsequent catheterization be necessary, it is usually easily 
performed. When acute symptoms have passed over, the stric- 
ture should be appropriately treated. 



220 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

If a soft catheter cannot be passed, success may follow the use 
of a silver instrument, although more often the point is pushed 
through the mucous membrane and burrows outside of the urethra 
without reaching the bladder. 

The bladder itself may be aspirated by means of a fine trocar 
and cannula inserted just above the pubes. As the groally dis- 
tended bladder has lifted the peritoneal reduplication, there is 
no danger that the instrument will enter the peritoneal cavity. 
When the bladder has been thoroughly emptied, catheterization or 
normal urination may become possible. 

In more severe cases of retention three methods of radical re- 
lief are available: namely, suprapubic cystotomy, internal ure- 
throtomy, and external urethrotomy. The objection to the first, 
if the retention is due to stricture, is that it does not relieve I lie 
cause of the retention. The second is only possible in case a fili- 
form bougie can be passed into the bladder. If this can be done, 
usually enough urine will escape around it to relieve very mate- 
rially the patient's condition, and after a few hours the stricture 
will dilate sufficiently to allow the passage alongside of the fili- 
form of the guide to Maisonneuve's instrument for internal ure- 
throtomy, or with the filiform alone in position an external ure- 
throtomy may be performed. This is a comparatively easy oper- 
ation under the circumstances. If, however, no guide can be 
passed into the bladder, the external urethrotomy may be ex- 
tremely difficult, since the finding of the urethra beyond the 
stricture may tax the surgeon's ability to the utmost. The details 
of these operations are found in all good surgical text-books. 

Incontinence of Urine. Dribbling of urine from an over- 
full bladder is really a symptom of retention, although it is gen- 
erally spoken of as incontinence. True incontinence, or the in- 
ability of the bladder to retain the usual amount of urine, may 
be due to disease of the bladder itself or to some alteration in its 
nervous control. An example of the latter is the incontinence of 
childhood. 

Incontinence of Childhood. This is seen in both sexes, and 
may be diurnal or nocturnal, though the latter is more common. 
It is a continuation of an infantile condition, but parents do not 
usually pay much attention to it until the child is five or six years 
old. It varies greatly in degree, some children wetting the bed 



INCONTINENCE OF URINE 221 

every night or twice a night, others being affected occasionally. 
The children who are affected in the daytime are seized with a 
desire to urinate and cannot retain the urine long enough to get 
to a closet. 

TREATMENT. The urine should be examined, the daily quan- 
tity determined,, and the maximum capacity of the bladder ascer- 
tained. Acid urine should be rendered bland. The possibility 
of vesical calculus should not be overlooked. 

The general health and habits should be attended to. One little 
girl showed marked improvement as soon as she gave up jump- 
ing rope. 

The intelligent cooperation of the child should be obtained. 
Usually the child has been scolded and punished until it is filled 
with fright and shame at the mere thought of urination. This is, 
of course, an unfavorable attitude of mind and should be changed 
as quickly as possible. To give the child a correct view of the 
functions of its bladder and of the possibility of strengthening 
them by exercise and by voluntary retention of urine after the 
desire is first noticed, will at once gain its sympathy and assist- 
ance. The amount of urine passed at one time and the length of 
intervals between urination should be graphically shown by a meas- 
uring glass and a record. 

The patient should not drink freely in the evening and should 
retire with an empty rectum as well as bladder. The clothing 
should be light. Constipation should be relieved. A long fore- 
skin should be removed by circumcision. In every case, male or 
female, a careful physical examination should be made. Some- 
times seat worms are an exciting cause. 

Belladonna, quinin, and some other drugs may be tried. Many 
cures have been reported following their use. 

In obstinate cases a small steel urethral sound should be passed 
twice a week. 

There is always a tendency toward recovery with the growth 
of the child. 

Incontinence of Old Age. This is chiefly found in women who 
have borne children and who have a laxity of the perineum and 
of the vaginal walls. Combined with this decrease in iuecli:uiie:il 
support of the bladder there is also a decrease in muscular power 
of the sphincter. The result is the inability to retain more than 



222 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

a few ounces of urine, so that it escapes upon coughing or motions 
which increase the intra-abdoininal pressure. In other cases a 
urethral polyp or caruncle may be at fault. 

Belief is to be looked for in operations which restore the in- 
tegrity of the pelvic floor. Sometimes a pessary, by preventing 
displacement or prolapse of the uterus, will render good service. 
Abnormally acid or alkaline urine should be brought to a normal 
reaction. Urethral polyp or caruncle should be removed by OIK.' ra- 
tion (see p. 270). 

Catheterization. A few words upon the best way to per- 
form this simple act may not be out of place in this connection. 
It is practically impossible to sterilize the meatus and urethra, so 
that patients whose condition requires catheterization for months 
or years usually succumb to infection of the bladder and kidneys. 
Nevertheless, the advantages of cleanliness are here very marked. 
Rubber catheters should be boiled or scalded with boiling water 
after being used, and kept in weak antiseptic solutions until 
wanted. They should then be rinsed with boiled water and lubri- 
cated with a sterile medium. The meatus of the patient, as well 
as the hands of the catheterizer, should be carefully disinfected. 
In fact, it is better to use rubber gloves, which can be readily dis- 
infected by boiling. As gloves for this purpose need not be very 
thin, they will last a good while. As soon as a rubber catheter 
loses its smooth surface it should be replaced by a new one. 

When one calls to mind the fact that men have catlicterized 
themselves for years, carrying a rubber catheter around in the 
vest pocket, and perhaps never washing it, and have still escaped 
infection, such precautions as have been above described may seem 
unnecessary. They are not so, however, and while some persons 
possess great power of resistance to disease germs, others fall an 
easy prey, and should be protected as far as possible. 

Eczema. The external genitals, both penis and scrotum, are 
favorite sites for eczema (Fig. 116). This condition is often due 
to or aggravated by uncleanliness or the larger or smaller parasites 
(scabies). 

Chancroid. A chancroid is a small ulcer appearing on the 
head of the penis, or foreskin, or possibly on the skin of the penis 
or scrotum, or even of the thigh. It is due to infection by direct 
contact with a virulent venereal discharge. Presumably some 



CHANCROID 223 

slight break in the skin allows the poison to gain a foothold. Such 
a lesion makes its appearance within a day or two after inocula- 
tion. It usually grows larger for several days, and may encircle 
the penis and eat away a considerable portion of its substance; 
but such rapid destruction is uncommon and the typical ulcer has 
the diameter of a quarter or half an inch. There may be more 
than one ulcer, either because the skin has been inoculated in more 




FIG. 116. ECZEMA OP THE PENIS OF FOUR MONTHS' DURATION. 

than one spot or because of autoinoculation from point to point. 
This explains the occurrence of ulcers upon the scrotum or thighs. 
The ulcers are usually shallow, not extending below the cutaneous 
layer. There is a certain amount of surrounding inflammation, 
and often lymphangitis and lymphadenitis; the vessels leading 
to one or both groins carrying the infection into the inguinal 
glands (inguinal adenitis or bubo). -The lesions in both skin 
and glands are painful, and there is the constitutional disturbance 



224 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

always seen in the presence of acute infection. The primary 
sore, unless some caustic has been applied to it, lacks the sur- 
rounding induration of a primary syphilitic Jesion. If I lie chun- 
croidal ulcer has been cauterized a differential diagnosis is more 
difficult. 

TREATMENT. A chancroid is best treated by a local hot bath 
two or three times daily, followed by careful cleansing vnth an 
antiseptic solution, such as peroxid of hydrogen diluted with four 
parts of water. Absorbent cotton, wet with a solution of zinc sul- 
phate 1 to 60, or some other lotion, may either be held in place by 
drawing the foreskin over it or by a bandage. In the latter ease 
the dressing should be moistened, without removing it, every hour 
or two to facilitate discharge. Surrounding skin should be pro- 
tected against contamination and the patient advised of the high 
degree of infectiousness of the discharge. By this treatment pain 
will be much relieved, the ulcer will soon take on a healthy appear- 
ance and will heal in two or more weeks, according to its si/e and 
the condition of the patient. The use of strong caustics is never 
advisable. Excision of the lesion and suture of the wound often 
fails to give primary union. 

TREATMENT OF BUBO. The inguinal glands, if moderately 
inflamed, may be treated by counter-irritants; e. g., equal parts of 
Belladonna ointment and an ointment containing ichthvol .">j to 
vaseline 5j- This is more likely to succeed in glands swollen from 
non-venereal causes. If pain and swelling arc severe the patient 
should go to bed and apply an ice-bag or hot moist compresses to the 
groin. If the glands suppurate, as they usually do, the individual 
abscesses may be opened or the glands entirely dissected away. If 
the abscesses are simply incised and drained, the patient will re- 
quire to be dressed for several weeks, but he will be able to go about 
without much discomfort. Complete removal of the glands seems 
a formidable procedure, but in about one-half of the patients so 
operated upon primary union of the parts may be obtained. This 
enables the patient to go home, entirely well, after ten days or two 
weeks of hospital treatment. If primary union is not obtained, 
the time of healing is probably no longer than would have been the 
case had a simple incision been made. According to the writer's 
experience, primary union may be reasonably expected if the skin 
overlying the glands is not affected. If, however, there are minute 



SYPHILIS 



abscesses in the roots of the pubic hairs, primary union need not 
be hoped for. 

Syphilis. A chancre is the primary lesion of syphilis and 
may occur anywhere upon the surface of the body. Since it is 
contracted by direct contact with another individual suffering from 
syphilis in an acute stage, the primary lesion in the male is usu- 
ally found at the meatus or upon the head of the penis or in the 
more delicate part of the foreskin just behind the corona; but it 
may also arise in the tougher skin of the penile body (Fig. 117). 
It is noticed, in most cases, ten days or two weeks after infec- 
tion. In some cases an in- 
terval of four weeks or more 
elapses. The lesion is then 
a small indurated nodule in 
the skin, with only a slight 
loss of epithelial covering. 
The ulcer increases some- 
what in size in the ensuing 
weeks, but if uncomplicated 
it never grows very large and 
is not very painful. It heals 
slowly and the 'induration 
lasts for many weeks after 
the ulcer has completely cica- 
trized. This is one of the 
chief points in the differen- 
tial diagnosis between a chan- 
croid and a chancre. The in-, 
guinal glands are usually 
somewhat enlarged, but they 
are not as tender as they are in connection with a chancroid, nor 
do they suppurate. 

TREATMENT. An uncomplicated chancre needs little treat- 
ment; it may be dusted with calomel or covered with mercurial 
ointment or some simple ointment. Constitutional treatment is 
required to cure the disease, and, for obvious reasons, such treat- 
ment ought to be withheld until such diagnosis is absolutely cer- 
tain, that is, until the micro-organism has been demonstrated in 

the serum from the lesion (spirocheta pallida) or secondarv mani- 
17 




FIG. 117. PRIMARY LESIONS OF SYPHILIS 
IN A PATIENT AGED SEVENTY-FOUR 
YEARS. Diagnosis made from micro- 
scopical examination confirmed by sub- 
sequently obtained history. 



226 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

festations of syphilis have appeared. Kesection of the chancre has 
been practised in the hope of preventing the syphilitic infection 
from gaining access to the body; but such treatment does not 
achieve this result for the obvious reason that the syphilitic virus 
has plenty of time to be absorbed before the surgeon has an oppor- 
tunity to remove the primary sore. The constitutional treatment 
is all-important (see p.. 61). 

Mixed Infection. A chancroid and chancre may be combined, 
that is, both sorts of infection may enter the body at the same 
point. In this case the lesion will present the hardness of the 
chancre and the acute virulence of the chancroid, and the inguinal 
glands may or may not suppurate. An ulcer of this mixed char- 
acter is much more difficult to heal than a simple chancroid, and 
it may eat away a considerable portion of the head of the penis 
before its processes can be stopped. A patient in this condition 
requires all the help which can be obtained from the best hygienic 
surroundings and food. The local treatment is substantially that 
indicated for a chancroid. The healing process is slow, and it may 
be advisable to change from one kind of dressing to another, as 
the stimulating effect of any one application grows less with its 
continued use. These mixed infections are often puzzles in diag- 
nosis until secondary syphilitic lesions appear. Previous to that 
time it may be impossible to say whether the induration is due 
to the virulence of the infection or to the coexistence of syphilis. 
If the spirochetse can be demonstrated in the discharge the ques- 
tion is at once settled. 

Secondary Lesions : Mucous Patches The usual papular lesions 
may appear on the penis and scrotum. If they are so situated as 
to be kept constantly moist by the apposition of cutaneous surfaces 
they may take on the characteristics of a mucous patch with a sur- 
face covered with a grayish, foul membrane, and possibly w r ith 
hypertrophy of the base, giving a papillary form to the growth. 
Such lesions are much commoner upon the female genitals and 
about the anus. (See Fig. 131, p. 268, and Fig. 140, p. 300.) 

Syphilitic Orchitis. One form of late syphilitic lesion is the 
involvement of one or both testicles syphilitic orchitis (Fig. 118). 
This may take place a few months after the primary lesion, or at 
any time afterward up to many years. The only early subjective 
symptom is a feeling of weight or dull pain in the slowly enlarg- 



SYPHILIS 



227 



ing testicle. This when examined is found to be uniformly indu- 
rated and enlarged. The enlargement involves chiefly the orchis, 
and the relatively small epididymis can usually be felt as a flat 
appendage at the rear. This is the common type of syphilitic 






Fio. 118. UNILATERAL SYPHILITIC ORCHITIS. Duration, six weeks. Patient aged 

sixty-eight years. 

orchitis, though occasionally the process is much more acute, and 
therefore painful; or distinct gummata may be noticeable from 
the beginning, giving the swelling a nodular character and prob- 
ably leading to involvement of the skin and slough (Fig. 119). 
Similar gumma and ulceration may occur in the penis. 

Syphilitic orchitis is a very slow process, both in its develop- 
ment and in its disappearance. It has one of three outcomes. It 
may entirely resolve, leaving the testicle as before. It may lead 
to atrophy of the testicle. It may ulcerate, and ultimately heal 
with more or less loss of testicular tissue and resulting scar for- 



228 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

mation. In this third form it is difficult to distinguish it from 
tuberculosis. 

In the early stage of these two diseases the difference in loca- 
tion can usually be made out, syphilis affecting the orchis and 
tuberculosis beginning in the epididymis. In the later ulcerating 
stage this distinction may be impossible, because the swelling has 
so altered normal relations and because of the extension of the 
inflammation beyond its original site. 

Another distinguishing mark of tuberculosis is the presence in 
most cases of several hard nodules due to separate foci of infec- 
tion. Such are wanting in syphilis. If the tubercular nodules 
exist also in the vas deferens, the diagnosis is at once clear. 




FIG. 119. SYPHILIS OF TESTICLE. Duration eight weeks. Ulceration through the 
skin of four days' duration: patient aged twenty-eight years. 

Tuberculosis breaks down more promptly than a gumma, dis- 
charges more pus, tends to form flabby granulations, and has less 
wide-spread induration about a single center of infection. 

Syphilis of the testicle must also be differentiated from malig- 
nant disease either carcinoma or sarcoma. A malignant growth 
increases rapidly in size, is softer, produces great dilation of the 
blood-vessels, superficial and otherwise, involves the skin of the 
scrotum, and often breaks down, forming a gangrenous ulcer. 



TUBEHCl LOSIS 229 

TREATMENT. The patient should \vcar a suspensory bandage. 
Belladonna ointment may he applied over the swollen testicle. 
The only curative treatment is constitutional, and consists in the 
administration of iodid of potash, either alone or in combination 
"with a mercurial. 

Tuberculosis. Tuberculosis of the genito-urinary system 
usually begins in the testicles in the male, although the kidneys, 
one or both, or rarely the bladder, may first show signs of the 
disease. Tubercular cystitis is one of the worst forms of disease 
a physician is called upon to treat. 

Tuberculosis in the testicle sometimes follows a slight injury 
and sometimes develops spontaneously. Its early progress may be 
unnoticed, or there may be a moderate acute swelling, chiefly of- 
the epididymis, which causes the patient a little pain. In either 
case the characteristic lesions soon appear. On palpation there 
will be found one or more moderately tender indurated foci in the 
epididymis. These are the tubercular nodules. As the disease 
progresses other nodules may appear either in the epididymis or 
in the cord, or in the corresponding seminal vesicle, as detected 
by the finger in the rectum. Possibly no nodule may be felt in 
the cord or seminal vesicle, these structures simply being harder 
and larger than' those of the opposite side. The testicle itself 
increases in size, owing to the inflammatory products around the 
tubercular nodule. Still later the centers of one or more nodules 
may break down and resulting purulent and necrotic fluid may 
work its way to the surface and be discharged. A permanent 
sinus will result, discharging the watery, flaky, seropurulent fluid 
characteristic of tubercular sinuses. 

Usually the disease is unilateral, although it sometimes hap- 
pens that both seminal vesicles will be affected, while only one 
testicle shows signs of disease. In the beginning of the trouble 
the patient's health may be good. Later, a careful examination 
will usually show some evidence of tuberculosis in the lungs or 
elsewhere. The differential diagnosis of syphilis of the testicle is 
given above. 

TREATMENT. The appropriate treatment is an early and com- 
plete removal of so much of the diseased tissue as is accessible. 
If a single movable node exists it may be allowable to excise it 
without removing the whole testicle. Usually, however, unilateral 



230 INFLAMMATIONS OF THE MALE GENITO-URINARY ORGANS 

castration should be performed and as much of the vas deferens as 
possible should be pulled out with it. No dangerous hemorrhage 
follows this so-called evulsion of the vas. To remove affected 
seminal vesicles through a perineal incision is a serious operation. 
If castration is early performed, and the patient is placed under 
constitutional treatment and lives out of doors as much as his cir- 
cumstances will permit, his chance of complete recovery is a good 
one. I have known a patient with limited means to effect his own 
cure, after both testicles had become affected, by spending almost 
the whole of his waking hours in the streets of New York. Some 
surgeons recommend the injection of ten per cent iodoforrn emul- 
sion in cases in which both testicles are involved. Such treatment 
is inadvisable. The retention of the testicles may spare the feel- 
ings of the patient, but it lessens the chance of a cure ; and even if 
the process is overcome, the functional activity of the testicles will 
be almost or entirelv effaced bv the extensive scar tissue. 



CHAPTER IX 

TUMORS AND DEFORMITIES OF THE MALE GENITO- 
URINARY ORGANS 

CYSTIC TUMORS OF THE EXTERNAL GENITALS 

Cysts of the Skin. A retention cyst containing serum or 
sebaceous material may be found in the skin of the penis (Fig. 
120) or scrotum. 

Sebaceous material retained back of the corona in children 




FIG. 120. SEHOUS CYST OF THE PREPUCE. This occurred in a patient aged fifty-five 
years, who had a large left inguinal hernia. 

with long, narrow foreskins frequently becomes encysted. The 
overlying epithelium in these cases is thin, and can be wiped away 

231 



232 TUMORS OF THE MALE GENITO-URINARY ORGANS 

with gauze as soon as the foreskin is fully retracted. Deeper col- 
lections of epithelial cells and sebaceous material may also form 
in this region (Fig. 121), possibly on account of inexact approxi- 
mation of the edges of epithelium 
after circumcision. 

The scrotum is also a common 
seat of milia (see p. 00). 

TREATMENT. Smaller <-\>t - 
may he evacuated and their cavi- 
ties allowed to granulate; but a 
better plan for them and for 
larger cysts is the removal of t he- 
lming membrane and suture of 
the incision in the overlying epi- 
thelium. Compare the operation 
for sebaceous cysts of the head, 
given on page 68. 

Cysts of the Testicle. - 
Retention cysts of the testicle are 

not so very rare. They are usually round, tense, fully movable, 
and situated in or near the upper end of the epididymis. Ana- 
tomically they may be connected with the testis or epididymis or 
the fetal remains of this vicinity, the paradidymis so called. They 
rarely reach an inch in diameter, and are usually single, but 
may be multiple. The contained fluid is pearly or whitish, and 
occasionally contains spermatozoa. Such a cyst in all but 
the contained fluid closely resembles a hydrocele of the cord (see 
p. 240). 

TREATMENT. Aspiration is usually performed to establish the 
diagnosis. It may be followed by the injection of a few drops of 
carbolic acid or the cyst may be dissected out through a short 
scrotal incision. 




FIG. 121. CYST OF PREPUCE FOLLOW- 
ING CIRCUMCISION IN A PATIENT OF 
FOUR YEARS OF AGE. 



SOLID TUMORS OF THE EXTERNAL GENITALS 

Papilloma. Multiple papillomata of the penis are often 
called venereal warts because they may follow an attack of gonor- 
rhea, though not necessarily so. They are usually found in the 
uncleanly or those who are unable to retract the foreskin, and are 



EPITHELIOMA 233 

situated in the neighborhood of the corona. They are small, ses- 
sile .or pedicled, and generally multiple. They cause no pain, do 
not lead to ulceration, and annoy the patient merely by their pres- 
ence. The best treatment is to snip them off with a pair of sharp 
scissors, and to cauterize the stumps with . a little chromic acid 
after the bleeding has been stopped by pressure. These warts may 
also occur about the anus. 

Epithelioma is by far the most common form of malignant 
disease connected with the external genital organs. It usually 




FIG. 122. SQUAMOUS CELLED CARCINOMA OF PENIS. 

begins near the corona, either upon the mucous membrane of the 
penis or foreskin (Fig. 122). It may, however, occur about the 
meatus. It may also begin in the scrotum, especially in the case 
of workers in paraffin and those who become covered with soot. 
Hence the name " chimney-sweep's cancer." It presents the char- 
acteristics of epithelioma of the skin in any part of the body. 
Upon the head of the penis it usually begins to grow upward before 
it ulcerates so that it looks like a wide-spreading wart, but sooner 
or later it will lead to hemorrhage and ulceration and present more 
nearly the usual picture of cancer. 

If the foreskin is retractable a mistake in diagnosis is scarcely 
possible. If there is felt through an irretractable foreskin a hard, 
tender mass in the vicinity of the corona, the foreskin should be 



234 TUMORS OF THE MALE GEN1TO-URINARY ORGANS 

at once incised so as to allow of its retraction and an accurate 
diagnosis. 

The lymphatic inguinal glands may not become affected for 
some months after the appearance of the tumor in the penis. This 
justifies the hope that an early excision of the disease will com- 
pletely effect a cure, and statistics show that this hope is a rea- 
sonable one. 

TREATMENT. The treatment of cancer of the penis is, of 
course, its early removal. This necessitates amputation of the 
penis in nearly all cases. The glands in both groins should also 
be removed. 

Epithelioma of the scrotum, if small and freely movable upon 
the underlying tissues, is easily excised. Owing to the great flexi- 
bility of the tissues there is no excuse for not removing with the 
tumor a wide margin of apparently healthy skin. The lymphatic 
glands likely to be involved in cancer of the scrotum are those of 
the inguinal region. They should also be removed. 

Sarcoma or Carcinoma of Testicle. Malignant disease 
of the testicle is not so very rare. It is of the utmost importance 
to recognize it early. In the early stages of the disease the testicle 
is swollen, smooth, but much harder and heavier than normal. 
There is little or no pain, but a sense of weight. As the 
disease progresses it may infiltrate the surrounding tissues and 
involve the skin. Even before this the superficial vessels are 
much dilated. 

Sarcoma or carcinoma is easily distinguishable from hydro- 
cele by the light test. This is the more important as a vascular 
tumor will often give a feeling of fluctuation, but no matter how 
vascular it is there will be little or no translucency. It should be 
borne in mind that hydrocele may be secondary to this and other 
severe lesions of the testicle. The collection of fluid is usually 
small, and ought in no instance to conceal the severer lesions from 
a careful observer. 

Sarcoma and syphilis have many points in common. The his- 
tory of syphilis as opposed to that of injury, and the beneficent 
effect of treatment by potassium iodid as opposed to a continued 
growth in spite of treatment, are aids in differential diagnosis (see 
also p. 228). Treatment consists in the immediate removal of the 
affected testicle, with cord and inguinal glands. 



TTTMORS OF THE PROSTATE: PROSTATIC HYPERTROPHY 235 

Castration. This operation may !>o performed under ;i lo<-;il 
or a general anesthetic. The latter is pivt'cndile in malignant, 
c;iM i s, as the dissection should then be carried well up into the 
groin. 

In non-malignant cases the skin of the scrotum should be 
cleansed and shaved, and the penis wrapped in gutta percha tissue 
or sterile gauze. An incision parallel to the cord should be made 
from the external ring downward for an inch or more. After divi- 
sion of skin, crernaster, and fascia, the testicle can be brought out 
of the wound. If there is any doubt as to the nature of the dis- 
ease, the testicle should be incised. If it is decided not to remove 
it, the incision may be sutured. This step is important, for cas- 
tration has been performed in cases of hematocele and even hydro- 
cele, a wrong diagnosis having been made. 

The attachment of testicle to the bottom of the scrotum is next 
to be divided. The testicle is then withdrawn from the wound 
and removed with so much of the cord as conditions make neces- 
sary. There are three arteries to ligate the cremastric, the sper- 
matic, and the artery of the vas deferens and several veins. The 
stump of the vas may be touched with carbolic acid, or a cautery in 
infective cases. kin involved by disease should be removed and 
healthy skin sutured. If a small gutta percha drain is placed in 
the lower angle of the wound or through the bottom of the scro- 
tum, it should be removed in two days, or as soon as the serous 
flow becomes scanty, so that a sinus may not be formed. 

TUMORS OF THE BLADDER AND PROSTATE 

Tumors of the Bladder. Tumors of the bladder may be 
either benign or malignant. They are apt to be papillomatous, 
and first attract attention either by obstructing the flow of urine 
or by giving rise to hemorrhage. Their diagnosis and treatment 
are often extremely difficult, and form an important chapter in 
major surgery. 

Tumors of the Prostate: Prostatic Hypertrophy. 
Tumors of the prostate are rare unless one considers as a tumor 
the chronic enlargement of the prostate so often found in men 
past middle age. This may remain unnoticed until its infringe- 
ment on the urethra causes delay in starting the stream, a feeble 



236 TUMORS OF THE MALE GENITO-URINARY ORGANS 

stream, and dribbling at the end. Where enlargement is more 
marked symptoms of urethritis and cystitis are added, and sooner 
or later the patient is likely to suffer from inability to pass water. 
Hence prostatic hypertrophy ought always to be borne in mind 
under such circumstances if the patient is over forty years of ;mc. 
If the enlargement is not too great or does not press forward too 
sharply against the urethral canal, a soft rubber catheter can 
usually be passed to the bladder and the patient be thus tempo- 
rarily relieved. If this is not possible the surgeon may suc- 
ceed in passing a silver instrument bent in an extra large curve, 
the so-called prostatic curve. Failing in this, he must resort 
to some of the measures spoken of under the caption " Reten- 
tion of Urine" (p. 219). In the early stages of this difficulty, 
the administration of urotropin or one of the various manu- 
factured medicines which contain it, will often cause the 
prompt disappearance of the symptoms. The relief thus obtained 
is, of course, not permanent, but it may last some weeks or months. 
When the prostatic enlargement again forces itself into notice, 
daily catheterization and irrigation, or cauterization of the pros- 
tate through the urethra (Bottini's method), or prostatectomy car- 
ried out through a suprapubic or perineal incision must be con- 
sidered. The description of these operations will be found in 
detail in books on major surgery. Castration was at one time 
extolled as a means of reducing enlargement of the prostate, but 
it has not proved successful in most cases. 

ACQUIRED DEFORMITIES 

Hydrocele. Hydrocele is an accumulation of fluid in the 
tunica vaginalis (Figs. 123 and 124). It may occur at any age 
and be unilateral or bilateral. It may follow an injury or may 
accompany inflammatory conditions, but in most cases no cause for 
it is apparent. 

DIAGNOSIS. Symptoms, if any, are due to the increased 
weight which drags upon the cord. Usually a hydrocele is readily 
recognized. If the accumulation of fluid is moderate, there will 
be felt alongside of and partly overlapping the testicle a flabby, 
fluctuating cyst. If the accumulation of fluid is greater, the tunica 
will be distended, and the cyst thus formed will be tense and flue- 



HYDROCELE 237 

tuating, while the exact location of the testicle may be uncer- 
tain. If the tunica is fully distended the whole swelling is pear- 




FIG. 123. SMALL" HYDROCELE. Duration four months. Patient aged sixty-two 

years. 

shaped, the small end being upward. A fluctuation wave is easily 
obtained if the mass is grasped in one hand and tapped with a 
finger of the other hand first in one place and then in another. 




FIG. 124. HYDROCELE OK TEN YEARS' DURATION. Growing most in the past two 
years. Never treated. Patient aged fifty-seven years. 



A hydrocele may usually be diagnosed by palpation. Occasion- 
ally, however, even the most skilful fingers will be deceived, so that 
in every case the light test should be employed. This depends upon 
the fact that light is more readily transmitted through serum than 
through a blood clot, a hernia, a swollen testicle, or a fleshy tumor, 
these being the conditions most likely to be mistaken for hydro- 
cele. The test is applied as follows : A tube about a foot long and 
one inch or less in diameter is pressed against one side of the 
elevated tumor, while the surgeon puts his eye close to the other 
end of the tube. A light is so held that its rays may pass through 
the tumor and tube to the eye of the surgeon. Daylight may be 
employed for this purpose, but is by no means so accurate as con- 
centrated artificial light. This test will serve not only to distin- 
guish a hydrocele from other swellings, but will show the position 
of the testicle and will thus enable the operator to avoid it in 
thrusting in a trocar for the purpose of aspirating the fluid. The 
light test is more delicate when performed in a darkened room. 
(For diagnosis of hematocele see page 204.) 

Hydrocele differs from hernia in that the inguinal canal is 
empty, there is no cough impulse, the tumor is irreducible, yields 
an exquisite wave of fluctuation, and generally transmits light. 
Hernia and hydrocele may coexist. 

A chronic hydrocele is differentiated from an inflamed testicle 
by its fluctuation and translucency, and by the presence of the 
normal uninflamed testicle, and by the absence of pain. An acute 
hydrocele is often a result of inflammation or injury of the testicle, 
but the amount of fluid is small in these cases. 

Hydrocele is differentiated from a solid (usually malignant) 
tumor by the absence of pain, by the better wave of fluctuation, 
and by translucency. Moreover, the solid tumor will weigh more 
in proportion to its size and will produce dilatation of the blood- 
vessels and possibly enlargement of the inguinal glands. A final 
diagnostic test is the aspiration of serous fluid. 

TREATMENT.- The simplest treatment for hydrocele is the 
aspiration of its contents. As the fluid usually reaccumulates in a 
few weeks, it is better in every instance after the aspiration of the 
fluid to inject a small quantity (five to thirty minims, according 
to the size of the hydrocele) of tincture of iodine or pure carbolic 
acid. This causes for a few minutes a burning sensation which is 



HYDROCELE 239 

not unendurable. In a day or so, owing to the effect of tlie irri- 
tation, the testicle and tunica may swell until the tumor is almost, 
as large as before aspiration. The swelling gradually decreases, 
however, and in a majority of instances the hydrocele does not 
recur. The patient should be informed of this inflammatory reac- 
tion, otherwise he may believe that the hydrocele has promptly 
recurred and will probably seek other medical advice. 

The aspiration and injection can easily be performed at the 
surgeon's office as follows: The patient should lie on his back. 
The scrotum should be carefully washed and made surgically clean. 
It should be supported and distended by an assistant, while the 
surgeon plunges the needle of a hypodermic syringe into the tunica 
at some point far removed from the testicle, which ordinarily lies 
in the lower posterior portion of the tumor. Serous fluid will 
immediately flow from the needle, which should be left in posi- 
tion, as the iodine or carbolic acid is subsequently to be injected 
through it. A small. sized trocar and cannula are thrust into the 
tunica near the hypodermic syringe. The trocar is withdrawn 
and the hydrocele fluid allowed to escape. The hypodermic 
syringe containing the fluid to be injected is then screwed on to 
the hypodermic needle and the injection is slowly made. The 
cannula and hypodermic needle are then withdrawn and the punc- 
tures covered with a little gauze, which is strapped to the scrotum 
and a suspensory bandage is applied. The advantages of this 
method of procedure are two : the introduction of the hypodermic 
needle causes little pain and further confirms the diagnosis, while 
the presence of the two instruments enables the surgeon to be 
absolutely sure that their points are still within the tunica vagi- 
nalis before he injects the iodine or carbolic acid, for they can 
be rubbed together and will produce a distinct click. Another 
good plan is to tap the hydrocele with a small trocar, to withdraw 
the same, and when the fluid has run off through the cannula to 
pass through it a second still smaller hollow blunt needle affixed 
to the syringe containing the carbolic or iodine. In this way the 
dosage of the injected fluid may be made accurate, as none is lost 
in the cannula. Unless some such method is employed it may hap- 
pen that the collapsed tunica retracts over the point of the cannula, 
allowing the injected fluid to pass into the scrotum outside of the 
tunica. 



240 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

A hydrocele may recur after injection. This is the rule if a 
very small quantity of fluid is injected, but the reaction after a 
small injection is very slight, so that a repetition of the aspiration 
and the injection, perhaps three or more times, is not objection- 
able. By this treatment the patient loses no time from his busi- 
ness and there is always a good chance that the second or third 
injection may effect a cure. 

Should a more radical treatment be desired, it may be carried 
out as follows: Make an incision through the skin of the scrotum 
anteriorly, parallel to the long axis of the body, extending from 
the upper end of the whole swelling to a little below its middle. 
It will be necessary to divide several layers of fascia and thin 
muscle (dartos) before exposing the tunica vaginalis. This should 
be incised throughout nearly its whole length. The fluid is fully 
evacuated, surplus portions of the sac are removed, and the edges 
of the sac so stretched to the edges of the skin that the sac remains 
open. Its cavity is filled loosely with gauze, and allowed to heal 
by granulation. 

Another method of operating consists in the removal of the 
greater part of the parietal portion of the sac. The visceral por- 
tion should be lightly scratched with a needle to facilitate adhe- 
sions between it and the subcutaneous tissue. The wound may be 
closed either partially or wholly. 

These severer operations require the patient to remain in bed 
for some days. 

Unusual Types of Hydrocele. In the hydrocele, as de- 
scribed above, the fluid collects in the normal tunica vaginal is. 
There are several other varieties of hydrocele. 

Congenital Hydrocele. The cavity of the tunica vaginalis may 
extend upward as far as the internal abdominal ring, or may even 
connect with the cavity of the perineum. Under such circum- 
stances the opening is usually small, but pressure upon the hydro- 
cele, if the patient is in a recumbent position, will cause the fluid 
to disappear into the abdominal cavity. It will reaccumulate 
when the patient resumes an upright position. 

Hydrocele of the Cord Fluid may collect in some unobliter- 
ated portion of the peritoneal process which accompanies the de- 
scent of the testicle. This is called a hydrocele of the cord. A 
hydrocele of the cord may coexist with hydrocele of the tunica 



VAHimrKI.K 241 

vaginalis, the two sacs being entirely distinct and | nxsil.lv .-vp;i 
rated by jin inch or more of normal cord, or the hydrocele of the 
cord may exist alone, or there may he more than one hydrocelc of 
the cord. 

The diagnosis of these conditions is sometimes easy, sometimes 
difficult. They are most likely to be confused with hernia. If 
the hvdrocele extends into the inguinal canal an impulse in the 
tin nor may be produced by coughing. Again, the possibility of 
reducing the fluid into the peritoneal cavity may be misleading, 
but the fact that it reaccumulates when the patient stands upright, 
even though the finger of the surgeon be lightly pressed upon the 
external ring, will usually suffice for a correct diagnosis. A her- 
nia may coexist with a hydrocele, and here again the diagnosis 
may be easy or difficult (see pp. 194 and 238). 

If the hydrocele of the cord is situated low down, it may be 
impossible to differentiate it from a cyst of the epididymis except 
by aspiration. The fluid in these cysts is pearly or milky white, 
while that in a hydrocele is straw-colored. 

TREATMENT may be by aspiration and injection of a few drops 
of carbolic acid or iodine ; but on account of the difficulty of exact 
diagnosis in many of these cases, it is better to expose the sac 
through a short skin incision, to dissect it free and to remove it, 
and suture the wound. In this way one avoids the chance of 
doing injury by aspiration and injection. It is better that the 
patient should go to bed for a week or two, with a reasonable cer- 
tainty of cure, than that he should be subjected to danger because 
the surgeon is working in the dark. 

Varicocele. Another common abnormal condition within the 
scrotum is varicocele. The essential feature of varicocele is a 
lengthening, dilatation, and contortion of the veins accompanying 
the spermatic cord (Figs. 125 and 12G). 

Varicocele is almost exclusively found upon the left side. A 
number of reasons have been given to explain this. It has been 
pointed out that the left spermatic vein is longer than the right 
and empties into the left renal at a right angle, whereas the ter- 
mination of the right vein is in the vena cava, and the angle is 
oblique. 

It seems probable that modern clothing has something to do 

with the development of varicocele on the left side. The almost 
18 



242 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

invariable habit men have of placing both testicles and the penis 
in the left leg of the trousers may drag upon the left cord so as 
to interfere with its circulation: At least the writer has known 




FIG. 125. VARICOCELE OF MODERATE DEGREE. Duration, one year. Patient aged 

thirty-six years. 

the pain from a moderate varicocele to disappear soon after the 
patient made it a practice to put testicles and penis in the right 
leg of the trousers, thus giving the support of the seam to the 
weaker (left) organ. 

Keyes calls attention to the fact that varicocele is almost exclu- 
sively a condition of young unmarried men, and frequently dis- 
appears within a short time after marriage. 

The veins first affected are usually situated just above the 
testicle or by the side of its upper portion. They may also extend 
well up to the external ring. A well marked varicocele has been 
aptly compared to a bag of earthworms from the sensation pro- 
duced upon the palpating thumb and finger. If the veins are very 



VARICOCELE 



243 



large there may IK I somr ini|Milse on coughing. The size of the 
tumor will be considerably reduced when the patient lies down. 

The symptoms produced in the patient are a dragging, heavy 
sensation, often associated with more or less constant pain in the 
testicle and cord, and possibly in the penis. Aside from this local 
discomfort the patient is often distressed by the thought that the 
continuance of the trouble will affect his virility. This does not 
appear to be true, although the atrophy of the corresponding tes- 
ticle often seen in connection with a long standing varicocele sug- 
gest this idea. The scrotum will usually be found relaxed to an 
uncomfortable extent. These local disturbances, combined with the 
mental distress, often affect the general health of the patient. 




FIG. 126. VARICOCELE OF KXTKKMK DKOKKK. Veins unusually large and distinct. 
Duration, fourteen years. Patient aged twenty-nine years. 

TKKATMENT. In many cases relief follows the use of a sus- 
pensory bandage, cold bathing and attention to the general health, 



244 DEFORMITIES OF THE MALE GEN1TO-UR1NARY ORGANS 

and particularly to the condition of the bowels. When these simple 
measures fail to bring relief, operation is indicated. 

There are several forms of operation which have proved suc- 
cessful. They are all capable of easy performance under eucain 
or cocain, unless the nervousness of the individual makes a gen- 
eral anesthetic desirable. A short incision parallel to the cord is 
made over the upper portion of the dilated veins. The mass of 
dilated veins is separated from the surrounding tissues and ligated 
in two places and divided. Before the ligatures are tied the sur- 
geon should convince himself that they do not include the vas 
deferens by actually feeling it outside of the ligature. A slightly 
more extensive operation includes the dissection of a part of or 
the whole mass of dilated veins and the careful ligation of their 
stumps. The upper and lower ligatures may be tied together, thus 
closing the gap caused by the removal of the veins and giving 
extra support to the testicle. The wound in the skin is sutured 
with fine black silk. If the scrotum is lax the above operation 
may be combined with removal of its most dependent portion. 
The major part of the excision should take place on the affected 
side. The wound is fully sutured. It makes no difference in 
which direction the suture line in the scrotum runs. 

Although these operations are simple and the patient can walk 
home after their performance, it is better for him to go to bed 
before operation and to remain in bed for a few days afterward 
to avoid bringing strain upon the parts and to lessen the risk 
of hemorrhage, always an unpleasant complication when it occurs 
in the loose tissues of the scrotum. 

The after-treatment consists in the wearing of a suspensory 
bandage for a time and attention to the general health. There is 
seldom recurrence, especially if a considerable part of the dilated 
veins have been removed. 



CONGENITAL DEFORMITIES 

Phlmosis. The commonest malformation of the male geni- 
tals is phimosis. The foreskin may or may not be of unusual 
length. Its opening is too small to permit the retraction of the 
foreskin over the head of the penis (Fig. 127). It may be so 
small as seriously to interfere with the passage of urine. If the 



PHIMOSIS 



245 



opening is minute the sebaceous secretion around the corona does 
not readily find an exit, and the slight irritation produced bv its 
presence often causes adhesions between the niiieoiis membrane of 
the head of the penis and the inner layer of the foreskin. Some- 
i lines these adhesions are easily broken up, sometimes the two 
layers of epithelium are so firmly grown together that one or the 




FIG. 127. TIGHT PHIMOSIS; CONGENITAL. Patient aged sixteen years. 

other is torn away in the complete retraction of the foreskin. In 
a more serious degree of pliimosis the entire space between the 
head of the penis and the foreskin is obliterated, and the skin 
covering the penis is attached directly around the meatus. 

TREATMENT. At birth the foreskin is so thin and elastic that 
even though its opening is very small, it can usually be forcibly 
retracted. If gauze is employed to prevent the foreskin from slip- 
ping through the surgeon's fingers, less force is necessary. The 
passage of a thin, flat probe between the foreskin and the glans 
penis will be found useful in breaking up any existing adhesions. 
Or the foreskin may be drawn forward and its opening enlarged by 
inserting in it the beak of a pointed closed artery forceps, and then 
separating the blades. The foreskin should then he retracted and 
the head of the penis smeared with a bland ointment to prevent 



246 DEFORMITIES OF THE MALE GENLTO-URINARY ORGANS 

the formation of adhesions. The foreskin should then be again 
drawn over the glans, and never left retracted lest paraphimosis 
be produced (p. 205). This treatment should be repeated every 
few days until the tendency toward retraction is outgrown. 

Operative treatment for phimosis consists in making a dorsal 
incision or two lateral incisions through the foreskin so as to in- 
crease the size of the orifice; or in the removal of a wide circle 
of skin about the orifice. This last operation is called circum- 
cision. 

Incision of the Foreskin. A dorsal incision is a temporary 
expedient to be resorted to in the presence of inflammation or 
edema, especially when the foreskin has been drawn back beyond 
the corona of the glans and cannot be brought over it again. It 
leaves an unsightly deformity, and should always be considered 
merely a temporary measure. It is performed as follows: 

If the foreskin is retracted, the tightest portion is obscured 
between the looser folds of skin of the inner and outer portions 
of the prepuce. These roll up in two rings of edematous skin. 
By separating them the tense constricting ring will be revealed. 
A few drops of cocain solution should be injected, and as soon 
as anesthesia has developed the tight ring should be seized with 
mouse tooth forceps and cut through with scissors or a scalpel, and 
the incision continued upward and downward sufficiently to enable 
one to draw the foreskin down over the head of the penis. When 
this is done it is easier to estimate the amount of division which 
is necessary. In general the inner layer of the foreskin should be 
divided to the corona ; the outer layer not quite so far. 

If the foreskin is not retracted, as in many cases of chancroid, 
the injection of cocain should be made along the line of incision, 
first in the outer layer of the prepuce and then in its reflected 
layer. The blunt point of a pair of straight scissors should then 
be passed between the head of the penis and the foreskin, and both 
layers of the latter split up for half an inch. The foreskin 
should then be partially retracted, and a second cut made in the 
inner layer of the foreskin so that its division shall be carried 
back to a point opposite the corona. This will enable the foreskin 
to be fully retracted. The operator must then judge as to the 
necessity of any further division of the outer layer, or of the wis- 
dom of an immediate circumcision. This should certainly be per- 



CIRCUMCISION 247 

formed in non-infective cases, and probably in many of the infec- 
tive ones as well. 

Two lateral incisions are made in a similar manner to the 
single dorsal incision. It is claimed for this method that it is 
never followed by a great edema around the freiiuin, which is often 
such an annoying sequel of the dorsal incision. 

Circumcision. This little operation can be performed in a 
number of ways. The practise among the Hebrews when circum- 
cision is performed as a religious rite is to draw the foreskin \\cll 
forward, to cut it off with one stroke of a long knife, to immerse 
the penis in wine held in the mouth of the rabbi to stop the hemor- 
rhage, and then to wrap it in linen rags. It is not surprising that 
dangerous hemorrhage and Infection sometimes follow this pro- 
cedure, and a few lives have been lost in consequence. 

Equally reprehensible is the practise among some surgeons of 
trying to perform this little operation in the shortest possible time. 
For this purpose clamps have been devised to hold the foreskin so 
that both the external and reflected portions can be cut away by 
a single stroke of the knife. It is obvious that the amount of skin 
thus removed cannot be controlled with certainty, and even if the 
line of incision 'be a perfectly smooth circular one, a thing which 
rarely happens, the adjustment in length of the external and in- 
ternal portions of the prepuce is at best uncertain. There is no 
part of the body concerning which most patients are more sensi- 
tive, so that the surgeon ought to be willing to give up a few 
minutes of his time in order to secure a perfect result. 

An extensive experience, both in the performance of this opera- 
tion and in the observance of the operation as performed by others, 
has convinced the writer that a perfect result is most likely to be 
attained in the following manner: The patient, if a very young 
baby, requires no anesthetic, or ether may be given. A local anes- 
thetic had better not be employed in patients under six or eight 
years of age, as it will not remove the fright of an infant or a 
young child. The parts should be carefully washed with soap 
and warm water and a weak solution of bichlorid of mercury, 
1 : 2,000 or weaker. Two sharp nosed artery clamps should be 
fixed upon the orifice of the foreskin to the right and left of the 
dorsal median line. If the orifice is too small to permit this, it 
should first be snipped dorsally with a pair of scissors. Traction 



248 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

being made upon the clamps, the foreskin is drawn well beyond 
the head of the penis and one blade of a straight scissors is passed 
between the head of the penis and the foreskin. An incision is 
made which extends nearly back to the reflection of the foreskin 




FIG. 128. OPERATION FOR PHIMOSIS. Dorsal and ventral incisions and two tension 

sutures. 

(Fig. 128). In drawing the foreskin forward in this manner 
there is danger that its outer portion will be cut farther back than 
will its inner portion; hence, after the first clip of the scissors 
the traction upon the clamps should be relaxed and the reflected 
portion of the foreskin should be cut farther if necessary. Two 
clamps are then placed upon the orifice of the foreskin at its lower 
edge and an incision is made between them. This incision is far 
shorter than the dorsal one. The two clamps on the left side are 
then drawn outward and the left half of the foreskin is removed, 
care being taken that the incision through the inner layer of the 
foreskin shall be nearly parallel to the corona of the glans, and 
that the incision through the external layer shall be directly oppo- 
site to it when only slight traction is made upon the clamps. The 
best result is obtained when the portion of the inner layer which 



CIRCUMCISION 



249 



is left is a third or a half of an inch in width. The right half of 
the foreskin is next cut away. Any bleeding points are clamped 
and tied if necessary with very fine catgut. If the hemorrhage 
can be stopped by pressure, so much the better. The edges of the 
external and internal layers of the foreskin arc then approximated 
by eight or twelve stitches of fine black silk (Fig. 129). The 
first one should be applied at the frcnum, the second upon the dor- 
sum of the penis, the third and fourth in the middle of the right 
and left sides respectively. In each of the four spaces thus marked 
off two or three stitches should be placed. AVhen sutured in this 
manner the foreskin will not be drawn unevenly in any direction. 
If preferred, the stitch at the frenum and the dorsal stitch may 
be introduced before the sides of the divided foreskin are removed. 
These stitches, if left long, will serve as retractors. In infants no 
dressing is required, except a little sterile gauze placed between 
the penis and diaper. The mother should be told to keep the penis 
clean by letting a little cooled boiled water run over it after each 
urination. In four or five days the stitches should be removed. 




FIG. 129. OPERATION FOR PHIMOSIS. Circular incisions complete; all sutures 

inserted. 

Silk is better than catgut, for the latter gives way sometimes and 
is, besides, more irritating to the tender skin. In older persons 
the skin should be well retracted and a circular bandage of sterile 
gauze wound around the penis behind the glans. If this become- 
soiled with urine it should be immediately changed. Attention 



250 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

on the part of the patient will usually prevent this accident. A 
good precaution is to lie down to urinate, turning almost upon 
the face. This prevents any backward dripping of the urine. 
Dressed in the manner described, the two cut edges of skin are 
closely approximated, and will unite with the minimum amount 
of adhesions. 

COMPLICATIONS AND LATE RESULTS. Painful Micturition. 
The disability following a properly performed circumcision is very 
slight. There may be a little burning during the passage of urine 
for one or two times. In an adult, if an erection occurs, it will 
only be painful in case the dressing is too tight. It can be relieved 
at once by loosening or removing the bandage. 

Hemorrhage is unlikely if all bleeding points have been ligated. 
If it does take place it is usually subcutaneous, and opportunity 
should be given for the escape of the blood through a gap in tin: 
skin incision. If bleeding is free, and is not. controlled by digital 
pressure or cold, the skin wound should be opened sufficiently to 
permit proper ligation of the bleeding vessel. This does not delay 
complete repair nearly as much as the presence of a subcutaneous 
hematoma. 

Edema is usually due to faulty technique, either malapproxi- 
mation of the skin, tearing of the tissues, or hemorrhage beneath 
the skin. It shows itself chiefly about the frenum, and may per- 
sist long after the wound is healed. It will ultimately disappear. 
Its disappearance may be hastened by hot applications, counter- 
irritants, pricking with a glover's needle, etc. 

Infection. If the wound becomes infected it should be drained 
at once by the removal of one or two stitches, by soaking the penis 
frequently in a mild, hot antiseptic solution, and by wet dressings 
of creolin 1 : 200, borolyptol 1 : 4, etc. Eetraction is likely to fol- 
low the removal of stitches, so that in a suppurative case they 
should be allowed to remain until granulations have fixed the 
skin edges in contact. 

Retraction of the skin of the penis, so that its cut edge is every- 
where separated from the cut edge of the mucous membrane, takes 
place in some cases of infection ; and sometimes without infection, 
if so much skin has been removed that there is undue tension upon 
the sutures. The immediate result is a circular band of granula- 
tions, over which new epithelium will creep in the course of a 



NARROW MEATUS 251 

couple of weeks. The ultimate result is generally good, although 
the immediate result is so discouraging. The skin of the penis is 
capable of great stretching, so that erection is not permanently 
interfered with, even by the removal of too much skin. 

Irregularity in Outline. An uneven section of the skin should 
be corrected at the time of operation, but if not noticed then it is 
better to correct it by a subsequent operation than to allow a 
patient to go away dissatisfied. A common error is to leave 
too much skin at the frenum. This projects beneath the tip 
of the penis and catches the last drops of urine, besides being 
unsightly. 

If circumcision is performed to aid the patient in overcom- 
ing the habit of masturbation, superfluous skin about the frenum 
should never be left, since it is most abundantly supplied with 
sensory nerves, and especially invites manipulation. 

Recurrence of Phimosis. If the inner layer is left long, say 
half an inch or more, and the suturing or the dressing has been 
carelessly done, it may happen that the inner and the outer layers 
of the foreskin will firmly unite for a distance of a quarter of an 
inch or more from their free edges. There will then be formed 
a strong band of cicatricial tissue completely encircling the penis, 
which by its contraction may so reduce the orifice of the foreskin 
as to render necessary a second operation. 

Short Frenum. The frenum should not take all the strain 
when the skin of the penis is retracted. If it is so short that it 
does so, the penis may be curved during erection, or erection may 
be painful, and normal coitus impossible. 

Under such circumstances the frenum should be put on the 
stretch and pierced and cut with a sharp pointed knife, the edge 
of which is directed away from the penis. 

Narrow Meatus. The external orifice of the urethra may 
be narrow. This condition may be an accompaniment of phimosis 
or it may exist alone. The narrowing is not usually sufficient to 
interfere with urination, and it does not ordinarily come .to the 
surgeon's notice until he has occasion to pass instruments or treat 
the patient for urethra! discharge. It is then an interference and 
should be divided. 

The narrowing of the meatus is usually due to an extension 
of the mucous membrane across the lower portion of the urethral 



252 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

orifice. Sensibility should be benumbed by the application of a 
drop of strong solution of cocain (ten per cent) or the hypoder- 
mic injection of a drop of a weak solution (one per cent). The 
web should then be divided by a blunt pointed narrow knife suffi- 
ciently to make the caliber of the meatus fully as great as that of 
the urethra. The patient should soak the end of the penis in hot 
saline, and separate the lips of the meatus once every day to pre- 
vent them from reuniting. The surgeon should pass a full si/cd 
sound through the meatus twice a week for two weeks, to insure 
the full benefit of the operation. 

Hypospadias. This malformation consists in a defect in the 
lower portion of the urethra, so that the urine is passed through 
a fistula in the glandular penile or perineal urethra. Usually 
there is an absence of urethra distal to the fistula. There is often 
an accompanying flattening of the head of the penis or a down- 
ward curving of the whole organ. 

TREATMENT. If the opening is not farther back than the mid- 
dle of the pendulous portion of the penis, a complete restoration of 
function, both urinary and procreativc, may be obtained by a 
simple plastic operation. The gutter which marks the site where 
the urethra should be may be covered by skin flaps cut from the 
edges of this gutter and turned over a small catheter. The raw 
surfaces of these flaps may be covered by the remaining skin of 
the penis or in some cases by flaps from the prepuce, if any prepuce 
is present. 

Another plan of treatment is to free by dissection the existing 
urethra, to puncture the blind distal portion of the penis, and to 
bring forward through the artificial canal thus made the dissected 
urethra. Its elasticity permits it to be stretched to twice its nor- 
mal length. The details of these ingenious operations, and others 
adapted to the more serious cases of fistula of the deeper -urethra, 
will be found in text-books on major surgery and genito-urinary 
surgery. 

Epispadias and Exstrophy of the Bladder. In epi- 
spadias the urethra opens upon the dorsal surface of the penis. 
This condition is often associated with exstrophy of the bladder, 
which renders a perfect restoration of function by means of opera- 
tion well-nigh impossible; and the patient is compelled to resort to 
the constant use of a urinal. 



UNDESCENDED TESTICLE 253 

Undescended Testicle. One or both testicles may be ab- 
sent from the scrotum, either in infancy or adult life. There is 
rarely a failure of the testicles to develop, but usually the testicles 
if not in the scrotum will lie in the inguinal canals, or still higher 
in the abdominal cavity. They may be functionally perfect. 
Their absence is due to an arrest of the descent of the testicles 
from the abdomen to the scrotum, which takes place normally in 
fetal life. 

There are varying degrees of undescended testicle. If one tes- 
ticle is found in the inguinal canal of an infant, but can be easily 
pressed out of the canal into the scrotum, the mother should 
be shown how to press it through the canal and lightly draw it 
down into the scrotum. If this performance is repeated every 
day one may safely trust to the growth of the parts to prevent the 
testicle from lodging permanently in the inguinal canal. 

In some infants and even in some young boys the inguinal 
canal is so large that the testicle, although it lies in the scrotum 
most of the time, may be pushed up into the abdomen at will. 
The effect of gravity and motions of the body soon bring it back 
into the scrotum. If this condition is not associated with hernia 
it need cause no alarm, and the growth of the child may be safely 
trusted to bring atout a normal state of affairs. 

TREATMENT. If the testicle is firmly fixed in the inguinal 
canal it will be exposed to injury by reason of its position, and 
it will not develop properly on account of the constant pressure 
exerted upon it. Attempts should therefore be made to bring it 
down into the scrotum, or at least to get it out of the inguinal 
canal and below the external ring. Gentle manipulation by the 
surgeon every two or three days should first be tried. If no 
progress is made the overlying parts should be incised and the 
testicle freed, all of the tissues of the cord except the vas and the 
vessels being divided. The testicle is brought down as far as the 
elasticity of the remaining portion of the cord will permit, and 
after a pouch has been prepared for it in the scrotum, it should 
be sutured to the subcutaneous tissue at the bottom of the scrotum 
by fine chromicized catgut. These sutures should of course be 
passed through the fibrous envelope of the organ and not deep 
into its substance. The inguinal canal should be strengthened by 
sutures if it is found weak or had to be split up to permit the 



254 DEFORMITIES OF THE MALE GENITO-URINARY ORGANS 

drawing downward of the testicle. After a few weeks, when all 
inflammatory reaction has subsided, gentle manipulation and trac- 
tion should again be resorted to. This will complete the cure in 
case it was not possible at the time of operation to bring the testicle 
well down into the scrotum. 

If the testicle at operation cannot be brought out of the ingui- 
nal canal, or if it is located under the skin of the thigh or peri- 
neum, it is better to push it back into the abdomen and to close by 
suture the internal ring, so that the testicle shall not be constantly 
exposed to injury and pressure. Within the abdomen it can carry 
on its functions normally. For this reason no search should be 
made for a testicle which is situated above the internal ring. 

If an undescended testicle is accompanied by hernia, an oper- 
ation for radical cure of the hernia should be performed at the 
same time. 

Some surgeons advocate the removal of an undescended testi- 
cle because of the fact that sarcoma sometimes develops in such 
an organ. This is a small risk, and removal should not therefore 
be made a routine treatment, if the testicle can be moved into a 
safe place. 



OTTAPTEK X 

AFFECTIONS OF THE FEMALE GENITO-URINARY 

ORGANS 

INJURIES AND FOREIGN BODIES 

Contusion. Contusions of the external genitals are not un- 
common either as the result of blows or falls, or in the case of 
young girls as the result of violent attempts at coitus. Bruises 
and abrasions and wounds should receive the same treatment given 
to these lesions in other parts of the body (pp. 2 and 13). Owing 
to the sensitiveness of the skin and its exposure to contamination 
from discharges, etc., especial efforts at cleanliness are recom- 
mended. 

Rupture of the Hymen The hymen is frequently rup- 
tured in early attempts at coitus, although usually the slight tear 
is not serious and requires no treatment. Sometimes the hemor- 
rhage is great enough to alarm the patient and may even require 
ligature. Unless the tear extends beyond the limits of the hymen 
no suture should be inserted. Irrigation with hot saline solution 
after urination will add to the patient's comfort and lessen the 
risk of infection. 

Rupture of the Vagina. If the vagina is narrow and 
non-elastic, it too may be ruptured in violent coitus. Indeed the 
rupture may extend into the rectum. It may also be ruptured by 
a fall upon some sharp object. 

The first step in treatment is a complete speculum examination, 
in order to determine the extent of the injury. If the breaks in 
the mucous membrane are slight it is better not to introduce a 
suture. The parts should be cleaned by irrigation with a hot 
mild antiseptic solution, and may be kept from adhering by a 
slender tamponade with aseptic gauze. 

Hematoma. A hematoma may be formed in the loose cel- 
lular tissue about the vaginal orifice. If small, it may be left to 

255 



256 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

be absorbed, but if large or near tbe surface, a short incision 
should be made one-half inch \vill usually suffice ami the blood 
clot should be evacuated. (See the treatment of hematoma given 
on p. 3.) The pressure of dry aseptic dressing will quickly cause 
the walls of the cavity to adhere. If there is any doubt of the 
asepsis a gutta-percha drain should be inserted. This should 
merely pass through the skin and not fill the cavity. After two 
days it should be removed, and not again inserted unless suppu- 
ration has taken place. If there is suppuration the cavity of the 
hematoma should be treated like that of an abscess, by free inci- 
sion and light gauze drainage (p. 38). 

Acute Laceration of the Perineum. The perineum may 
be torn by external violence, but the almost invariable cause is 
childbirth. The tear is usually a straight one in the median line 
or near it, the variation in different cases being merely one of 
extent. Slight tears heal with sufficient exactness, even without 
sutures, but it is a good plan to suture every laceration, as other- 
wise some deeper ones are sure to be overlooked. 

The portion of the perineum which tears is wedge-shaped, with 
the thin edge of the wedge forward. When torn, therefore, there 
are two surfaces for the insertion of sutures, namely, the vagina 
and the skin. The vaginal sutures are the more important, since 
they should protect the deeper part of the wound from the lochial 
discharge. The web between the thumb and fingers is similar to 
the perineum. If it is cut through there will be a palmar skin 
woiind and a dorsal skin wound, corresponding to the vaginal and 
skin wounds in a pcrineal tear. Similarly, if the cut extends 
deeper, muscles will be divided. If one bears this analogy in mind, 
in suturing a torn perineum he will have little difficulty in the 
correct apposition of the torn surfaces. 

TREATMENT. The proper treatment for laceration of the 
perineum is the immediate aseptic suture of the separated tis- 
sues in their normal relation. This is very easy under favorable 
conditions. If the patient weighs one hundred and eighty pounds 
and lies in the middle of a low soft bed and no trained assistant 
is obtainable, the task is well-nigh impossible. The patient should 
lie on the back, with thighs well flexed and hip close to the edge 
of the bed and raised on a hard pillow. An anesthetic is a con- 
venience, but is not absolutely necessary in many cases. The 



HEMORRHAGE 257 

labia are drawn well apart, and the wounded surface wiped dry 
with a gauze sponge. Blood from the cervix or uterus can be pre- 
vented from flowing over the perineal wound by pushing one or 
two gauze sponges well up into the vagina. The extent of lacera- 
tion can then be accurately seen. 

If any muscles or the perineal body have been torn, deep as 
well as superficial sutures must be inserted. Plain catgut, No. 2, 
or ten day chromic catgut, No. 1, is a good material for the deep 
suture. It saves time to insert it as a continuous suture. The 
vaginal tear should then be sutured from its upper end down- 
ward. The same material may be used for suture. It is of the 
greatest importance that the upper end of the tear shall be accu- 
rately sutured. Otherwise fluid may trickle down into the wound 
and defeat union altogether or in part. The wound in the skin 
should be sutured W 7 ith fine black silk ; or if it is desired to insert 
these sutures more deeply, so that they shall aid in holding to- 
gether the perineal body, silkworm gut is an excellent material. 

If the tear extends into the rectum, the mucous membrane 
of the latter should be sutured with fine black silk, in addition 
to the muscular and cutaneous sutures mentioned above. 

After-treatment consists in keeping the suture line as clean 
as possible. The patient may be catheterized ; but if she passes 
Avater voluntarily, the line of sutures should be cleansed each 
time with sterile water, and carefully dried with sterile gauze. 
The patient should lie on her side and face a part of the time, 
and not continuously on her back. Non-absorbable sutures should 
be removed in ten days. For the late treatment of laceration of 
the perineum, sec page 275. 

Hemorrhage. Jn the treatment of hemorrhage of the female 
genitals, it is all important to locate its source. It is necessary to 
insist upon this point, since a feeling of delicacy upon the part 
of the patient and physician as well, may result in the injudicious 
application of tampons or external compresses by the nurse or 
patient. The only rational procedure is a complete exposure of 
the parts in a good light, thorough cleanliness, and the ligatimi 
if necessary of bleeding vessels. Slight hemorrhage can be con- 
trolled by gauze compresses, applied either within or outside the 
vagina by the surgeon himself, under the favorable conditions 

mentioned above. If the patient is sensitive an anesthetic should 
19 



258 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

be given. The introduction of gauze within the uterine cavity 
to control hemorrhage is a procedure rarely required and one 
worthy of the most careful antiseptic precautions and subsequent 
treatment in bed. The use of dilute solutions of suprarenal ex- 
tract to control hemorrhage has been spoken of on page 6. Larger 
bleeding vessels should be ligated with fine catgut, and any wounds 
closed by sutures of catgut or fine silk. 

Rape. A physician is sometimes called upon to examine a 
woman or young girl in order to determine whether rape has been 
attempted. He ought to exercise great caution in making a posi- 
tive affirmation, unless the laceration of the hymen and possibly 
of the vagina clearly show a violent distention of these parts. 
Purely external injuries may of course have beeen caused by 
other means. The microscopical demonstration of semen upon 
the clothes of the female is better evidence, but this is a subject 
for medico-legal experts. On the other hand, coitus, though 
forced, may leave no external evidence in case of an adult, so that 
a negative statement should not be carelessly made. The doctor 
ought rather to confine himself to a statement of the condition 
in which he finds the external and internal genital organs. 

Also in the matter of a purulent vaginal discharge, which in 
young girls often excites suspicion that they have been improp- 
erly handled by some man, a physician should be careful not to 
claim too much. A purulent discharge of this character may or 
may not be due to gonococci, and, even if it is demonstrated to 
contain gonococci, it may have been set up by contact with some 
other female or by the use of a dirty towel, or in some other man- 
ner than by attempted coitus. 

Foreign Bodies. Foreign bodies are frequently introduced 
into the vagina and urethra for the sake of sexual excitement. 
The patient seldom loses control of such objects in the vagina, 
but 'those which are introduced into the urethra may slip from 
the fingers or be broken in the canal, and thus medical aid will 
have to be summoned. The greatest variety of objects have been 
found under such circumstances, either in the urethra or partially 
or wholly within the bladder. Slate-pencils, hairpins, and hat- 
pins are among the commonest. The pins are introduced head 
foremost, so that their extraction is difficult. Foreign objects 
in the vagina are usually neglected pessaries, or some objects which 



FOREIGN BODIES 

have been introduced by the patient to prevent prolapse of the 
uterus. 

The symptoms produced will depend upon the location and 
character of the foreign body. It may interfere with urination, 
or cause a bloody or purulent discharge, or set up inflammation 
of the urethra or bladder. Tf the foreign body remains a long 
time in the urethra or bladder, it may become the core about 
which a calculus is formed. If it is in the vagina it may also 
become incrusted, or it may partially bury itself in the vaginal 
walls. 

DIAGNOSIS. The diagnosis of a foreign body is made partly 
from the symptoms above enumerated, but chiefly from the results 




FIG. 130. URETHROSCOPE FOR EXAMINATION OF THE FEMALE URETHRA. A portion 
of the bladder can be seen through such an instrument. It is well to have such 
instruments of three sizes, ranging in diameter from 5 to 15 millimeters (J to | inch). 

of physical examination. Digital examination, direct inspection 
through a vaginal speculum, or through a smaller urethral specu- 
lum, called a urethroscope (Fig. 130), are the usual methods em- 



260 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

ployed. When the foreign body is in the bladder, it usually lies 
transversely, especially when the bladder is empty, since the long 
axis of the collapsed organ is transverse. Its presence may be rec- 
ognized by means of a sound or by the finger passed through the 
dilated urethra, or by the cystoscope. 

TREATMENT. The removal of these foreign objects affords a 
wide scope for the ingenuity of the surgeon. If the foreign body 
is in the vagina, this canal should be thoroughly cleansed by irri- 
gation and sponging with an antiseptic solution, in order to reduce 
the risk of infection in wounds which may be made intentionally 
or accidentally in removing the foreign body. An old pes.sary 
can usually be extracted without difficulty, even if it is encrusted. 
Some objects are best removed after being cut into two or three 
pieces. 

A blunt pointed object lying in the urethra may possibly be 
worked out of the canal, a little at a time, in the manner described 
in connection with foreign bodies in the male urethra (p. 207). 
If a pin lies in the urethral canal with the point directed out- 
ward, it may be possible to pass a small rubber tube into the ure- 
thra and over the point of the pin, so that the latter can then be 
crowded outward, or safely grasped with a slender pair of for- 
ceps and extracted. The adult female urethra is capable of dila- 
tation .sufficient to permit the passage of the little finger. This 
dilatation not only facilitates an exact diagnosis, but it is a mate- 
rial help in the extraction of foreign bodies by means of slender 
forceps. Small foreign bodies and calculi can be extracted whole. 
Larger calculi and friable objects may be crushed and extracted. 
If the foreign body cannot be moved through the moderately 
dilated urethra, it is better to perform suprapubic cystotomy than 
to ; >run the risk of permanent incontinence by too great dilatation 
of the urethral canal. 

INFLAMMATIONS 

Pruritus. An intense itching of the vulva, most marked in 
the vicinity of the clitoris, and associated with a thickening of the 
skin is commonly called pruritus. Objection has been made to 
this word, since it expresses a symptom rather than a distinct dis- 
ease, but it serves a useful purpose, and for the present at least 
had better be retained. 



SIMPLE VULVITIS AND VAGINITLS 261 

Pruritus is due to a number of causes, such as an irritating 
vaginal discharge, or to decomposition of the urine in diabetes, 
or to parasites, such as pediculi or seat worms. In other cases 
it is due to the use of drugs, or to improper articles of diet. Some- 
times no cause for the itching can be ascertained, and the pruritus 
is assumed to have a nervous origin. In severe cases the patients 
are most miserable, and scratch and tear the skin until it bleeds. 

TREATMENT. In every case the cause for the pruritus should, 
if possible, be discovered and removed ; but even when this can 
be done, a certain amount of local treatment is necessary. The 
parts should be bathed twice a day with very hot water, or hot 
boracic acid solution. This should be followed by the applica- 
tion of a five per cent solution of carbolic acid, or a solution of 
corrosive sublimate, one grain in a half ounce each of alcohol and 
water. Tincture of iodine, or five per cent solution of creolin or of 
nitrate of silver, twenty grains to the ounce, have also been used 
with benefit. The folds of the vulva should be kept from contact 
by talcum powder or boracic acid or dermatol; or they may be 
separated by thin layers of gauze smeared with boracic acid oint- 
ment or an ointment containing menthol or chloral or cocain. 
Parasites should be destroyed by mercurial or sulphur ointments. 

In obstinate cases success has sometimes followed resection of 
the sensory nerves which supply the clitoris and labia minora. In 
other cases portions of the labia and the clitoris have been re- 
moved. 

Eczema. Eczema of the vulva often follows vulvitis and 
pruritus. Its treatment is similar to that of eczema in other por- 
tions of the body (see p. 57). 

Simple Vulvitis and Vaginitis. The delicate skin about 
the entrance to the vagina and the vagina itself may become in- 
flamed as a result of many causes. Such predisposing factors as 
poor health, exposure to cold and wet, and traumatism have to be 
considered, while more immediate causes are irritating urine, hem- 
orrhagic and mucous discharges from the uterus or urethra, in- 
discreet coitus, constant rubbing to relieve pruritus, etc. Inflam- 
mation due to the gonococcus is considered on page 262. 

The symptoms are those of inflammation everywhere, edema, 
redness, increased heat and tenderness, plus a mucopurulent or 
purulent discharge, which more or less mats together the folds of 



262 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

skin and the hairs. Urination is not usually attended with burn- 
ing, unless gonorrhea exists. 

TREATMENT. It is desirable to know the cause of the inflam- 
mation, and in every case in which this is obscure, or in which the 
inflammation is severe, the discharge should be spread on a glass 
slide, dried and stained for gonococci. Even in the non-specific 
cases precautions should be taken to prevent the infection of other 
persons either by direct contact or by the use of towels, etc., which 
have been used by the patient. 

Attention to the bowels, rest, and frequent bathing of the in- 
flamed surfaces with a boracic acid solution or one of aluminum 
acetate, two per cent, will usually cure these patients in a few 
days if the cause of the inflammation is not a continuous one. 
The cleansing is best performed by irrigation both within and out- 
side of the orifice of the vagina, and the solutions should be as hot 
as can be borne. In the case of little girls, in whom inflammations 
of this character are rather common, the irrigation should be made 
with the utmost gentleness, and care should be taken not to block 
the orifice in the hymen by the nozzle of the syringe. The folds 
of skin should be carefully dried and anointed with cold cream or 
boracic acid ointment to prevent chafing. 

Acute Gonorrhea. Gonorrheal Vulvitis. The acute symp- 
toms of a gonorrheal infection of the vulva are similar to those 
of a simple vulvitis excepting that they are more marked. There 
is more or less constant pain aggravated by walking, and as the 
urethra is generally involved, there is pain on micturition. The 
skin is reddened, possibly excoriated in places, and there is a pro- 
fuse mucopurulent discharge. When this has been sponged away, 
it will be observed that the mucous membrane at the urethral ori- 
fice is red and swollen, and pressure of the finger upon the urethra 
will cause a drop of pus to exude. The orifices of Bartholin's ducts 
are often similarly affected, and the glands themselves may be 
swollen (see p. 263). The diagnosis of gonorrhea should always 
be confirmed by a microscopic examination of the discharge. 

TREATMENT. Gonorrheal inflammation of the vulva is of 
itself not serious, except in the case of young children. The risk 
of the infection depends chiefly on its possible spread to the bladder 
or to the uterus and Fallopian tubes, and through them to the 
pelvic peritoneum. The treatment recommended by different wri- 



INFLAMMATION OF BARTHOLIN'S GLAND 263 

I ITS varies considerably. Some believe that such simple local 
treatment as a hot vaginal douche is capable of spreading the 
infection, and should not, therefore, be advised. The majority 
take the opposite view, and recommend a hot douche with a per- 
manganate solution of the strength of one part of permanganate 
of potash to two thousand of water ; or the use of vaginal tampons. 
One plan is to insert after the douche a tampon saturated with 
five per cent argyrol solution, and to remove this in ten minutes, 
and to follow it by a tampon saturated with boroglycerid or some 
other astringent, and to allow this to remain in place until the 
next treatment, twelve hours later. Whatever plan of treatment 
. is followed, the patient should remain absolutely quiet in bed until 
the acute symptoms have passed over. The diet should be 
simple, large quantities of water or milk should be given 
daily, and urotropin or some other urinary antiseptic should 
be administered. (Compare the medication recommended on 
page 213.) 

In the later stages of the disease with profuse leucorrheal dis- 
charge a douche of sulphate of zinc oj and powdered alum oij to 2 
quarts of water is very effective. 

Gonorrheal TJrethritis. Treatment for gonorrheal urethritis in 
women is similar to that employed for men. The solutions used 
for injection through a blunt pointed syringe may be somewhat 
stronger. When the general inflammation has subsided, local 
areas of persistent infection may be touched through an endoscope 
with a cotton swab wet with a solution of silver of a strength of 
ten per cent or less. 

Inflammation of Bartholin's Gland. On either side of 
the vaginal orifice is situated the gland named after its discov- 
erer, Bartholin. This gland lies immediately under the skin, and 
is subject to infection through its short duct. The infection is 
usually of a gonorrheal origin. Swelling of the mucous membrane 
of the small duct prevents evacuation of the mucus and pus from 
the cavity of the gland. 

Upon examination there will be found by the side of the 
vagina, just outside of the hymen or its remains, a smooth, rounded, 
slightly movable swelling, very tender on pressure, and giving an 
indistinct sense of fluctuation. If the inflammation is a violent 
one the surrounding cellulitis will obscure these signs, or if the 



264 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

suppuration has broken through the gland into -the subcutaneous 
tissue there will be the usual signs of abscess. 

TREATMENT. The skin should be anesthetized and the abscess 
opened at the point where it lies nearest the surface. When its 
contents have been evacuated, a small triangular portion of the 
skin and subcutaneous tissue overlying the abscess should be cut 
away. This will greatly facilitate subsequent dressings, for if a 
simple straight incision be made it will be found difficult to rein- 
sert the gauze necessary to keep open the incision until the cavity 
of the abscess has granulated from the bottom upward. 

Simple Suppuration. The usual forms of suppuration, 
boils, abscesses, and cellulitis, may occur in the skin of the exter- 
nal genitals. The treatment is similar to that outlined on page 
34 et seq. 

Chronic Gonorrhea. When the acute symptoms due to 
gonorrhea have subsided the trouble may be found to have 
lodged in the bladder or cervix uteri. The chief symptoms of 
cystitis will be increased frequency and urgency of micturition, 
with a sense of discomfort and heaviness or well marked pain. 
The general health of the patient is a good deal affected by this 
constant irritation. Daily irrigations of the bladder with mild 
antiseptic solutions should be practised. Nitrate of silver is the 
favorite remedy for this purpose. The solution first used should 
not contain more than one part of this drug in four thousand of 
water, but this proportion may be increased as the patient be- 
comes accustomed to the drug. Argyrol in solutions of two per 
cent or more makes another good fluid for irrigating the bladder. 

If the gonorrheal process extends to the cervix and uterus, as 
shown by a persistent leucorrhea, the cervix should be dilated and 
the lining of cervix and uterus swabbed with cotton moistened 
with a ten or twenty per cent solution of argyrol every two or 
three days. 

Endocervicitis : Erosion of the Cervix. Inflammation 
of the cervix uteri may be due to congestion of the uterus caused 
by malposition, etc., or to laceration or to gonorrhea. There is 
usually an exposure and hypertrophy of the columnar epithelium, 
which gives the os a pouting or unnaturally raw red appearance ; 
hence the term ulceration is often used, though incorrectly. 

The most marked symptom of endocervicitis is an increased 



ENDOMETR1T1S 265 

discharge of mucus from cervix and vagina (loucorrhea). Some- 
times there is a thick yellowish plug of mucus hanging from the 
os at all times. This is said to be characteristic of gonorrhea, but 
the diagnosis should be made only after microscopic examination. 
Leucorrhea may be due to endometritis as well as endocervicitis. 
It is also found in women who have not borne children. It is the 
symptom of endocervicitis for which treatment is usually sought. 

TREATMENT. Whether there is a local cause for it or not, the 
state of the health has an important bearing upon the continuance 
of leucorrhea, just as it has upon catarrh, of other mucous mem- 
branes, and the treatment of the patient should always include 
directions calculated to improve the general health. Local treat- 
ment consists in the use of hot vaginal douches once or twice a 
day. The fluid used for this irrigation may be pure water or a 
weak solution of carbolic acid (one teaspoonful to the quart) 
or any other antiseptic or astringent solution. To the astringent 
action of douches may be added that of drugs placed upon a cotton 
tampon and applied through a speculum directly to the cervix. 
Ichthyol, ten per cent in glycerin, tannic acid, and glycerin and 
iodine are favorite remedies. Applications of nitrate of silver, ten 
to twenty per cent, may be made to the cervical canal. If there is 
any malposition of the uterus or laceration of the cervix or any 
other condition which may tend to prolong the discharge, it should 
be made the object of special treatment, the details of which will 
be found in text-books on gynecology. 

Gonorrheal endocervicitis is particularly difficult to cure. The 
canal may be touched with strong solutions of silver, or antiseptics 
and astringents may be introduced in the form of suppositories 
into the uterine cavity. Amputation of the cervix is frequently 
necessary to bring about a cure. 

Endometritis. There are various forms of endometritis, 
both acute and chronic, but the common form and the only one 
which will be considered here is the hyperplastic form, marked 
by chronic congestion with thickening of the mucous membrane 
which lines the uterus. It has various causes, among which con- 
stipation, stenosis of the cervix, uterine displacement and cervical 
laceration are the chief. 

The symptoms are an abnormal discharge of blood either at 
the menstrual period or at other times, and a discharge of mucus 



266 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

leucorrhea, which for the most part is due to the accompanying 
eudoceryicitis. 

Diagnosis is made from the symptoms, from bimanual exami- 
nation, and from examination through a speculum. The uterus 
is enlarged and soft, and may be variously displaced. Mucus pro- 
trudes in many cases from the eroded cervix (see p. 264). Pas- 
sage of a probe shows an elongation of the uterine canal, with a 
possible relaxation of the internal os. 

TREATMENT. Hot douches and tampons (see p. 265) may 
give temporary relief, but cannot effect a cure in most cases, since 
they do not remove the cause of the congestion. Constipation 
should be overcome, bad habits of life corrected, and an effort made 
to tone up the general system. Operative treatment consists in 
dilatation of the cervical canal and removal of the hypertrophied 
mucous membrane. Lacerations should be repaired and malposi- 
tions corrected. 

Dilatation of the Cervical Canal. Dilatation of the cer- 
vical canal is the most important of minor gynecological opera- 
tions. This can be performed in many cases under a local anes- 
thetic, but a general anesthetic is usually more satisfactory for 
both surgeon and patient. 

Dilatation is performed for the relief of dysmenorrhea, to over- 
come sterility, and to permit of curettage or other operations 
within the cervix or uterus. The technique is as follows: The 
bowels should be thoroughly emptied the day previous by laxa- 
tives and an enema. The hair should be removed by shaving, or 
better, it should be clipped short by scissors, thus saving the patient 
from a good deal of discomfort when the shaved hairs begin to 
grow out. The external parts should be cleansed with soap and 
hot water, and the vagina douched with a five per cent solution 
of creolin or some other antiseptic. The patient is put in the 
lithotomy position, and the posterior wall of the vagina is de- 
pressed with a weighted speculum. The anterior lip of the cervix 
is seized with a tenaculum forceps and drawn down. If a local 
anesthetic is employed, three drops of two per cent solution of 
cocain should be injected into the tissue grasped by the forceps, 
and similar injections should be made into other portions of the 
cervix and up the cervical canal. An applicator wrapped with 
absorbent cotton saturated with a ten per cent solution of cocain 



CTTRETTAGE 207 

should be passed into the cervical canal, and allowed to remain 
in place for at least ten minutes. It is necessary that the tip of 
the applicator pass the internal os, as otherwise the anesthesia will 
not be complete. 

The direction of the cervical canal should next be determined 
by the uterine probe. The knowledge thus gained is of impor- 
tance in inserting the dilator. The dilator should be fully intro- 
duced before its blades are opened. A little rotation in one direc- 
tion or the other facilitates its introduction. Gentle pressure is 
then made upon the handles for ten seconds. The pressure is 
then relaxed, the dilator rotated for a sixth of the circle, pressure 
again exerted, and so on. In this manner, by brief periods of 
gentle pressure made in different directions, the cervix can be 
sufficiently dilated to permit the introduction of a curette or other 
instrument or the insertion of an intra-uterine stem pessary. The 
patient should remain in a recumbent position for at least twelve 
hours after this operation. 

Curettage. The inner lining of the uterus is frequently 
scraped out as a means of treatment in cases of endometritis, 
and also as a means of removing portions of placental tissue 
remaining after abortion, or as a means of obtaining tissue for 
a microscopical examination in cases of suspected cancer of the 
uterus, etc. 

The cervical canal is first to be dilated. The extent and direc- 
tion of the uterine cavity is then determined by the uterine probe, 
and its lining scraped from the fundus to the cervix by a sharp 
curette. This should be systematically done, as otherwise the 
scraping is apt to be excessive in certain portions and insufficient 
in others. The detached shreds of mucous membrane should be 
thoroughly washed out by means of a double current uterine cath- 
eter. The fluid used for irrigation should be hot to aid in con- 
trolling hemorrhage. 

The patient should remain in bed for two days or more, accord- 
ing to the cause for which the curettage is performed. A custom 
which some operators have of packing the cavity of the uterus 
with gauze is not to be recommended in most cases. 

If the scrapings from the uterus are of a fungoid or exuberant 
character, they should be examined microscopically, since they 
may be part of a malignant growth. 



268 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

Chancroid. A chancroid may occur anywhere about the 
vaginal orifice or its immediate vicinity. If it is so situated as 
to lie between two folds of skin, the lesion is often reproduced on 
the opposing surface. For this reason several chancroids of vary- 
ing ages and sizes are often found in the same patient. The 
progress of the disease and the best method of overcoming it are 
described on page 222. It is desirable to keep apart, as far as 
possible, the folds of skin so as to limit the spread of the infec- 
tion, hence the necessity of frequent dressings and thorough clean- 
liness. A fold of gauze laid between the labia of the right and 
left side, and held in place by the perineal strap of a T-bandage, 
will be found helpful. 




FIG. 131. MULTIPLE SYPHILITIC TUMORS OF THE VULVA. 

Syphilis. A chancre, the primary lesion of syphilis, may 
occur at any exposed portion of the genital organs of the female, 



SYPHILIS 269 

but is most likely to be found upon the labia minora or some 
other portion of the delicate skin about the vaginal orifice. It 
may be single, or two separate lesions may coexist. 

The primary lesion of syphilis is apt to be overlooked in the 
female. The surface where it may occur is much greater than is 
that of the male, and is not so readily examined. Hence, a woman 
may contract syphilis without knowledge of the fact. This ex- 




FIG. 132. SYPHILITIC TUMOR OF THIGH NEAR THE VULVA. Patient a negress aged 

twenty-seven years. 

plains the occurrence of later lesions of the disease in women who 
deny that they have ever had syphilis, and whose truthfulness there 
is often no reason to doubt. 

The diagnosis is not difficult when a primary lesion is found. 
Its appearance is similar to that of a primary lesion upon the 
male genitals. 

The later lesions of syphilis are not infrequently found upon 
the vulva. The tissues are prone to hypertrophy under the in- 
fluence of prolonged irritation, so that mucous patches develop 
strongly and condylomata become extensive, later syphilides often 
assuming a multiple papillomatous character (Fig. 131). This is 
the more usual form, although single tumors also occur (Fig! 132), 
as well as gummatous ulceration. 

For the local and constitutional treatment of syphilis, see 
page 61. 



270 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

TUMORS 

Benign Tumors. The benign tumors of the external gen- 
itals, such as papilloina, lipoma, etc., require no especial descrip- 
tion. The treatment is the same as when similar tumors are found 
elsewhere in the body (see p. 185). 

Cyst of Bartholin's Gland. The duct of Bartholin's gland 
may become obstructed, leading to a distention of the cavity of the 
gland with mucus. This gives a fluctuating, rounded tumor at 
one side of the vaginal orifice, covered by normal skin, and freely 
movable on the deeper parts. It should be dissected out through 
an anteroposterior incision and the wound closed by suture. Or 
it may be cut into at the site of the normal opening of the duct, 
and drained with a small wick of silk threads until the artificial 
canal thus formed has become lined with epithelium. 

Suppuration of J>artholih's gland is described on page li.s:;. 

Urethral Caruncle. This is a vascular tumor of the meat us, 
made up of connective tissue and hypertrophied papilla; and nu- 
merous dilated blood-vessels. It is covered with epithelium. Such 
a little tumor is often extremely sensitive, so that the passage of 
urine or the slightest touch will give the patient great pain. 

The diagnosis is easily made if the labia are separated and 
the urethral orifice is inspected. There will then be noticed a 
bright red tumor, usually entirely outside of the urethra, but some- 
times partly within it, springing from the mucous membrane by 
a slender pedicle. Sometimes more than one such tumor exists. 

TREATMENT. The caruncle should be thoroughly removed 
after anesthesia has been produced by cocain. On account of the 
delicacy of the overlying epithelium, the application of a bit of 
absorbent cotton saturated with a ten per cent solution of cocain 
will produce a complete anesthesia in a few minutes. The mucous 
membrane should then be divided around the pedicle, dissected 
back for a short distance, so that the base of the tumor may be 
divided below the level of the surrounding mucous membrane. 
The vessels should be ligated with fine catgut and the cuff of 
mucous membrane sutured with fine black silk so as completely to 
cover the raw area. The stitches should be removed in four days. 

Polyp of the Cervix. A polyp of the cervix is a more or 
less rounded tumor composed of the same tissues as the mucous 



CARCINOMA 271 

membrane from which it springs. It is usually distinctly pedicled. 
It generally springs from the mucous membrane of the cervical 
canal, and gives rise to more or less hemorrhage and pain. As 
soon as it appears in the external os the cause of the hemorrhage 
is evident. Before such appearance the diagnosis is extremely 
difficult. 

TREATMENT. The pedicle of a polyp may be seized with for- 
ceps and twisted off. If the point from which the polyp springs 
is not distinctly visible, the cervical canal should first be dilated. 
On account of the possibility that polypoid degeneration of the 
cervical mucous membrane may be the initial stage of cancer the 
operation should be a more thorough one in patients who have 
passed their fortieth year. A general anesthetic should then be 
given, the cervix fully dilated (p. 266) and the base of each 
polyp, or the mucous membrane from which the polyps spring, 
should be resected. In every case the excised tissue should be 
examined microscopically. 

Carcinoma. Carcinoma of the vulva begins in a hard swell- 
ing which soon ulcerates, infiltrates, and affects the inguinal lym- 
phatic glands. In other words, its characteristics are those of 
cancer in other portions of the body. Owing to the abundant blood- 
supply of the parts its growth is rapid. Carcinoma of the vagina 
as a primary lesion is seldom seen. 

Carcinoma of the cervix is very common and may be recog- 
nized both by palpation and inspection as an indurated swelling, 
with rough surface, ulcerating, and having a putrid odor. There 
are, however, some cases of erosion of the cervix, due primarily 
to laceration and secondarily to inflammatory discharges from the 
uterus, which do not present the ordinary appearances of cancer, 
but which upon microscopical examination may prove to be malig- 
nant. In suspicious conditions of this kind it is important to 
remove a section of the ulcer for examination by a competent 
pathologist. This can be easily done through a bivalve or tubular 
speculum, the pain being prevented by the injection of a few drops 
of a two per cent cocain solution. 

TREATMENT. A malignant tumor, whether beginning exter- 
nally or internally, should be thoroughly removed if possible. If 
this is not possible, it had bettor be left alone. Those who advo- 
cate a partial removal for the sake of getting rid of foul discharges 



272 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

apparently forget that ulcers will soon form again, and that the 
patient will, sooner or later, be subjected to the annoyance of an 
ulcerating cancer, unless perchance she succumbs to the so-called 
palliative operation. 

~No mention is made of benign tumors of the body of the 
uterus, or other abdominal tumors, since the consideration of such 
lesion is wholly out of the range of minor surgery. 

ACQUIRED DEFORMITIES 

Relaxation of the Sphincter of the Bladder. Inconti- 
nence of Urine. Incontinence of urine is an affection of old age 
whose treatment is most unsatisfactory. With advancing years the 
sphincter of the bladder becomes relaxed until a woman finds it 
impossible to hold her water as long as she has been accustomed 
to do. If the relaxation of the sphincter is slight, incontinence 
will only take place when the patient coughs or otherwise suddenly 
increases the pressure upon the bladder. In more marked degrees 
of the trouble there is a constant dripping of the urine, which 
keeps the patient in a distressing condition not only for herself, 
but for those about her. This weakness is often increased by a 
local condition of cystocele or prolapse of the uterus. The possi- 
bility of an overfilled and overflowing bladder should be borne in 
mind, though this condition is less common in women than in men. 

Before condemning a patient to the constant use of a rubber 
urinal the urine should be drawn by catheter and carefully exam- 
ined so that its amount and character may be known. One should 
not forget the possible presence within the bladder or urethra of 
a calculus or other foreign body, or a polyp or other tumor, which 
may be the cause of the incontinence. Attempts should be made 
to stimulate the sphincter by massage, by astringent applications 
applied in the urethra or vaginally, by cold bathing, and by elec- 
tricity. If the urine is found to be neutral or alkaline, benzoic 
acid may be given, or the l>enzoate of soda ten grains a day. These 
drugs are irritating to the stoluach and should therefore be given 
well diluted one hour after meals. More often the urine is scanty 
or too acid, so that an abundance of drinking-water and alkaline 
diluents should be prescribed. Cystocele or prolapse of the urethra 
or uterus should be relieved by a pessary or cured by operation. 



RETENTION OF URINE 273 

Incontinence of Childhood. Incontinence of urine by niglit or 
by day is not uncommonly seen in both male and female children, 
but is more troublesome in girls than boys (see p. 220). *The 
attention of the parents should be directed to the general condi- 
tions which favor this affection, and they should see that the child 
sleeps under light clothing and drinks plenty of water in the fore- 
noon and but little or nothing for some hours before going to bed. 
It is often of advantage to arrange the mattress so that the hips 
are slightly higher than the shoulders. Cold sponge baths night 
and morning are also of assistance in overcoming the trouble. In 
no case should a child be punished for a weakness it cannot avoid 
and which mortifies it extremely. Among the various drugs which 
have been tried with more or less success belladonna has attained 
quite a reputation, and its use is sometimes followed by marked 
improvement. The urine should always be examined, and if it 
is unduly acid, alkaline diluents should be given. In obstinate 
cases the occasional passage of a cold steel sound into the bladder 
will stimulate and strengthen the sphincter so as to increase 
its control. Another good plan is to give the child a measuring- 
glass, and encourage it to retain its water for a time after the 
first inclination to urinate is noticed. Such restraint should not 
be carried too far, the idea being a gradual strengthening of the 
muscles through systematic exercise. One can safely predict 
that the lack of control will disappear before the age of puberty 
is reached. 

Retention of Urine. CATHETEKIZATION. Retention of 
urine in the female is rarely seen except after an operation or after 
childbearing. It is due sometimes to the anesthetic, sometimes to 
the changed abdominal pressure, sometimes to the operative wound 
in the immediate vicinity, and sometimes simply to the horizontal 
position. There are women who are unable to pass water lying 
down, even in health. 

The risk of catheterization is a slight one, but it should be 
avoided when possible. It is better, therefore, to postpone it until 
the patient has made some ineffectual attempts to empty the blad- 
der and feels pressure. This will usually mean the lapse of twelve 
or sixteen hours after an operation or delivery. After many gyne- 
cological operations the nature of the operation makes it unde- 
sirable to allow the patient to urinate. In such casos the bladder 
20 



274 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

should be emptied regularly by catheter, without waiting for the 
patient's sensations. 

Catheterization, which is so simple to one accustomed to its 
performance, may be very embarrassing to the beginner, especially 
if the nurse announces that she is unable to find the urethra. It is 
therefore worth description. 

The old practise of passing a catheter by touch has no place 
in modern aseptic technique. The operator should sterilize his 
hands or wear sterile gloves, although if he proceeds properly and 
a glass catheter is used this is not strictly necessary, for he will 
not touch any part of the catheter which enters the urethra. The 
patient flexes the thighs and separates the knees widely. If she 
is lying on a soft bed, a pillow should be placed under the hips to 
raise the vulva well above the level of the bed. With the thumb 
and fingers of one hand the operator separates the anterior part 
of the labia minora widely, so as to expose the vestibule. With 
the other hand he wipes the vestibule clean, using a swab of ab- 
sorbent cotton wet with a mild antiseptic. He next drops the 
swab, and with the same hand takes the sterile catheter, near its 
outer end, and passes it gently into the meatus. The catheter 
should be wet with saline solution. No other lubricant is needed, 
unless the catheter is unduly large. It will readily follow the 
urethra to the bladder, and the urine at once streams out. When 
the bladder is empty, the forefinger is placed over the end of the 
catheter in order to prevent the escape of the urine as it is with- 
drawn. If a rubber catheter is used, some lubricant is generally 
necessary, and this fact, together with the necessity of grasping 
the catheter near the tip, makes it desirable that the hands of the 
operator shall be sterile. The irritation which follows the repeated 
use of a glass catheter is probably due to the fact that it is too 
large, or is taken from an irritating solution before insertion, or 
that it is not introduced with sufficient gentleness. 

Prolapse of Urethra. The female urethra may prolapse 
from the meatus and cause much discomfort, or even sharp pain. 
The prolapse may be complete, that is, affecting the whole surface 
of the mucous membrane, or partial, only one side of the urethra 
being affected. Astringents will relieve symptoms in mild cases. 
In severer cases cauterization, both by heat and by chemicals, is 
often tried, but usually proves unsatisfactory. It is better to ex- 



PROLAPSE OF UTERUS 275 

else the protruding membrane and to make an exact suture of the 
cut edges, using a sharply curved needle and fine black silk. If 
the prolapse is extensive the whole circle of mucous membrane 
must be removed and the wound closed with exactness. The best 
method of suturing is by a number of interrupted fine black silk 
stitches. The stitches should be removed in four or five days. 
This operation may be performed under cocain, applied on a cot- 
ton s\vah directly to the mucous membrane. A four per cent soln- 
tion should be used for the purpose. If it is found neeessary 
to inject cocain, the area of mucous membrane to be removed 
should be marked out with a scalpel before the injection is made. 
Otherwise the swelling caused by the injection may easily 
mislead the operator as to the amount of tissue which it is neces- 
sary to excise. 

Another method of operating upon prolapse of the urethra is 
to make an incision through the mucous membrane of the vagina 
a little way above the orifice, and to draw out through this in- 
cision so much of the urethral mucous membrane as is considered 
to be superfluous. This is cut away and the wounds in urethra 
and vagina are sutured separately, the former at least with ab- 
sorbable sutures. 

Old Laceration of the Perineum. The operation to re- 
store the perineum after an old laceration rests on the same prin- 
ciples as that to close a fresh wound in the perineum. The surface 
of the cicatrized area must, however, be dissected away before the 
sutures are inserted, and either removed entirely or left to project 
as a fold into the vagina. These operations require a general anes- 
thetic and a treatment in bed of not less than ten days or two 
weeks in order to secure a perfect result. Their details are given 
in every gynecological text-book. An operation to restore the 
perineal body is strongly to be advised as a preventive of future 
prolapse, even though the patient has no present symptoms. 

Prolapse of Uterus. The uterus may sink so low down as 
to present itself partially or wholly outside the vaginal orifice. 
This condition is known as prolapse of the uterus and is usually 
found in women who have borne several children. For the occur- 
rence of a prolapse three things are necessary: a torn perineum, 
greatly relaxed vaginal walls, and a lengthening of the ligaments 
which normally hold the uterus in position. In addition, the whole 



276 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

uterus, or at least its cervix, is usually elongated and heavier than 
normal. 

A uterus which protrudes partly or wholly from the vagina 
causes the patient discomfort, prevents her from walking easily, 
and often makes it impossible for her to retain urine for more 
than an hour or two during the day. Moreover the cervical mu- 
cous membrane being unaccustomed to such exposure, often ulcer- 
ates, so that a foul discharge may be added to the other discom- 
forts of the sufferer. 

TREATMENT. In simple cases if the outlet of the vagina is 
not too much widened, a retroversion pessary (Fig. 133) may cure 





FIG. 133. RETROVERSION PESSARY WHICH IN MANY CASES WILL KEEP WITHIN 
THE VAGINA AN OTHERWISE PROLAPSED UTERUS. 

the patient of all symptoms. In many cases, however, the pessary 
will gradually work out of the vagina as the patient walks about. 
Special supports have been devised, but the pressure which they 
make upon the cervix is often painful and may cause ulceration. 
The usual form of apparatus consists of a belt to which is at- 
tached posteriorly a spring. The spring passes between the legs 
of the patient and curves upward into the vagina. At its ex- 
tremity is a ball or else a little cup which fits over the cervix. 
Such apparatus is cumbersome, hard to keep clean, and should 
not be advised whenever an operation is possible. A T-bandage 
will sometimes give temporary relief if the uterus is crowded well 






ADHESIONS OF THE CLITORIS 277 

upward by several large cotton tampons pushed into the vagina 
before the perineal strap of the bandage is secured. 

Several operations have been advised for prolapse of the uterus. 
The perineum may be restored by suture. The caliber of the 
vagina may be reduced by partial excision and suture of its walls. 
A hypertrophied cervix may be amputated, the round ligaments 
may be shortened, the uterus may be suspended by suture to the 
abdominal wall, or finally a complete hysterectomy may be per- 
formed. This last operation, while entailing a somewhat greater 
risk than the others, has the great merit of not being followed by 
recurrence. 

Fistula of the Vagina, etc. Fistula; between the ureters 
and vagina, or bladder and vagina, or urethra and vagina, or 
vagina and rectum may be due to necrosis of the septa between 
ihe^e various tubes, brought about by long continued pressure in 
childbirth, or as the result of an accident, or as the result of in- 
flammation, or they may be due to malignant ulceration. 

The existence of a fistula is made known by the passage of gas 
or fecal matter from the rectum into the vagina or bladder; or 
of urine into the vagina or rectum. Sometimes a probe can be 
passed through the fistula or digital examination may demonstrate 
its presence. 

Fistula from a benign cause may be cured by a plastic opera- 
tion, many ingenious forms of which have been devised. Suc- 
cess is most likely to follow an operation in which the defects 
in the two mucous surfaces are closed in such a manner that the 
suture line in one organ is not exactly opposite the suture line in 
the other. Cf course no attempt should le made to close a fistula 
due to malignant ulceration unless the tumor has first been wholly 
removed. 

CONGENITAL DEFORMITIES 

Adhesions of the Clitoris. Adhesions of the prepuce to 
the clitoris may wall in sebaceous material, and give rise to irri- 
tation which in turn may induce habits of masturbation. This 
condition should therefore be sought for in cases of unexplained 
reflex irritation. The clitoris is exposed by drawing outward and 
upward the upper ends of the labia minora, at the same time 
pushing the fingers backward against the symphysis, in order to 



278 AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS 

make the head of the clitoris project forward. The technic is 
similar to that performed to uncover the head of the penis of a 
fat squirming baby. If adhesions are present, this manipulation 
will make them appear. 

TREATMENT. The parts should be saturated with twenty per 
cent cocain solution for ten minutes. The prepuce can then be 
withdrawn without pain, and while tension is made upon it, a 
small flat probe should be passed around the head of the clitoris 
to break up all adhesions. The raw surfaces should be smeared 
with cold cream. The parts should be washed daily with warm 
water, and this retraction and anointing should be repented 
every second day for a week or two to prevent the reformation of 
adhesions. If there is a redundancy of prepuce, it may be ex- 
cised and the wound sutured with fine black silk. This is a 
material aid in breaking up the habit of masturbation, as the 
practise is interrupted for a few days by the soreness and the 
changed sensation assists, the child in not resuming the habit. 

Imperforate Hymen. - The hymen may be without an 
opening. As a result of this malformation, when menstruation 
first occurs, the escape of blood from the vagina may be pre- 
vented. Such a patient will have the usual subjective symptoms 
of menstruation without any flow of blood. Under these circum- 
stances a careful examination will reveal a cystic distention of 
the hymen, and the dark blue color of the concealed fluid will 
at once explain matters. An incision should be made and the 
blood and blood clots allowed to escape. 

In other cases the lack of development may extend higher up 
and the vagina be partly or wholly absent or the cervix be with- 
out an opening. 

Stenosis of the Cervix. An imperfect development of 
the cervical canal is one of the commonest causes of dysmenor- 
rhea. The opening may be so small that it will only admit the 
passage of a small probe. This may be sufficient for the escape 
of fluid blood, but not for the easy passage of even a small blood 
clot. The result is a contraction of the uterus, continued until 
the cervix is sufficiently dilated to permit the clot to escape. The 
pain thus caused may be very severe, even causing unconscious- 
ness. The stenosis may disappear with repeated menstruation 
or with the sexual stimulus of marriage, but such is not al- 



STENOSIS OF THE CERVIX 



279 



\viivs the case. It is permanently overcome in most cases by 
pregnancy. 

TREATMENT. It is surprising how many young women are 
allowed to suffer unnecessary pain during the first day or two 
of menstruation year after year, when a slight operation and 
a little subsequent treatment would avoid it. The indication 
under such circumstances for dilatation of the cervical canal is 
clear enough. The teclmic of its performance is given on page 
266. In these cases it should 
not be followed by curettage, as 
the uterine mucous membrane is 
in no wise at fault. When the 
cervix has been dilated, a hard 
rubber plug (Fig. 134) should 
be inserted and left in place 
for two or three months. This 
should be about 22 or 25 French 
catheter scale, and should be 
long enough to reach through 
the internal os, as otherwise it 
may slip out of place. These 
plugs are sometimes made with 
a lateral groove to permit the 
escape of blood during menstruation. This is unnecessary, as 
the blood escapes around the plug and the groove makes a lodging- 
place for blood and mucus. If symptoms of obstruction recur 
in a few months after the removal of the plug, it should be 
reinserted. 

This operation can be painlessly performed with cocain ; but 
in many cases the sensibilities of the patient render a general anes- 
thetic desirable. 

A hard rubber plug of this shape acts as a valve and will pre- 
vent the entrance of seminal fluid into the uterus. The dilata- 
tion of the cervical canal which follows its use is favorable to 
pregnancy after the plug has been removed. 




FIG. 134. HARD RUBBER PLUGS FOR 
THE CURE OF STENOSIS OF THE CER- 
VIX. 



SECTION V 

AFFECTIONS OF THE ANUS AND 
EECTUM 



CHAPTER XI 

INJURIES AND INFLAMMATIONS OF THE ANUS 
AND RECTUM 

METHODS OF EXAMINATION 

Examination of the Patient. There are two positions of 
the patient which are satisfactory for an office examination of the 
anus and lower portion of the rectum. If the patient is a man 
lie may stand with his back toward the light and bend well for- 
ward, resting his hands upon the seat of a chair. This position 
affords the examiner an excellent view of the region of the anus, 
and it also facilitates digital examination, especially of the ante^ 
rior portion of the rectum. 

The other position, which is to be employed with women, and 
which is preferred by some surgeons in all cases, is the lateral 
recumbent position, with both thighs flexed upon the abdomen. 
The thigh which is uppermost should be flexed a little farther than 
the other. 

Examination begins with inspection not merely of the skin, 
but also of the anal canal. The folds of the anus should be sepa- 
rated and the anal mucous membrane should be drawn out a 
little at a time, and the patient should also be directed to strain, 
so that the examiner may see how much venous dilatation is 
thereby produced. 

Palpation is chiefly of service to reveal the extent of inflam- 
matory exudation, and to show the existence of a hidden fistula. 

If a sinus exists, the passage of a probe will sometimes reveal 
its direction and extent. This is usually a painful method of 
examination, and the knowledge thereby gained is not always 
very extensive. 
280 



K.\ \.MI.\ATIO\ OK 'I'll!. PATIENT 281 

Digital examination is of the greatest importance. A rubber 
glove may be worn or the finger may be covered with a finger cot. 
The latter is thinner than a glove, and so does not dull the sen -a 
tion to the same degree, but it does not protect the base of the 
finger from contamination. Even by the thinnest finger cot the 
tactile sense is somewhat obscured, as any one may prove for 
himself by making tests upon various rough objects. 

The finger should be well oiled, preferably with a heavy lubri- 
cant, such as vaseline, or one of the preparations from Irish moss. 
It should be inserted slowly and rotated during the insertion, in 
order to clear the folds of mucous membrane. When the finger 
has been fully inserted, all of the rectum within reach should be 
systematically palpated with the palmar surface of the finger. It 
is possible to recognize in this way a wound, irnpaction of fecr~, 
a foreign body, a fissure, an abscess, a fistula, inflammatory thick- 
ening of the rectal wall, a stricture, a benign or malignant tumor, 
or a hemorrhoid. 

One can usually obtain far more knowledge from a digital ex- 
amination made when the rectum is empty; but since it may be 
desirable to know what is the usual condition of the rectum, it is 
just as well to make an examination when the patient first presents 
himself, and if the rectum is found to be full of feces, the bowel 
should be thoroughly emptied by a cathartic or enema, and a sec- 
ond examination made. 

There is one other position in which a patient should some- 
times be examined: namely, a squatting position. In this posi- 
tion, and especially if the patient strains, the examiner's finger 
will reach portions of the rectum which arc inaccssible in other 
positions. Furthermore, if the normal planes of tissue have been 
in any way weakened, this fact will be manifest, in this position 
as in no other. This is equally true of excessive valvular forma- 
tion within the rectum, and of hernia I protrusions outside of it. 

Inspection of the interior of the rectum by means of a procto- 
scope will often yield valuable knowledge without an anesthetic. 
The instrument used should be short, not more than three or four 
inches in length, and preferably an inch or more in diameter 
(Fig. 135). If a tube of much smaller caliber is employed, the 
mucous membrane will lie in such deep folds that a great deal 
of it will escape observation. If the hips are higher than the 



282 INJURIES OF THE ANUS AND RECTUM 

abdomen, and the clothing is all loosened, the intestines will fall 
away from the pelvis, and the lower portions of the rectum will 
gape open and fill with air. This facilitates very much the inspec- 
tion through the proctoscope. The knee-chest position is espe- 




FIG. 135. A SUITABLE RECTAL SPECULUM FOR OFFICE EXAMINATIONS. 

cially good for this purpose. In many patients, even though no 
inflammation be present, the passage of the proctoscope excites a 
painful spasm of the sphincter ani. This method of examination 
is not suited to cases in \vhich acute inflammation is present. 

Stretching of the Sphincter Ani. It may be necessary to 
stretch the sphincter ani for purposes of examination, or as a 
means of treatment, or as a preliminary to treatment. It is best 
performed in the following manner: The patient should be thor- 
oughly anesthetized with gas, ether, or chloroform, and should 
be in either the dorsal position, the legs being held by a crutch or 



STRETCHING OF THE SPHINCTER ANI 



283 



an assistant; or else he should lie in the lateral position, with 
the knees well drawn up toward the chest. The anal region should 
be cleansed with soap and warm water. The two forefingers of the 
operator should be lubricated and pushed well up into the rectum. 
Their palmar surfaces should be directed away from each other. 
Steady pressure should next be made to separate the two fingers, 
and this pressure should be exerted in different directions antero- 
posteriorly, laterally, and obliquely. As the sphincter gives way, 
a third finger should be inserted, and then a fourth. The sphinc- 
ter cannot be considered dilated unless the two fingers of each 
hand may be pressed against the ischia on either side without the 
use of much force. Some oper- 
ators prefer -to stretch the sphinc- 
ter with the thumbs. Digital dila- 
tation" in the manner described is 
safer and otherwise more satisfac- 
tory than dilatation by means of 
any instrument. The mucous 
membrane at the anal margin will 
usually be cracked here and there, 
but these superficial breaks in the 
mucous membrane require no 
treatment other than that of 
cleanliness. The patient may get 
up and go about as soon as the 
dizziness caused by the anesthetic 
has passed off. 

Stretching of the sphincter 
often causes some hemorrhage in 
the deep tissues, so that on the fol- 
lowing day the anus may be sur- 
rounded by a black and blue zone. 
This will disappear without treat- 
ment in a few days. 

Stretching the sphincter great- 
ly facilitates inspection of the rec- 
tum through a speculum. A bi- 
valve instrument (Fig. 1 "><>) can then be employe. 1 :md turned 
in different directions, so us to pive ;i view of the whole 




;. 130. BIVALVE Ki-:ciAf, Si-i.ri- 
I.T.M. A good instrument to em- 
ploy after the sphincter has been 
stretched. 



284 INJURIES OF THE ANUS AND RECTUM 

INJURIES 

Wounds of the anal region are for the most part due to 
falls upon sharp objects; or they may be the result of violence 
inflicted by the patient or others. Slight wounds may follow the 
passage through the anal canal of some sharp object, such as a 
splinter or fish bone which projects from a fecal mass. In making 
the examination of a patient who has fallen upon a sharp object 
it is well to remember that a small foreign body may pass the anus 
and penetrate the wall of the rectum without leaving any external 
sign of injury; hence the importance of a speculum examination 
in such cases. 

TREATMENT* The first indication for treatment is the control 
of hemorrhage. External hemorrhage will be noticed at once, and 
may be controlled by pressure or styptics, such as adrenalin or JXT- 
oxid of hydrogen. If a vessel is lacerated above the sphincter, 
hemorrhage may take place into the rectum and not make itself 
manifest for some time. Under such circumstances the pas- 
sage of a speculum or of a rectal catheter or any other tube 
will show at once whether the bleeding is continuous. If 
so, the * sphincter should be dilated and the ruptured artery 
ligated.'- 

If the wound is so placed as to be pulled upon by the dila- 
tion and contraction of the sphincter, which takes place during 
defecation, it is better to stretch the sphincter fully, so as to insure 
rest to the wound. This not only adds to the patient's comfort, 
but hastens repair. 

Wounds in this vicinity should be treated like all other wounds 
by thorough cleansing, and if of sufficient size, by a careful suture. 
Although exposed to contamination, wounds of this region heal 
promptly in many cases, thanks to the free blood-supply. Fine 
black silk is the best suture material to employ for the portion 
of the wound which is external. The portion of the wound which 
is so situated that the stitches cannot be easily removed should 
be sutured with plain catgut or a fine ten day chromicized gut. 
If the wall of the rectum is wounded, the possibility of peritoneal 
involvement should be borne in mind. 

Hemorrhage. Hemorrhage into the rectum or from the anus 
may be due to a gross injury or to a small ulceration occurring 



HKMOKUHAGE 28T) 

in connection with hemorrhoids, prolapse, or tumors. Further- 
inoiv, the hemorrhage following operation upon the rectum, while 
not. strictly speaking within the domain of minor surgery, often 
shows itself after the operator is out of reach, and its treatment 
should therefore be understood by every practitioner. 

TREATMENT. As stated above, bleeding from an external 
wound or ulcer is readily controlled by pressure, ligation, or 
styptics, such as peroxid of hydrogen or adrenalin. If there i- 
capillary oozing, as from a prolapsed hemorrhoid, the appli- 
cations of swabs wrung out of very hot water will usually con- 
trol it. 

Hemorrhage from a vessel so far up that it is n<>( included in 
the sphincter ani is far more dangerous, and demands prompt and 
thorough treatment. When this follows operation within a few 
hours it either comes from a vessel which has not been ligated 
or from which the ligature has slipped. The usual symptoms are 
these; The patient will complain of sonic pain in the rectum, and 
state that he feels that his bowels are going to move. The nurse 
or doctor will probably tell him that he is mistaken, and that his 
fee I ings are due to the operation or to the presence of gauze in 
the rectum, if a plug of this material has been inserted. In a 
few minutes the patient will again insist that his bowels are going 
to move, and the passage of four or more ounces of fluid blood 
will prove the correctness of his statement. Under such circum- 
stances any gauze should be removed from the rectum, the bowel 
irrigated with as hot a sterile saline solution as the patient can 
hear, and if the flow of blood continues, an anesthetic should be 
given, the sphincter dilated, a bivalve speculum inserted, and the 
bleeding point exposed and ligated. 

This accident is peculiarly liable to follow operations upon 
internal hemorrhoids, performed under coca in, with incomplete 
or no dilatation of the sphincter. The cocain, or mixture of 
cocain and adrenalin deceives the operator in regard to the 
amount of bleeding possible from the cut surface, and when 
the astringent action of these drugs passes off the real mischief 
begins. 

There is also the so called secondary hemorrhage, due to the 
opening of an artery by the sloughing away of the ligature which 
has been put around it. This is most likely to follow when masses 



286 ' INJURIES OF THE ANUS AND RECTUM 

of other tissue are included with the artery in the ligature, a 
method of technic advised by some operators upon hemorrhoids. 
Such secondary hemorrhage may therefore occur five or seven or 
even ten days after the operation. Its symptoms and treatment 
are the same as those given above. 

Foreign Bodies and Impacted Feces. Foreign bodies are 
frequently inserted into the rectum, either for the purpose of sex- 
ual excitement or to assist in defecation or in urination. Insane 
persons sometimes pass foreign bodies into the rectum. The rec- 
tum, especially in old people, is tolerant of foreign bodies, owing 
no doubt to the fact that in civilized life many persons habitually 
allow fecal matter to remain in the rectum for hours or possibly 
for days. Such hardened balls of feces may become so firm that 
they cannot be evacuated and require the treatment of foreign 
bodies. 

TREATMENT. The extraction of a foreign body is a simple 
process after the sphincter lias been dilated (p. 282). Smaller 
objects may be extracted with the finger or a dressing forceps 
guided by the finger. In this way the patient may be saved the 
annoyance of a general anesthetic. A hardened ball of feces can 
usually be broken up digitally and extracted piecemeal by the 
finger or by dressing forceps or washed out by repeated injections, 
after it has been broken up. The rectum should have rest for a 
few days to recover its tone and to allow for healing of the abra- 
sions which may be produced. Hot external applications are grate- 
ful to the patient. 

INFLAMMATIONS 

Intertrigo. Intertrigo, or chafing of the skin, may occur 
on any portion of the body where two skin surfaces come into con 
tact. It is especially troublesome between the folds of the but- 
tocks. It may be due to a lack of cleanliness, to irritating dis- 
charges, or to an unusual amount of exercise. When due to the 
last named cause, it may be so severe that blisters develop. When 
due to irritating discharges, if it is long continued it may pass 
into eczema. 

The essentials of treatment are cleanliness, separation of the 
folds of the skin by gauze or cotton saturated with a cooling 
lotion, or the reduction of friction between opposing surfaces by 



PRURITUS ANI 287 

means of a simple ointment, such as cold cream or a dusting pow- 
der. If unusual exercise is to be taken, the chafing can be pre- 
vented in many instances by a preliminary application of cold 
cream to the opposed surfaces. 

Pruritus Ani. This name is given to the troublesome itch- 
ing about the anus which may occur at any age, but is espe- 
cially common among elderly persons. In children it is often 
due to pinworms. In adults it may be caused by an irritating 
discharge from the rectum or vagina, or it may be due to hemor- 
rhoids or to fissures. In every case the affected part should be 
examined in a good light. The folds of the anus should be sepa- 
rated in order to expose hidden fissures. If nothing is found 
externally a speculum should be passed, and the mucous mem- 
brane of the rectum examined. Digital examination should also 
be made, in order to determine the presence of hemorrhoids 
and the amount of contraction of the sphincter. The stools 
should also be examined, since they may be of an irritating 
character. 

TREATMENT. If any cause for the pruritus is found, it 
should be removed. If there are pinworms, a pint of water con- 
taining an ounce of the fluid extract of quassia should be in- 
jected into the rectum, and kept there fifteen minutes. In a 
child a less quantity will suffice. This treatment should be re- 
peated on two or three succeeding days. If a fissure or hemor- 
rhoid or ulcer of the rectum or other obvious cause of pruritus 
exists, suitable treatment should be instituted. 

In all cases errors in diet should be avoided. The patient 
should give up alcohol, tobacco, and coffee. Constipation should 
be corrected. The rectum should be regularly emptied, and kept 
empty, by saline laxatives or enemata. If the sphincter is tight, 
it should be stretched. This may be performed by the doctor's 
fingers, the patient having been rendered unconscious by laughing 
gas ; or a gradual dilatation may be preferred. The latter is best 
performed by the patient, who every night upon retiring should 
insert a hard rubber rectal dilator, and leave it in place for fif- 
teen to thirty minutes. These dilators come in three sizes. After 
a few nights the patient will be able to pass the largest size with- 
out pain. When the dilator lias boon removed, the patient should 
liberally apply the following ointment: 



288 INFLAMMATIONS OF THE ANUS AND RECTUM 

ty Camphorae gr. 4 ; 

Menthol gr. 3 ; 

Ac. carbol gr. 30 ; 

Ac. boric gr. 10 ; 

Calomel gr. 10 ; 

Ung. zinc, ox q. s. ad. oz. 1. 

M. 

This treatment should be continued every night for a month, 
or until the sphincter is looser than normal. 

Some patients are relieved by the application of hot or cold 
water two or three times a day. This may be followed by an 
application of a powder composed of one part each of camphor 
and chloral rubbed together and added to thirty parts of starch. 

The itching may be stopped temporarily by the application 
of a solution containing ten per cent or less of resorcin ; or of 
one containing five per cent or less of carbolic acid. Another 
method of using carbolic acid is to apply it pure, and wash it off 
almost immediately with alcohol. This will sometimes stop the 
itching for several days. The surface may be painted with a 
mixture of equal parts of the tincture of iodine and the fluid 
extract of hamamelis. 

If the skin is excoriated or inflamed by reason of scratching, 
it is a good plan to keep a fold of gauze between the nates, wet 
with some cooling lotion or smeared with vaseline containing 20 
grains of carbolic acid and 10 grains of cocain to the ounce. 

Proctitis. Inflammation of the rectum, or proctitis, may be 
either acute or chronic, and the latter is again divided into a trophic 
and hypertrophic proctitis. 

The acute form of the disease may be due to mechanical in- 
jury or to a sudden change in temperature, as when a person after 
exercise sits upon cold, damp ground; or to chemical irritation 
following the ingestion of improper food or to intestinal fermenta- 
tion or to bacterial infection, either from the feces or from 
objects introduced into the rectum. 

The symptoms of heat, fulness, and pain are common to 
catarrhal inflammation of all mucous membranes, and in addi- 
tion there is a constant or oft repeated desire for evacuation. 
Usually the movements are fluid or mixed with mucus and blood. 



FISSUKK 289 

TREATMENT. The bowels should be irrigated for clean-in:: 
purposes, and this should be followed by a continuous irrigation 
for ten or fifteen minutes, with either hot or cold normal saline 
solution. This may be carried out through a specially devised 
double current rectal tube, or, as is more comfortable to many 
patients, two small soft rubber catheters may be employed, one 
for the inflow and one for the outflow. After the irrigation, a 
suppository of opium and iodoform should be inserted, or one 
containing iodoform and tannic acid, for in these cases opium and 
morphine must be used with caution. At least twice a day the 
saline irrigation should be followed by a stimulating enema. Vari- 
ous solutions have been recommended for this purpose, such as 
nitrate of silver, 1 : 3,000 ; boric acid, 3 per cent ; acetate of lead, 
1 : 500 ; fluid extract of hydrastis an ounce in two quarts of hot 
water, etc. 

In chronic proctitis similar measures are to be employed. 
Usually the cause is a long continued one, and it may not be possi- 
ble to remove it entirely. At least one may attend to the diet and 
keep the stools soft with castor oil or one of the milder salines. 
The astringent enemas may be somewhat stronger than in acute 
proctitis, but it is better to begin with the milder solutions and 
to increase their strength gradually as the effect is evident. Per- 
sistent ulcers may be sprayed or swabbed with still stronger appli- 
cations. 

Fissure. Fissure of the anus is a crack in the mucous mem- 
brane at the orifice of the anal canal, and situated generally near 
the anterior or posterior commissure. It is due, in most cases at 
least, to the scratching of the mucous membrane by the passage 
of hard fecal masses and infection of the small wound. The espe- 
cial development of the sinuses of Morgagni near the commissures 
is thought to determine the frequent development of fissures in 
these situations. 

In its early stages a fissure gives the patient only a little dis- 
comfort. There is a stinging pain as the fecal mass passes the 
fissure, and a drop or two of blood may be found either on the 
expelled feces or on the paper used to cleanse the anus. There 
is also a feeling of heat or a throbbing dull pain for a few min- 
utes. As the fissure becomes deeper and more unlimited these 
slight symptoms are greatly increased. In an extreme e:i^e the 
21 



290 INFLAMMATIONS OF THE ANUS AND RECTUM 

thought of defecation fills the patient with terror, and the entrance 
of the fecal mass into the anal canal excites a violent spasm of the 
sphincter, which makes the act of defecation tenfold more diffi- 
cult. The pain thus caused may last for hours and seriously 
interfere with the patient's daily life. 

TREATMENT. The treatment of fissure that can be carried 
out by the patient is most important, since under its influence 
many fissures of slight degree will permanently heal. The bowels 
should be made regular and the stools semisolid by changes in 
diet and such laxatives as are found to agree best with the par- 
ticular patient. Straining at stool is to be avoided. Lubrication 
of the anal canal before defecation will do much to prevent the 
formation of a fissure and to favor the healing of one already 
existing. The patient can accomplish this by injecting a small 
syringeful of oil or by passing his greased finger into the anus. 
After defecation the anus should be washed, not rubbed with a 
dry and perhaps stiff paper. If the patient will not take this 
trouble he can at least expectorate upon the paper before apply- 
ing it. The alkaline viscid saliva is non-irritating to the mucous 
membrane. 

If the pain is marked, the patient should lie down for a half- 
hour after defecation, holding a hot water bottle or a hot wet 
sponge firmly against the anus. 

By the measures above mentioned patients will succeed in 
curing many small fissures and in preventing many more. In 
severer cases these home remedies must be supplemented by treat- 
ment by the physician. Two plans have been found reliable, 
namely, treatment of the wound by antiseptics and stimulating 
applications and stretching or division of the sphincter ani. 

If applications are decided upon, the fissure should be cleansed 
daily. This is best accomplished through a small conical speculum 
with a window in one side. Only mild antiseptic solutions should 
be employed, such as bichlorid of mercury, 1: 10,000; boric acid, 
2 per cent; or peroxid of hydrogen, 1 part to water 8 parts. When 
the fissure is clean and dry it should be painted with the stimu- 
lating liquid. Balsam of Peru (40 per cent in oil); ichthyol, 20 
per cent in water; silver nitrate, 2 to 5 per cent; argyrol or one 
of the other newer silver preparations in 1.0 to 20 per cent solutions 
are all good remedies. 



ABSCESS L'MI 

By far the best treatment in many cases is the stretching of 

the sphincter ani under a general anesthetic (p. 282). This at 
once stops all spasm of the sphincter, does away with most of the 
p:i!n during and after defecation, frees the fissure from injuri- 
ous contact with the fecal mass in its passage, and without other 
treatment in many cases will effect a rapid cure. 

During the stretching the fissure will probably be cracked 
open, but if care is taken not to make the pull all the while in 
one direction, the deepening of the fissure will not be serious. In 
fact, this very tearing open of the fissure itself has been said to 
he one of the chief elements in the rapid healing which follow- 
stretching of the sphincter. This probably is not so; at any rate 
there are sufficient other grounds on which to explain the good 
results of this method of treatment. 

There is still another method of treatment which has its advo- 
cates, and that is division of the external sphincter through the 
tissure. If the lissnre should happen to be exactly in the anterior 
or posterior commissure, the incision may be made to one or both 
sides of it. While this method of treatment is unquestionably 
followed by a cure, it is difficult to see why one should enlarge 
the existing wound or add two fresh wounds, when the relaxation 
of the sphincter can l>e equally obtained by digital dilatation. 

Abscess.- An abscess in the vicinity of the anus or rectum 
is generally called an ischiorectal abscess. Strictly speaking, many 
of i he ahscoses found in this vicinity are not situated in the ischio- 
rectal space. The term is, however, so well established that it 
will probably remain in use, at any rate for the deej>er absc 
of the vicinity. 

it is well to recognize at least four types of abscess in this 
vicinity: (1) A cutaneous furuncle or boil; (2) an abscess beneath 
the skin at. the margin of the anus, sometimes called a marginal 
absces.-,; (')) an abscess within the wall of the rectum, sometimes 
called an intramural or siibmucous abscess; and (4) an abscess 
outside of the rectum, which may be designated a perirectal or 
ischiorectal abscess. A still further differentiation is made by 
rectal specialists, but this classification is sufficient for practical 
purposes. 

The source of infection in many abscesses can be determined. 
Thus it is evident that a furuncle starts around the root of a hair 



292 



INFLAMMATIONS OF THE ANUS AND RECTUM 



or from some abrasion in the skin. In marginal abscess and in a 
submucous abscess the infection enters through a fissure or some 
other break of the overlying skin or mucous membrane. Many 
ischiorectal abscesses have their origin in some wound or ulcer of 
the rectum ; others are extensions of one of the three simpler types 
of abscesses mentioned. In still other cases no entering point for 
the infection can be discovered, and the determination of the site 
of the abscess seems to follow a bruise, or unwonted exercise, or 
sitting on damp ground, etc. 

In the majority of superficial and deep abscesses of the anal 
region the pus contains bacilli coli or streptococci or staphyloeocci 
or tubercle bacilli. This is their order of frequency according to 
Gant. 

The symptoms are those of abscess everywhere. If the ab- 
scess is small and superficial (Fig. 137), it will not give much 




FIG. 137. SMALL SUPERFICIAL ISCHIORECTAI, ABSCESS. 

tient aged thirty years. 



Duration one week. Pa- 



pain except during defecation or when pressed upon. In other 
cases the pain is constant and intense. The deeper abscesses are 
usually situated either in the right or left ischiorectal fossa. Oc- 
casionally they extend across the posterior commissure ; rarely 
across the anterior. Left to themselves, most of the abscesses 
tend to "point" through the skin or into the rectum (Fig. 138); 
others burrow upward into the pelvis, and thereby add to ths 



ABSCKSS 293 

gravity of the situation. When the abscess bursts, either through 
the skin or into the rectum, there is a sudden discharge of pus, 
and an equally sudden relief of symptoms. Such a rupture usu- 
ally drains the abscess very imperfectly, so that there will be a 




FIG. 138. A LAIIGKK AND DKKIM-:H ISCIIKIKKCTAL ABSCESS. Duration three 
Patient aged twenty-two years. 

more or less constant flow of pus, with partial subsidence of the 
induration, and a fistula which opens either into the rectum or 
through the skin, or in both directions, as the case may be (see 
p. 295). 

TKKATMENT. Treatment of an abscess of any one of the four 
forms mentioned should be surgical; that is, the abscess should 
be opened with sufficient freedom to permit the easy escape of 
the pus, and the incision should be maintained by a drain or other 
wise until the abscess cavity heals by granulation. A submucous 
abscess should be incised longitudinally; a marginal one, radially. 
All other abscesses of this region should be opened by an incision 
which is parallel to the fibers of the sphincter muscles. Such an 
incision will correspond more or less perfectly to an arc of a cir- 
cle drawn around the anus. 

While a small abscess may be o|>ened without 'much pain to 
the patient by first freezing the skin and then injecting coca in, a 
general anesthetic is advisable t'>r three rea<i-n<: It -aves the 
patient from any pain: it enables the operator to explore more 



294 INFLAMMATIONS OF THE ANUS AND RECTUM 

fully the deeper portions of the abscess, if such exist ; and it per- 
mits him to stretch the sphincter. This will enable the operator 
to determine whether tlie abscess communicates with or closely 
approaches to the rectum, and it also makes subsequent defeca- 
tion much easier, and thus hastens the patient's recovery. 

The steps of the operation are these: The patient is anes- 
thetized and placed either on his back, with his thighs well flexed, 
or else upon the affected side. In the latter case the upper thigh 
should be flexed more than the lower. A preliminary cleansing 
of the lower bowel and rectum by cathartics and enema is painful 
and may be omitted. The external parts are cleansed, the sphinc- 
ter ani is dilated to a certain extent, the rectum is emptied by irri- 
gation, and the abscess cavity is incised either radially or cir- 
cumferentially, according to the principles stated above. The 
edges of the wound are retracted, and its cavity is irrigate* I with 
hot saline solution, and explored with the finger or a blunt pointed 
probe. Two points should be determined, whether the pus has 
burrowed in any direction, so that an extension of the incision 
is necessary, and secondly, whether the abscess cavity communi- 
cates with the rectum. To determine the latter, one finger is 
inserted in the rectum while a probe is passed into the different 
portions of the abscess cavity. If the probe touches the finger, or 
comes so close to it that only mucous membrane intervenes, all of 
the tissue between the finger and the probe should be divided by 
a radial incision (see the treatment of fistula, p. 207). 

The cavity of the abscess should be irrigated with saline and 
drained with gauze. It should not be curetted, since the removal 
of the necrotic lining of the cavity in this manner will simply 
destroy the adjacent cellular tissue; nor should septa be broken 
down unless they are so placed as to interfere with drainage. 
They almost invariably represent blood-vessels which have been 
able to maintain their vitality in spite of the infection around 
them, and they will prove of assistance in the repair of the wound. 
The gauze used for drainage may be impregnated with iodoform 
or creolin or nosophen or covered with glutol. The cavity should 
not be packed ; only sufficient gauze should be used to keep the 
walls apart. 

If the abscess is small, so that the incision is short, it is well 
to remove from the center of the incision on one side a triangular 



FISTULA 295 

piece of skin. This will facilitate drainage and keep the cut 
edges of I lie skin from uniting before the abscess cavity has time 
to fill with granulations. 

Moist dressings should be employed, at least until granula- 
tion is well established. The outer dressing should be changed as 
often as it becomes soiled ; the gau/e drainage in the wound should 
not be changed for the first three or four days. After the first 
week the wound may be drained with gauze soaked with balsam 
of Peru, as this does not readily adhere to the wound, and dry 
gauze may be used externally. In many cases it is not necessary 
for the patient to remain in bed. 

If the wound does not heal completely within a reasonable 
time, it is probably either tuberculous or communicates with the 
rectum. The latter point may usually be determined by the probe. 
The former may be inferred from the sluggish appearance of the 
sinus and from the amount of induration around it, and from the 
existence of tuberculosis elsewhere in the body. It can be defi- 
nitely determined by the microscopical examination of a portion 
of the wall of the sinus removed under cocain. 

If an ischiorectal abscess is known to be tuberculous at the 
time of operation the treatment should be more radical than that 
outlined above. The abscess cavity should be incised, irrigated, 
and explored as there stated. The edges of the wound should be 
fully retracted, and all infiltrated tissue dissected away with scal- 
pel or scissors. The life of the patient may depend upon the 
thoroughness with which this is done. Bleeding points should 
then be secured, and the wound drained and dressed as stated 
above. An exception should be made in case the person has in- 
curable tuberculosis in the lungs or elsewhere. Under such cir- 
cumstances the operation should be limited to simple drainage. 

Fistula. The ordinary fistula in ano is simply a partially 
healed abscess, the complete healing of which does not take place, 
either because drainage is imperfect, or because fecal matter and 
gas enter the fistula from the rectum, or because the fistula is sur- 
rounded by an inflammatory process (tuberculosis, syphilis, etc.) 
which the body cannot overcome (Fig. 139). 

For practical purposes fistulas about the anus are of four kinds : 
either blind external or blind internal or complete, having both 
an internal and an external opening or complex. The first three 



296 



INFLAMMATIONS OF THE ANUS AND RECTUM 



terms are sufficiently descriptive. Under the last we shall here 
include not merely fistulse with more than one branch, but those 




FIG. 139. FISTULA ACCOMPANYING A SYPHILITIC STRICTURE OF THE RECTUM. Fe- 
male patient, aged forty-four years. 

with openings into the vulva, vagina, urethra, or bladder, as well 
as fistulsc due to disease of bone. 

DIAGNOSIS. The symptoms of fistula are : The discharge more 
or less constantly of a small quantity of mucus, mixed possibly 
with blood or fecal matter; more or less swelling, induration, and 
tenderness, symptoms which are more marked when the fistula has 
no external opening, or, having one, drains imperfectly. The 
diagnosis is usually made by the patient before he seeks medical 
advice. 

Examination will show the external opening, if one exists. 
It is usually surrounded by a slight elevation of the skin or mu- 
cous membrane, although it is sometimes hidden in a fold, and 
is sometimes temporarily covered with intact epithelium. Pal- 
pation with the finger-tips will show the presence of induration, 
whether the fistula opens externally or not. The indurated tissue 
may or may not be tender. Examination with a probe should be 
conducted with great gentleness, and if found painful should be 
at once discontinued, since the information obtained in this man- 
lier has only a slight value. In some cases the fistula leads so 



MSTULA L'!)7 

directly to the, rectum lluit. a prole can lie pas>ed, and its point, 
I'd! l)\- I IK- inserted linger. 

If a fistula is suhmucous or subcutaneous only, its external 
opening is near the anus. If the external opening is farther away, 
the fistula probably leads to the rectum, either through the sphinc- 
ters or above them. 

TREATMENT. A patient may obtain relief from the pain of a 
fistula by the repeated use of a hot sitz bath. 

There are three methods of treating fistula which are likely 
to effect a cure within a short time, and arc therefore worth con- 
sideration. They are incision, excision, and excision with suture. 
The first is the method usually employe* 1. 

The preparation of the patient for operation is important. 
In this as in all other rectal diseases in which a few days' delay 
in operation is not prejudicial, the bowels should be emptied with 
great thoroughness. This requires at least three days, as no cathar- 
tics should be given within twenty-four hours of the time set for 
operation, and no enema should be given within twelve hours of 
that time. If the preliminary treatment is thoroughly carried 
out, and a small dose of morphine is given four or six hours before 
operation, the patient will come to the operating-table with a dry 
and empty rectum, and there will be no evacuation during the 
operation to infect the operative wound. On the other hand, if 
cathartics are given the day before operation, and an enema an 
hour or so before operation, the wound is almost certain to be 
soiled with fluid feces, and the chance of primary union is greatly 
decreased. 

If the fistula is blind externally, the overlying tissue is split 
up by an incision more or less parallel to the sphincter ani, and 
the fistulous tract is curetted or cauterized. ]f scar tissue is 
abundant, or if tuberculosis is suspected, the tissue l>ordering on 
the fistula should he dissected away. The wound may then be 
sutured in whole or in part. 

]f the fistula is a blind internal one, similar principles should 
govern the operator. The sphincter must be fully dilated, t In- 
lining of the rectum carefully examined by means of a specu- 
lum, and any openings explored in various directions, with a 
bent probe. All fistula- should be laid wide open. If a blind 
internal fistula extends nearly to the skin, an external opening 



298 INFLAMMATIONS OF THE ANUS AND RECTUM 

should be made, and the case treated like one of complete 
fistula. 

The usual fistula in ano is a complete fistula, having an open- 
ing into the bowel and one through the skin. The fistula itself 
may lie beneath the mucous membrane and the skin, or it may 
pass through the sphincter muscle, or between the external and 
internal sphincter, or above them both. When the sphincter has 
been fully dilated, a probe, or better still, a grooved director, is 
passed through the fistula into the bowel, and all the tissues lying 
upon it are then divided. The division of the sphincter should be 
strictly a radial one. Many fistula pursue an oblique course; 
hence, besides the direct cut through the sphincter it may be neces- 
sary to make an oblique incision in the skin, or one parallel to the 
fibers of the sphincter. It is possible in many cases to excise the 
the fistulous tract, suture the Avound, and obtain primary union. 
The possibility of hidden suppuration should be borne in mind, 
and if the temperature rises, or tenderness or swelling increase 
after operation, the wound should be promptly reopened and 
drained. 

Complex fistula? that are of the same nature as the fistultc 
already described should be similarly treated. Each branch should 
be thoroughly laid open or injected with a solution of nitrate of 
silver, 960 grains to the ounce. Fistula? connecting with other 
hollow organs in the vicinity present such technicalities in their 
treatment that they will not be considered here. Fistula? due to 
diseased bone will heal as soon as the focus of disease has been 
obliterated. Fistula? between the anus and coccyx may be of con- 
genital origin (see p. 181). 

If the fistula is tuberculous or syphilitic, suitable constitutional 
treatment of the patient should be instituted. Tuberculous fistula? 
can be healed even though there are other foci in the body, but 
their rate of healing is slow, and subsequent operations may be 
necessary. 

Gauze drainage is satisfactory after incision or excision of a 
fistula. The bowels should be moved by the third day, and daily 
thereafter by mild laxatives. After each movement the wound 
should be irrigated with hot saline solution. 

Gonorrhea. Gonorrhea is occasionally found in the rec- 
tum, either as a result of an extension of the process from the 



CHANCROID 299 

vagina or by direct infection from a penis introduced into the rec- 
hini. The symptoms are those of a seven' prut-tit is, namely, burn- 
ing, a feeling of weight, pain in the rectum and hack, greatly 
increased by defecation, and more or le*s teiiesmns. There, is a 
mucous or purulent or bloody discharge. If the person has been 
subject to unnatural coitus, the anus will probably be relaxed, 
and the swollen mucous membrane may pout from the orifice. 
Often there are erosions or fissures due to the irritating discharge. 
Frequently the patient will deny the possibility of direct infec- 
tion. The demonstration of the gonococci in a smear made from 
the discharge is the best proof of the gonorrhea! character of the 
inflammation. 

TREATMENT. Pain can be somewhat relieved by a hot sitz 
batli or by hot applications applied moist and covered with oiled 
silk, and kept hot by a hot bottle or brick ( p. 1_!T). lint if pain 
is severe morphine must be given in a suppository or hypoder- 
mic-ally. The rectum should be irrigated twice daily with hot 
saline, followed by a 2 per cent boric acid solution, or one of 
silver nitrate, 1: 3,000, or protargol, 1 per cent, or permanganate 
of potash, 1:4,000, or even weaker. Other antiseptics suitable 
for injection are mentioned on pages -2\'-\ and _M>:>. If the sphinc- 
ter is tight, it should be stretched. This will often relieve the 
patient of a good deal of the pain both during defecation and at 
other times. Care must be exercised not to make deep tears in 
the infiltrated mucous membrane. 

Chancroid. Chancroids about the anus or in the anal canal 
may be reimplantations from chancroids of the genitals, or they 
may be due to direct infection from another person. They are 
far commoner in women than in men. The sores are usually mul- 
tiple. In character they are similar to chancroids of the genitals. 

In some cases there are few symptoms, and the disease runs a 
favorable course. In others the ulcers are phagedenic in char- 
acter, or so situated that defecation is very painful. The inguinal 
glands are not infrequently swollen and may suppurate 1 . 

TUI.ATMKXT. "Most chancroids run a more or less definite 
course to recovery, but much can be done to prevent further infec- 
tion of the surrounding skin. The parts should IK> bathed twice or 
three times a day with mild antiseptics, in order to remove and 
neutrali/e the discharge. The individual ulcers may be touched 



300 



INFLAMMATIONS OF THE ANUS AND RECTUM 



with stronger liquids, such as peroxid of hydrogen or carbolic 
acid solution, 5 per cent, or with pure ichthyol. Some writers 
recommend cauterization with the Paquelin cautery or with 
strong acids. If the spasm of the sphincter causes pain, it should 
be stretched, but with great gentleness, as extensive inflammation 
and death has followed this procedure in cases of chancroids. In 
all cases the folds of the nates should be kept from contact by a 
double layer of gauze or a thin piece of cotton wrung out of an 
antiseptic solution. 

Syphilis. Chancre, the primary lesion of syphilis, is not 
often seen in the anal region. When it does occur, it causes little 




FIG. 140. SYPHILITIC OONDYLOMATA ABOUT ANUS OF THREE WEEKS' DURATION. 
Patient a male aged sixteen. 

pain and heals promptly, so that Tuttle suggests that the rarity 
of its observation may be the explanation of the numerous cases 
of syphilis seen for the first time in the secondary stage and with- 
out any history of a primary sore. Mucous patches may develop 
about the anus and undergo hypertrophy, so that their surface 
presents something of the appearance of cauliflower. They have 



ULCER OF THE RECTUM 301 

received the name of condylomata lata (Fig. 140). The lesions 
.in apt to be transplanted from one fold of skin to another. 

TREATMENT. The treatment is that of syphilis in general 
(see p. 61). Local treatment consists in cleanliness and protec- 
tion of the sore and surrounding skin by dusting the former with 
calomel or oxid of zinc, or a mixture of the two, and keeping a 
fold of gauze between the nates. 

Ulcerating lesions should be cleansed with an antiseptic solu- 
tion and dried and dusted with any simple powder, or kept covered 
with moist gauze. The use of blue ointment upon every syphilitic 
sore is a disgusting practise which happily is going out of fashion. 
Tests show that ulcers do not heal as rapidly under it as when 
dressed with red wash or some other solution, provided the gen- 
eral treatment of the patient is the same. 

Late Syphilitic Lesions Tertiary lesions, both gumma and 
diffuse syphilitic endarteritis occur in the rectum. They pro- 
duce tedious ulcers, as is mentioned below, and are also of im- 
portance because they may be followed by stricture (q. v. p. 304). 

Tuberculosis. The anal region may be the seat of tubercu- 
losis in the form of ulceration, cither primary or resulting from 
a tuberculous fistula. In the former case the ulceration is shallow, 
but may spread over a wide area. In the latter case it may bur- 
row deeply into the perirectal spaces. The rectum may also be 
the seat of tuberculous ulceration, usually secondary to tuberculosis 
of the lungs. 

TREATMENT. In these conditions the general treatment is all- 
important. Unless the resisting power of the individual can be 
raised, local treatment, such as curettage or cauterization, or even 
excision of the diseased tissues, is almost certain to be followed 
by a recurrence, or rather extension, of the process. Hence it is 
better to confine the local treatment to mild measures, such as 
daily cleansing with peroxid of hydrogen solution, one part of 
pcroxid to eight of water, and the application of gauze saturated 
with balsam of Peru, or a solution of methyl blue, ten grains 
to the ounce. For the treatment of tuberculous fistula see 
page 297. 

Ulcer of the Rectum. Ulcer of the rectum may be due to 
traumatism, such as abrasion of the mucous membrane by hard 
fecal masses in a person whose vitality is at a low point; or it may 



302 INFLAMMATIONS OF THE ANUS AND RECTUM 

be due to the intensity of an inflammatory process, either simple 
or venereal; or it may be due to tuberculosis, or to syphilis, or to 
a malignant growth. 

DIAGNOSIS. The symptoms of ulcer of the rectum are pain, 
diarrhea, the discharge of mucus, pus, or blood, excoriation of the 
skin around the anus, tenesmus, spasm of the sphincter muscle, or 
possibly relaxation of the same if the ulcer is of long standing. 
These are general symptoms, some of which will be present in 
every case of ulcer, no matter what its cause. 

The pain varies greatly. It is a prominent symptom in those 
cases in which the ulcer is situated low down, so that it is grasped 
by the sphincter. 

Diarrhea is a prominent symptom in most cases. During the 
night, when the patient is in a recumbent position, there may be 
no stools. On rising he may have two or three in quick succession. 
The diarrhea is often accompanied with tenesmus. The doctor 
should never be satisfied to accept as satisfactory the patient's diag- 
nosis of chronic diarrhea without assignable cause. In many of 
these cases an ulcer of the rectum exists, of which the diarrhea is 
the chief or only symptom. 

The diagnosis can be made from the symptoms, but should 
never be considered complete until the mucous membrane of the 
rectum has been inspected through the proctoscope. For this pur- 
pose three or four tubes, of varying sizes and lengths, each fitted 
with an obturator, are necessary. The patient, with the clothes 
about the abdomen fully loosened, is placed in the knee-chest posi- 
tion, and as large a tube as the anus will admit is passed in as 
far as it will go readily. This is usually a distance of four to six 
inches. The obturator is then withdrawn, and light reflected from 
a head mirror is thrown into the rectum. As the tube is slowly 
withdrawn the mucous membrane of the rectum appears, inch by 
inch, at its inner orifice. In this manner most of the mucous mem- 
brane of the rectum can be inspected, provided a tube having a 
caliber of at least an inch can be used. It is important that the 
rectum shall be empty. In many cases, when the obturator is with- 
drawn, air will pass into the rectum and separate its walls to a 
certain extent. This facilitates examination, and under such cir- 
cumstances a tube not more than three inches long may suffice for 
the inspection of the rectum for twice that distance. 



ULCER OF THI<; IMOCTUM 303 

If the anus will admit only a small tube, or if the insertion of 
anv tube causes much pain, it is better to give an anesthetic, mod- 
erately dilate the sphincter, and insert a full sized tube. Special 
proctoscopes are made with glass obturators so as to permit the 
forcible distention of the rectum by air pumped into it. 

TREATMENT. If spasm of the sphincter exists, or if there is 
great pain on defecation, the sphincter should be moderately di- 
lated. The patient should take as much rest in bed as he can 
afford. The feces should be kept, if possible, in a semisolid con- 
dition, as they then cause the least amount of irritation. The 
rectum should be irrigated at least once a day with a warm normal 
saline solution. The surface of the ulcer should be painted or 
sprayed with stimulating solutions, such as nitrate of silver, 1 
per cent, zinc sulphate, 2 per cent, protargol, 5 per cent, argonin, 
10 per cent, etc. If a stronger caustic is indicated, a solution of 
chlorid of zinc, 10 or 20 per cent, may be used. A bit of cotton 
is saturated with it and held in contact with the ulcer for some 
minutes. Another plan of treatment is to apply the remedy chosen 
in the form of a suppository or in the form of an ointment in- 
jected through a special ointment syringe. 

In all cases of ulceration in which the deeper tissues of the 
rectum have been involved the possibility of resulting stricture 
should be borne in mind. During the later healing of the ulcer, 
and for some weeks after it has entirely healed, well lubricated 
flexible bougies should be passed at least once a week in order to 
prevent the formation of a stricture. This treatment should always 
be carried out with gentleness ; otherwise the induration and scar 
formation will be increased by it (p. 306). 

As the vitality of most patients who suffer from ulcer of the 
rectum is below normal, suitable tonic treatment should always be 
carried out. This is especially true in case of tuberculous ulcera 
lion, and will do far more toward elTeH ing a cure of the nicer lhan 
any number of scrapings or excisions of diseased tissue. 

In syphilitic ulceration antisyphilitic treatment is the curative 
treatment, but it should be combined with the local treatment al.ove 
indicated. The frequency <>l* stricture in these patients ^eeins to 
be due in great measure to the neglect of treatment during the 
active stage of the ulceration. 

The ulceration of malignant disease is an unimportant com pi i- 



304 INFLAMMATIONS OF THE ANUS AND RECTUM 

cation, which of itself docs not require other than cleansing treat- 
ment. 

Stricture of the Rectum. Stricture of the rectum may be 
congenital or inflammatory or due to a new growth. The first kind 
is described on page 323, and the last on page 317. 

Inflammatory, or non-malignant, stricture is due to the con- 
traction of scar tissue- following long standing ulceration. Fre- 
quently stricture and ulcer coexist. 

DIAGNOSIS. The symptoms of stricture are due in part to the 
obstruction which exists, and in part to the accompanying ulcera- 
tion. The symptoms of ulcer, as stated above, are pain, diarrhea, 
the discharge of mucus, pus, or blood, excoriation of the skin 
around the anus, tenesmus, and spasm, or possibly relaxation of 
the sphincter muscle. The symptom of the stricture, exclusive of 
ulceration, is constipation, with its attendant disturbances of diges- 
tion. Some patients go for several days without any movement of 
the bowels. In other cases constipation alternates with diarrhea. 
In some cases the stool is ribbonlike in character, DTit this may be 
produced by a contracted sphincter in cases in which no stricture 
exists. The symptom has, therefore, little importance except that 
it indicates the necessity of a thorough examination. 

The tendency of most strictures is to grow smaller, and for 
that reason the symptoms of obstruction are likely to increase. At 
any time the obstruction may become absolute, just as it does in 
cases of malignant stricture. When this takes place neither gas 
nor fecal matter passes the rectum. The abdomen becomes dis- 
tended, and in the course of four or five days vomiting will prob- 
ably set in. As these patients are accustomed to infrequent move- 
ments of the bowels, complete obstruction will sometimes exist a 
surprisingly long time before alarming symptoms develop. 

Usually, before obstruction becomes complete, the patient will 
pass through a number of periods of partial obstruction, attended 
with griping pains, due to increased peristalsis and swelling of the 
abdomen. Such an attack is often relieved either with or without 
the use of cathartics and enemas, so that in three or four days the 
patient's condition is the usual one. 

The stricture may be at the anus, for instance, when it follows 
a badly performed operation for hemorrhoids, or it may be within 
easy reach of the finger, or it may be at the upper portion of the 



STRICTURE OF THE RECTUM 305 

rectum, and so be beyond the reach of the finger in most cases. It 
is worth remembering that the rectum can be palpated digitally 
for a greater distance when the patient is in a squatting position 
than in any other position. If the finger is able to reach the stric- 
ture the surgeon should determine its distance from the anus, its 
caliber, its distensibility, the amount of surrounding induration, 
and the presence of an ulcer. If the finger can be passed through 
it, he should also determine the extent of the stricture, both circum- 
iVivitfially and longitudinally. 

Further knowledge of the stricture may be obtained by the use 
of the proctoscope, and also by the passage through it of olive 
tipped or flexible bougies. 

In the female vaginal and rectal examination combined will 
often give added information in regard to the extent and form of 
the stricture. 

TREATMENT. The non-operative treatment of stricture of the 
rectum consists in the regulation of the diet, which should contain 
a considerable portion of nitrogenous articles and a good deal of 
fat; in the use of sufficient laxatives to prevent the accumulation 
of hard feces above the stricture, and in the daily use of injections 
to keep the lower bowel empty. If difficulty is experienced in 
causing the injected fluid to pass the stricture, the enema may be 
given in the knee-chest position. If the stricture is due to syphilis, 
mercury and potassium iodid should be given; but little benefit 
is experienced from their use if the stricture is an old one. 

If the above mentioned treatment does not relieve the patient 
of pain and tenesmus, hot applications to the anal region should 
be employed. The use of anodynes is to be avoided as far as pos- 
sible! on account of the tendency of these patients to become drug 
habitues. 

Operative Treatment. Several operations for the treatment of 
rectal stricture have stood the test of time. They are gradual or 
rapid dilatation, internal proctotomy, external or complete proc- 
totomy, resection, and, when all other measures fail to overcome 
the obstruction, colostomy. Only the methods of dilatation will 
be here deseribi'd, since the other procedures are outside the domain 
of minor surgery. 

II' the stricture is within the area of the sphincter, it should 
be forcibly dilated by the fingers under a general anesthetic. This 
22 



306 INFLAMMATIONS OF THE ANUS AND RECTUM 

will save the patient much time and pain. When a sufficient cali- 
ber has been obtained in this manner it may be maintained by the 
passage of hard rubber plugs every night by the patient himself. 
If the stricture is above the level of the sphincters, its rapid dila- 
tation, or divulsion, as it is called, produces one or more lacera- 
tions of the bowel. These may become infected, and they will 
almost certainly add to. the amount of scar tissue, the contraction 
of which will have to be overcome in the future. For these rea- 
sons gradual dilatation is preferable. This may be accomplished 
by the finger or by flexible bougies, if the stricture is beyond the 
reach of the finger. This treatment, to be successful, must be. very 
gentle; violence is sure to excite the formation of additional cica- 
tricial tissue. The bougie, well lubricated, may be passed under 
the guidance of the finger or, in difficult cases, through a speculum. 
This last method, recommended by Tuttle, avoids the risk of mak- 
ing a false passage with the tip of the bougie. The first bougie 
passed should be of such caliber that it enters, the stricture easily ; 
the second one should be a little larger, and should remain in 
position until the stricture somewhat relaxes its hold upon it. In 
some cases a third may be passed. At the next treatment, two or 
three days later, the first bougie should be slightly smaller than 
the largest one employed at the previous treatment. An attempt 
should not be made to increase the size of the bougies at every 
treatment, lest too much reaction be excited. During the treat- 
ment the patient should be in a lateral position, with the knees 
well drawn up, and should not attempt to get up for at, least fifteen 
or twenty minutes after the treatment is Concluded. 

Internal proctotomy is chiefly of service in order to rid the 
patient of obstruction caused by an annular stricture, or a thin fold 
of membrane. 

Complete or external proctotomy, resection of the rectum, and 
colostomy or the establishment of an artificial anus, are major 
operations, which are fully described in text-books on surgery, as 
well as in those on rectal diseases. 



CHAPTER XII 

TUMORS AND DEFORMITIES OF THE ANUS AND 

RECTUM 

BENIGN TUMORS 

Venereal Warts. Venereal warts, or pointed condylomata, 
are small papillomatoua tumors which form about the anus, as well 
as in the vicinity of the urethral orifice. They are not strictly of 
venereal origin, hut develop when the skin is kept moist by any 




FIG. 141. VENEIIEAL WAHTS AHOTT THK ANUS OF A MAN AGED TWENTY-THKKK 
YEARS. Duration, six months. 

sort of an irritating discharge. They are covered by epithelium, 
which is sometimes so delicate that they bleed at the slightest 
touch (Fig. 141). They can be distinguished from the broad or 

syphilitic condylomata by the fact that they always grow from 

307 



308 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

slender pedicles, and they can be distinguished from malignant 
epithelial growths by the fact that there is absolutely no indura- 
tion of the underlying true skin. 

TREATMENT. The warts should be clipped off even with the 
skin by scissors, and the free hemorrhage controlled by hot water 
and pressure. If the warts are extensive, a general anesthetic is 
desirable. Recurrence 'is unlikely if the parts are kept clean 
and dry. 

If the patient is unwilling to undergo this treatment, a slower 
cure can be effected by the use of caustics, of which monochloracctic 
acid is one of the best. 

Polypus. This small tumor of the anus or rectum has usu- 
ally a slender pedicle containing a small artery and a soft body 
made up of flabby adipose and fibrous or myxomatous tissue, and 
covered with either normal mucous membrane or with mucous 
membrane which has undergone adenomatous changes. Such a 
tumor may be recognized by the palpating finger or it may pro- 
trude from the anus. It often gives- rise to hemorrhage, but other- 
wise its presence is not apt to be noticed by the patient, unless it 
projects externally or becomes caught in the sphincter, causing the 
patient to feel that all of the fecal matter has not been evacuated. 
It may also become inflamed and acutely painful. If the polypus 
is situated above the reach of the finger, an exact diagnosis requires 
the use of the speculum (p. 281). 

TREATMENT. If the polypus is small and easily accessible it 
can be ligated and removed through the speculum, or the defect 
in the mucous membrane may be closed by one or two black silk 
sutures. If it is of larger size or has a broad pedicle, it is better 
to etherize the patient, dilate the sphincter, cleanse the rectum, 
remove the polyp, ligate its vessels, and accurately close ilic wound 
by fine black silk interrupted sutures. The aftertreatment is the 
same as that which should follow the removal of a chronic henior- 
rhoid (p. 316). 

Hemorrhoids. A hemorrhoid is a more or less pedicled 
swelling, either within or outside of the anus, which is covered 
with mucous membrane or skin, and in the center of which are 
one or more dilated veins. If the hemorrhoid is of long standing 
it usually contains in addition considerable cicatricial tissue of 
inflammatory origin. 



HEMORRHOIDS 



300 



Hemorrhoids are spoken of as external or internal, according 
to their situation. Those which are placed so far outward as to 
rest normally outside the sphincter ani are called external hemor- 
rhoids; others are spoken of as internal, although many of them 
do not lie wholly within the sphincter. 

According to their age and manner of development, hemor- 
rhoids may also be classed as acute and chronic. 

Acute External Hemorrhoid. A hemorrhoid may appear sud- 
denly. While the patient is at stool or lifting a heavy weight, a 







FIG. 142. ACUTE EXTERNAL, HEMORRHOID, ONE WEEK. Note the dark point which 
indicates a threatened rupture and discharge of the blood clot. Three years 
previously a similar acute hemorrhoid relieved itself in tliis way. Patient a man 
aged forty-four years. 

vein about the anus may rupture subcutaneously, causing the blood 
to clot in its lumen or, more often, outside of it. There will ilien 
be felt upon examination a small rounded tumor, containing in its 
center a solid elastic clot of blood (Fig. 142). If the mucous 
membrane or skin whicli covers it is edematous the blood clot can- 
not be felt so perfectly. 



310 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

Such a liemorrhoid is sometimes situated wholly outside of the 
sphincter ani, although it is usually grasped, in part at least, by 
this muscle. It should not be confused with a true " strangulated 
hemorrhoid," which is a chronic internal hemorrhoid, prolapsed 
and pinched by the sphincter. 

The symptoms of an acute hemorrhoid are those of discom- 
fort, burning, and, if the affected vein lies within the grasp of 
the sphincter ani, there will also exist sharp pain, which grows 
more acute in the lapse of a few hours and which is greatly in- 
creased upon defecation, and may even render that act impossible. 

If a hemorrhoid of this character is not treated, one of two 
things will follow. If the pressure upon the overlying mucous 
membrane or skin is great enough to cause necrosis, the blood clot 
may be discharged, the patient will be relieved of the symptoms, 
and the tumor will shrivel up in part and become one of the exter- 
nal tabs of skin so often seen about the anus and which are some- 
times called cutaneous hemorrhoids. If necrosis of the overlying 
skin or mucous membrane does not take place the blood clot will 
in time become organized, and the tumor will decrease in size, 
though remaining harder and larger than is the case when the 
blood clot is discharged. 

TREATMENT. The best treatment for an acute hemorrhoid is 
radial incision, or excision of the most prominent part of the over- 
lying skin, removal of the clotted blood, insertion of a bit of gauze, 
or possibly suture of the wound. If the hemorrhoid is situated 
wholly outside of the sphincter, this operation may be performed 
in a few seconds, either with or without a local anesthetic. If the 
lesion has caused great pain, it almost certainly extends upward 
within the grasp of the sphincter. In this case no operation should 
be done until after the sphincter ani has been dilated, and for 
this a general anesthetic is desirable (see p. 282). 

If the external acute hemorrhoid is not seen until the symp- 
toms are subsiding, and the danger of necrosis of the skin is past, 
it may be well to postpone operation and allow the thrombus to 
organize and shrivel up. At any rate operation at this stage will 
not be followed by the prompt collapse of the skin and quick 
restoration to normal which follows operation when the clot is 
freshly formed. 

External tabs of skin, the so called cutaneous hemorrhoids, the 



III.MnKUIlnlHS ;||| 

result of previous acute hemorrhoids, u.-ually ^i\e ri-e ! no -vni[i- 
tom>. If their presence is disfi^urm-: they >honld ! removed and 
the resulting wounds sutured radially tu tin- anus with tine black 
silk. 

Chronic Hemorrhoid. Another form of bemorrhoid whicb may 
IK- spoken of ;is ehroiiie to distinguish it from the ;ieiite form ;ii 
de-crihed is due to const ipat ion. The dry harl fecal matter eliiiL'- 
to the miK-oiis memhrane above the sphincter, and a strong ahdom- 
inal pressure exerted by the jiatieiil to expel the feces dilates the 
veins of the rectum and those ahotit the anus. In the normal 
individual in perfect health defecation can take place without 
straining, -ince the peristaltic action of the intestine is continued 
down to the anus, and is sufficient to expel the fecal mass. When 
the feces is allowed to remain for hours each day in the rectum, 
the latter hecomes tolerant of its presence, so that it is difficult 
to excite it to peristaltic action during the act of defecation. 

In time the dilatation of the veins become permanent, and 
although the change may not he noticeaMe when the parts arc at 
rest, it is evident when the patient -trains. This ives a jnitTy 
appearance to the skin around the anus. These dilated in: 
of veins, with their covering of skin, are called chronic external 
hemorrhoids. 

From this repeated straining at stool, and from the long reten- 
tion of feces in the rectum, the caliber of the lower portion of 
the rectum becomes excessive, and when it is empty the superfluous 
mucous memhrane is naturally thrown into folds. Such a fold 
covering a ma>s of dilated veins is known as an internal hemor- 
rhoid. At each defecation it is draped downward, and in time 
comes to assume the shape of a pedided tuiuor. One or more of 
these internal hemorrhoids may protrude from the amis after 
defecation until rephuvd by the tinkers ( Kiir. 11'5). 

If the hemorrhoids are laru'f and the sphincter ani by rea-on 
of the irritation of the parts has tightened its grasp, the reduction 
of the hemorrhoids may be attended with ditlicully. In this man 
ner a true strangulation of a hemorrhoid may take place, and 
result in gangrene of a portion of its mucous membrane. 

In the usual case of chronic hemorrhoids, there may be one or 
two of the folds above de>crihed or a complete circle of them, or 
the whole lower segment of the rectum may become so loosened 



312 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

and dilated that it turns outward during the act of defecation, 
thus simulating the normal behavior of the rectum of the horse 
during defecation. 

SYMPTOMS. The symptoms arising from chronic hemorrhoids 
vary greatly according to the situation of the dilated veins and 




FIG. 143. INTERNAL HEMORRHOIDS OF SIXTEEN YEARS' DURATION. Patient aged 

fifty-two years. 

whether or not inflammation is present. Chronic external hemor- 
rhoids existing alone often give rise to no symptoms whatever, or 
possibly to a slight burning sensation after defecation, possibly to 
pruritus. Internal hemorrhoids, on the other hand, are far more 
painful, and when well developed they bleed easily and interfere 
with defecation. These patients are almost invariably constipated, 
and while constipation is one of the chief factors in the causation 
of hemorrhoids, it often happens that laxatives by temporarily 
increasing the size of the tumors, and the freedom with which 
they protrude, add to the discomfort of the patient. The pain 
may be constant or it may be caused by defecation, and last for 
half an hour or so after the rectum has been emptied. The hem- 
orrhage is of variable quantity. It is usually due to abrasions 
of the mucous membrane, caused by the passage of hard fecal mat- 
ter through the sphincter, or to abrasions caused by the patient, 
if the mucous membrane protrudes from the anus and he uses a 



rough, dry paper to cleanse himself or to relieve the itching. Hem- 
orrhage may also be due to congestion or ulceration within the 
rectum; and if so, it usually occurs in greater quantity than 
when it is due to the mechanical abrasions spoken of. The itch- 
ing may be intolerable. This may be the chief or only symptom 
of hemorrhoids, and hence the term itching piles. It is appar- 
ently dut! to the disordered circulation about the anus, and if so, 
disappears with the relief of the hemorrhoids, lint pruritus ani 
may exist without hemorrhoids (see p. 287), and may therefore 
coexist independently. 

TI;I :A TMK.N :r. The non-operative treatment of hemorrhoids i- 
of importance because it may relieve all symptoms in the milder 
cases, and because many patients absolutely refuse operation, even 
when it is clearly indicated. If the regulation of the diet and 
mode of life is not sufficient to overcome constipation, mild laxa- 
tives should be given. Straining at stool is to be avoided, even 
though a small injection of cold water has to be used each time. 
The patient should make it a practise after the rectum is empty to 
contract the sphincter four or five times with considerable force. 
Bathing with cold water will also improve the tone of the tissues, 
and, when possible, these measures should be followed by a few 
minutes' rest in a recumbent position or with the hips elevated. 

Local treatment will naturally be directed to the relief of the 
most annoying symptoms: thus, if the patient is annoyed with 
itching, the parts should be painted with a five per cent solution 
of carbolic acid or a salve containing tannic acid and ichthyol, 
each one part, belladonna ointment and die cerate of lead subace- 
tate, each five parts. For the bleeding and pain of internal hem- 
orrhoids, a multitude of salves and suppositories has been recom- 
mended. 1'erhaps as good as any is a suppository containing 
two grains of iodoform and five of tannic acid, with the addition 
of a small quantity of morphine, if the pain is great. 

Hemorrhage is for the most part not serious, unless on account 
of its frequent recurrence. Any particular bleeding cither ceases 
spontaneously or will usually do so as soon as the patient assumes 
a horizontal position or applies cold and pressure to the anus. 

A prolapsed hemorrhoid can usually be replaced by a few 
moments' steadv pressure. This is more effectual if the mucous 
membrane of the opposite side of the bowel is drawn outward 



314 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

before the pressure is made. Its return will then assist in drag- 
ging the prolapsed hemorrhoid back into place. The patient usu- 
ally learns to make this manipulation himself. If he fails on ac- 
count of pain or swelling, the prolapsed hemorrhoid will rapidly 
increase in size, so that in an hour or two its reduction will be 
more difficult. If left out for a longer period it may become gan- 
grenous in part. 

The application of cold by an ice-bag or cracked ice will re- 
duce the swelling and favor reduction. Constant elastic pressure 
obtained by a big pad of nonabsorbent cotton and a firm T-band- 
age may in an hour or two reduce the prolapsed hemorrhoid. The 
cotton should be separated from the hemorrhoid by a layer of 
gauze spread with any simple ointment. 

If these measures fail, or if immediate reduction is desirable 
on account of intense pain, the patient should be given a general 
anesthetic and the sphincter ani dilated. Return of the prolapsed 
hemorrhoids is then accomplished with the greatest case. A rub- 
ber tube left in the rectum will allow the escape of gas. 

While the palliative treatment above indicated will relieve the 
symptoms in mild cases of hemorrhoids, they are ill adapted to 
severe cases. In these the gross lesions are so marked that one 
does his patient an injustice who does not advise him to submit 
himself to operation. 

OPERATIVE TREATMENT. The curative treatment of chronic 
hemorrhoids consists in the dilatation of the sphincter ani and the 
removal of the superfluous skin or mucous membrane and the 
underlying dilated veins. This may mean the removal of a single 
fold or several folds, or the removal of a complete circle of the 
bowel in cases in which there is so much prolapse. Tlie wounds 
caused in the mucous membrane and skin should be carefully 
stitched with fine black silk after the veins and arteries have 
been ligated and excised. In other words, the same surgical prin- 
ciples should be applied here as are followed in the removal of 
superfluous tissue in other portions of the body. ISTo one would 
think of clamping an angioma of the cheek, ligating or cauteri- 
zing its stump, and leaving the wound to heal by granulation. The 
rectum should be treated with no less respect. The rapidity with 
which the parts will heal, the absence of pain, and the lack of 
any visible scar will be a surprise to those who have only seen 



heim irrlii >ids t routed by the older methods. As fai -ible the 

suture lines slimild lie made longitudinal f> ;iv(id subsequent con- 
traction of Iho anus. 

Ti-r/ituc of O^crnl'mn.- Whenever possible, three days should 
be allowed to prepare the patiem I'm- (i|iei-ati.in, as this preparation 
is most important The bowels slionld lie thoroughly moved three 
davs before operation and two clays before operation. On the day 
immediately preceding operation one or two reel a 1 enema- -hould 
be given. After this the rectum should not be disturbed. It will 
then be found clean and free from fluid at operation. "For the 
last day the diet should be fluid and of a character to leave little 
residue, and a small dose of morphine may be ^iven a fe\v hours 
before operation. 

The patient is anesthetized and placed in the lithotomy po-i- 
tion. The sphincter is slowly but completely dilated (p. 282). 
A bivalve speculum is inserted and opened in different direction-;. 
so that the operator may determine the amount of hemorrhoidal 
tissue which it is desirable to resect. The speculum is removed 
and an individual heniorrhoid is clamped longitudinally. The 
mucous membrane and the skin, if the honiorrhoid extends so far 
downward, is divided on either side of the clamp, and dissected 
and pushed back from -the central mass of vessels. The pedicle 
of the heniorrhoid, which is composed chiefly of vessels, is trans- 
fixed and ligated in two sections with line catgut. The upper 
portion of the wound in the mucous membrane is then closed by a 
continuous suture of fine chromic catgut. Before this is drawn 
taut the portion of heniorrhoid included in the clamp is cut away. 
Care should be taken to cut far enough away from the ligatures 
on the pedicle so that they will not slip off. The chromic catgut 
suture is then continued until the wound i- dosed; or if preferred 
the upper half of the wound only is dosed in this way, and the 
lower half is stitched with fine black silk. This caii-es less irri- 
tation, and almost never suppurates; but it is difficult to remove, 
without anesthesia, stitches more than an inch above the normal 
lower level of the amis. 

Other hemorrhoids are treated in this manner until the normal 
contour of the bowel has been restored. One should be careful 
not to remove too much of the mucous membrane and skin, es|>e- 
cially in the anal canal, lest a stricture result. It is rarely de- 



316 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

sirable to remove more than four clampfuls of tissue. The clamp 
should never contain more than one-eighth of the total circumfer- 
ence of the bowel. 

Internal hemorrhoids are often continuous with external ones, 
and if such is the case, the radial excisions of mucous membrane 
should be continued outward far enough to remove the surplus 
skin, and permit the ligation and excision of the dilated under- 
lying- veins. The remaining skin will " fit " more smoothly if the 
line of suture, strictly longitudinal within the rectum, becomes a 
spiral one when it passes outside of the anus. 

Postoperative Treatment. After the operation the patient 
should be kept on a fluid diet for two days. The white of an egg, 
stirred raw into a half-glass of water, probably leaves as little 
residue in the intestine as any form of nourishment. A little 
fruit juice may be added for taste. This may be given every two 
or three hours. The bowels should be moved by a laxative on the 
third or fourth day, and after that the patient may get up, though 
if he can afford a longer rest, so much the better. 

All things considered, this plan of treatment seems the best 
that has been devised. It is the cleanest, gives the smallest wound 
for the work done, and is followed in most cases by primary union. 
The various forms of office treatment by means of electrolysis, 
injections of carbolic acid, etc., prolong the patient's discomfort 
for several weeks, even if they do not add to it, and often fail to 
effect a cure. 

MALIGNANT TUMORS 

Carcinoma. Cancer of the anus and rectum is a common 
disease, especially in men over thirty years of age. It may origi- 
nate in the skin around or within the anus, in which case it is a 
squamous epithelioma ; or it may originate in the mucous mem- 
brane of the rectum, in which case it may be of any one of the 
types of cancer which are found growing from mucous membrane. 
In more than one-half the cases the tumor involves the supraperi- 
toneal portion of the rectum ; while in about one-fourth of the cases 
it involves the infraperitoneal portion of the rectum or the anus. 
In these latter situations it is easily accessible to the finger, and 
there is, therefore, the less excuse for failure to make an early 
diagnosis. Yet so strong is the dislike of many physicians for a 



SMICOMA 317 

rectal examination that patients arc frequently seen \vith \vcll de- 
V('|(|KM| carcinoma (,f tin- rectum who have I teen treated for COn- 

slipation, hemorrhoids, etc., for months without a physical exami- 
nation being made. This is a sufficient excuse, if any is needed, 
for introducing this serious subject into a book on minor Mirgery. 

DIAGNOSIS. The diagnosis in anal carcinoma is easily made, 
since at least a part of the growth is visible. There will be in- 
duration of the skin and a hard tumor, slightly eleva ted, and pre- 
senting in its older portions cracks or ulcers partially covered by 
scabs. Microscopic examination of a section of the tumor will 
remove any doubt which may exist as to its nature. 

The early symptoms of carcinoma situated above the anal canal 
are irregularity in the stools, constipation or diarrhea, and a di 
charge of mucus or pus or blood, the discharge usually having an 
extremely foul odor. The discharge frequently eau-es en -.-ions of 
the skin about the anus. The amount of pain varies in ditl'erent 
cases. The. fact that it is often a late symptom is no doubt one 
reason why these tumors sometimes attain so great a size before 
surgical aid is called for. 

If the carcinoma is within reach of the finger, it can be rec- 
ognized as a hard, nodular growth, more or less elevated above 
the level of the mucous membrane of the rectum. It is inelastic, 
so that if it extends through more than one-half of the circumfer- 
ence of the rectum, the caliber of the latter is distinctly reduced. 
If it extends all the way around the rectum, there is usually a 
well marked stricture. 

The fact that no tumor can be reached with the finger is no 
proof that the rectum is free from cancer, since it may be situ- 
ated too high up to be accessible in this manner. In every such 
case, therefore, an examination with the speculum should be made. 

Sarcoma. Sarcoma of the rectum starts outside of the mu- 
cous membrane, so that at first the mucous membrane is movable 
over it For the same reason ulceration is not an early symptom, 
nor is gangrene of the surface, with its characteristic odor, so 
prominent a symptom. Sarcoma may obstruct the rectum by its 
bulk, but does not tend to form a cicatricial stricture. 

TREATMENT. This is not the place to consider the treatment 
of cancer of the rectum, but the matter is such an important one 
that it cannot be insisted upon too strongly that every physician 



318 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

who is consulted by a patient for the relief of rectal symptoms 
should make a careful digital examination, and if the diagnosis 
is not perfectly clear, an examination with the speculum should 
also be made. Were this the rule fewer malignant troubles would 
go so long unsuspected. 

ACQUIRED DEFORMITIES 

Prolapse. Acute prolapse of the rectum is often seen in 
young infants. At an early age the rectum is a delicate structure, 
more like the small intestine in the adult than like the adult rec- 
tum. It is loosely attached in the pelvis, and is therefore easily 
everted by excessive straining at stool, either the result of con- 
stipation or of diarrhea. Such a prolapse usually measures from 
one to three inches in length and can hardly be mistaken for any- 
thing else. It is a soft tumor covered with mucous membrane, 
either in a normal state or congested or edcmatous or gangrenous, 
according to the amount of constriction of the anus and the dura- 
tion of the prolapse. 

It sometimes happens that an invagination of the gut above the 
rectum may appear at the anus. Even so high an invagination 
as that of the small intestine through the iliocecal valve has been 
known to protrude from the anus. Under these circumstances the 
protruding gut is apt to be in a serious condition. If the rectum 
alone has prolapsed its vitality is not seriously affected in most 
cases. 

TREATMENT. The treatment indicated in acute prolapse is 
the immediate replacement of the protruding bowel. The patient 
should be placed in some position which will bring the hips well 
above the epigastrium. A small child may be inverted, if this 
can be done without exciting crying. Delicate manipulation with 
the fingers will usually succeed. As in reducing a hernia this 
may be carried out in two ways : The protruding mass may be 
grasped with the hand and compressed, much as one compresses 
the bulb of a hand syringe. This pressure may force the central 
part of the prolapse back into the rectum, and if so the rest will 
easily follow. The other method is to push upward the lowest 
part of the prolapse with the finger. The trouble with this method 
is the difficulty in preventing the prolapse from recurring when 
the finger is withdrawn. A good plan is to wrap the finger with 



C11KONIC PROLAI'SI. 319 

dry gauze or tissue paper, which sticks to the mucous membrane, 
,111.1 then by rotation of the finger to unwind this from the finger, 
leaving it in the rectum until the prolapse has been entirely re- 
duced. 

It is necessary to prevent a recurrence of the prolapse for some 
weeks. Sufficient laxatives or enemata should be given to pre- 
vent si ruin inn' ;it stool. Defecation should take place in a hori- 
zontal position, cither on the hack or side;. The buttocks should l>e 
tightly strapped together \vith adhesive plaster. If this becomes 
soiled, the central part should be cut away and new strips placed 
over the old, as the daily peeling off of the old and application 
of new strips will make the skin sore in a short time. 

In infants a cure can almost invariably be effected by these 
means. 

If the prolapse is due to an invagination al>ove the rectum, 
merely crowding the gut back within the anus will not of course 
relieve the trouble. Something may be accomplished, however, 
digitally or by the injection of warm oil combined with inversion 
of the patient. Jf these simple means are not sufficient to effect 
a cure within a few hours after the first, symptoms, laparotomy 
should be performed. 

Chronic Prolapse. In the lesser degrees of this condition 
there is a protrusion after defecation of the mucous membrane. 
Ill the severer decrees not only the mucous membrane, but. all the 
coats of the rectum are turned out, and when replaced, they again 
prolapse as soon as the patient assumes an upright position and 
takes a few steps. 

The causes of chronic prolapse are the same as the causes of 
chronic hemorrhoids, namely, dilatation and atony of the rectum 
and straining to expel a constipated movement. Prolapse is also 
favored by the overstretching or laceration of the perineum at 
childbirth, by unwise operations upon the rectum leading to paral- 
ysis of the sphincter ani, as well as by the relaxation of the tissues 
which comes with old age. It is therefore especially fre<pienl in 
old and feeble persons, though by no means confined to them. 

DIAL. \<sis.- The symptoms are slight, the annoyance of the 
protruding mass covered with mucous membrane being often the 
only one. If this ulcerates, there will of course be a purulent and 
slightly bloody discharge. The diai:iio-i- is always easy, though 



320 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

it may not be so easy to say just what is the degree of prolapse, 
nor whether it is accompanied by a hernial protrusion or not. 

TREATMENT. The treatment outlined for acute prolapse can- 
not be expected to cure chronic prolapse; the conditions are too 
different; and yet something may be accomplished by attention 
to the bowels, the use of cold water both within and outside of the 
rectum to tone up the' muscles, and by rectal and abdominal mas- 
sage. Astringents may also be used within the rectum (see p. 
313) or applied to the protruding bowel. 

The bowel may be stiffened by the injection of irritating fluids 
into its tissues, or by the cauterization of its surface. It - is evi- 
dent that anything which will reduce the flexibility of the rectum 
will make it less easy for a prolapse to occur. It is -claimed by 
the advocates of this plan of treatment that the caliber of the 
rectum is also reduced thereby. A fluid commonly employed for 
intramural injection is composed of the following substances: 

I> Salicylic acid 1 part ; 

Sodium biborate 2 parts ; 

Carbolic acid 4 " 

Glycerin : 16 " 

A few minims are injected in two or three places around the 
neck of the prolapse, and after a few minutes the reduction is 
made. For two weeks thereafter the patient should keep tlio 
buttocks strapped together, and should defecate in a horizontal 
position. 

Cauterization of the protruded rectum may be performed 
with a strong acid or with the Paquelin cautery. It is recom- 
mended that this cauterization be made in longitudinal lines ? 
from four to six according to the size of the bowel. Another 
plan is to reduce the prolapse and insert a speculum having six 
narrow slits in it, so placed that they are wholly above the anal 
canal when the speculum is inserted. The mucous membrane 
projects through these slits into the lumen of the speculum, and 
can be readily and accurately cauterized. 

If these simpler measures fail there are a number of opera- 
tions to choose from, such as excision of longitudinal or circular 
strips of mucous membrane; enfolding of a longitudinal fold of 
the whole rectum through a posterior incision ; suspension of the 



1. \rn\TI \KNCE OF THE SPHINCTER ANT 321 



rectum tlin.H^h ;i posterior or an abdominal incision, etc 1 . The 
details of llirsr ;inil oilier operations arc found in special ami 
general text hooks. 

Rectal hernia, with prolapse of a part of the rectum, is 
found in women whose sphincter ani has been damaged in child- 
hirth. Such a prolapse is of the nature of a hernia, the outer 
portion of which is covered with the everted mucous membrane 
and within which there may be a portion of the vagina .or the 
uterus or the intestine or other contents of the peritoneal cavity. 
Such a hernia is always easily reducible. Its cure is to be sought 
by re-ioraiioii of the sphincter ani. 

Incontinence of the Sphincter Ani. Inability of the pa- 
tient to retain his feces may be due to a great number of causes, 
such as injury to the spinal cord, other forms of paralysis, rup- 
ture or division of the sphincter, rigidity of the anal canal, as 
seen in cases of malignant disease, etc. 

A patient may be able to retain solid fecal matter, but un- 
able to retain fluid fcces. This is frequently the case after resec- 
tion of the rectum for malignant disease. 

DIAGNOSIS. The diagnosis of incontinence is easily made 
from the statement of the patient or those who care for him. But 
the mere knowledge of this one symptom is not a satisfactory diag- 
no>is. The physician must ascertain whether incontinence exists 
at all times, and if not, under what circumstances it occurs. He 
must also continue his examination until he has learned the exact 
cause of the lack of control. If proctitis exists, or an ulcer or 
a stricture or malignant disease, appropriate treatment is to be 
instituted. If the loss of sphincteric control has followed a trau- 
matism or an operation for hemorrhoids, fistula, or abscess, the 
physical examination should reveal the ability of the patient to 
contract the sphincter ani muscle or its segments in case it has 
been divided in more than one place. These are the cases in which 
a slight operation may cure or benefit a patient otherwise very 
miserable. 

TREATMENT. If examination shows that there is no paralysis 
of the sphincter, but that loss of control is due to separation . of 
the cut ends of the muscle, an operation should be performed to 
reestablish its continuity. This should not be performed as long 

as any ulcer or sinus exists. 
23 



322 TUMORS AND DEFORMITIES OF THE ANUS AND RECTUM 

The patient should be prepared as for other rectal operations 
(p. 315). A general anesthetic is desirable. A circular incision 
should be made at a distance of a half inch or more from the mar- 
gin of the anus, and long enough to expose the cut ends of the 
sphincter ani. Both of these are freed by careful dissection, the 
intervening scar tissue is cut away, and the clean ends of the mus- 
cle are closely approximated by three or four sutures of fine 
chromicized catgut prepared to resist absorption for twenty days. 
The skin wound is sutured with fine black silk. Primary union 
is striven for and often obtained; but should this not be the case 
the ultimate result of operation may still be satisfactory if the 
deep sutures hold the muscular ends firmly together until granu- 
lation is complete. Hence the desirability of suturing the musple 
with a catgut which will resist absorption for three weeks. 

The bowels should be kept quiet four or five days. Oil in- 
jections should then be administered and mild laxatives. After 
the movement the parts should be carefully cleansed. 

This treatment by restoring the original condition is the best 
that can be employed. Unfortunately it is many times inapplica- 
ble, either because of wasting of the sphincter or paralysis of a 
part or the whole of the muscle or on account of the loss of the 
muscle, as after many cases of rectal resection. Under such cir- 
cumstances attempts have been made to establish continence by a 
purse string wire suture introduced subcutaneously and allowed 
to remain; by twisting of the rectum and suture in its new rela- 
tions; and by other plastic operations described in special text- 
books. 

Much can be done to relieve the patient by keeping his stools 
in a solid condition and by washing out the feces regularly once 
or twice a day. If all these measures are of no avail, the question 
of left inguinal colostomy should be considered. A continent 
artificial anus in a situation where it can be cared for by the 
patient is in many respects better than an incontinent natural anus. 

CONGENITAL DEFORMITIES 

Imperforate Anus. The only important malformation of 
the anus or rectum is a lack of communication of the lumen of the 
bowel and the outside world through the anus. The lower bowel 



I.MI'I.U"!' Ml. AM S 

may terminate in the vagina, and normal defecation lake place 
in this manner lor years. There ma\ I.e only a ininiite owning 
between the anus and rectum a congenital stricture. There may, 
however, be nu ojtciiing to the bowel, ami unless this condition is 
relieved within a short time after liirth the death of the infant 
must follow. The anus and the sphincter ani mav or mav not be 
normally present If the external structures are perfect and the 
bowel reaches to within a quarter or half an inch of the skin, an 
opening is easily made through the septum, and the continuity of 
the lumen is restored. If the distance from the lower end of the 
rectum to the surface is more than half an inch it may be difficult 
to find the rectum at operation, and some surgeons consider eol..~ 
tomy preferable to a prolonged attempt to find the bowel. One of 
the difficulties of finding the lower end of the rectum is the fact 
that instead of being situated immediately above the ini|terf<>rate 
anus, it is often deflected one way or another, usually lying an- 
terior to its normal situation. In these cases the mortality after 
operation is high, as it is also after colostomy for imperforate 
anus. If merely a congenital stricture exists, it may be dilated 
or divided, according to circumstances. If dilation is easily per- 
formed, it is preferable, as a wound is thereby avoided. 



SECTION VI 

AFFECTIONS OF THE ARM AND HAND 
(UPPER EXTREMITY) 



CHAPTER XIII 

INJURIES TO THE SOFT PARTS OF THE ARM AND 

HAND 

THE upper extremity is especially exposed to tramnatism. 
Fractures of the various bones in the arm and hand constitute a 
large part of all fractures. The proportion of slighter traumatisms 
is perhaps larger. Moreover so many important structures lip 
close to the skin of this part of the body that a slight injury may 
have serious effects. Familiar examples are an incised wound 
of the front of the wrist, opening the radial or ulnar artery, or 
dividing some flexor tendons ; a burn of the palm, producing per- 
manent flexion of the fingers; suppuration involving a tendon 
sheath, and preventing further motion of the tendon. 

Contusions. Diagnosis of contusion is easily made from the 
redness and abrasion of the skin, tenderness on pressure, ecchy- 
mosis, and swelling. If there is loss of function, or if manipula- 
tion of the underlying bone is painful, search should be made for 
a fracture or sprain. It may be difficult to differentiate a contu- 
sion involving a bone, from a partial fractvire, or a fracture with- 
out displacement. Without the aid of the X-ray it may be nec- 
essary to wait a week or two, to see if the symptoms of deep 
tenderness and disability disappear before asserting positively 
that the bone is uninjured. 

TREATMENT. The treatment of simple contusion is given on 
page 2. A sling is in most cases advisable. It is less conspicuous 
if made of a black silk handkerchief or a black ribbon two or three 
inches in width; or if the patient's pride does not permit even 
this, he may keep his hand between the second and third buttons 
of his coat. 

324 



ii i :M \TC\I\ 

< 'o||lll-ion> about the joints ;iiv often a-sociated with sprain-, 
and they HIT therefore discussed under lli:il heading. 

Blister. A Mi>tn- is the lifting up of the .-upertirul portion 
of the epidermis with .-.emus <>r Beropurulent r bloody tluid. 
I Misters :IIT common lesions iu many diseases. They are al.so 
seen iu liurus and frost-bites. They :dso follow traumation. 

The hist is the only type (d' blister which \vill be here con-id- 
ered. The t rauinat ism may be a slight, oft repeated friction UjH>n 
skill unaccustomed to it or a sudden more severe I raiiinat ism, usu- 
ally in the form of the pinching of the skin. Hitters of the first 
lype are common upon the palms of the hand, from rowing a boat 
or using heavy tools, and upon the heels and toes as a result of 
an unusual amount of walking. Blisters of the second type usu- 
ally contain a certain amount of blood, and are called blood-blis- 
ters. Such a blister is a small hematoma (v. infra). 

TREATMENT. In the treatment of a blister the object is to 
protect the tender underlying epithelium for a few days until it 
becomes harder. Hence the blister should not be removed, but its 
fluid should be withdrawn by the oblique passage into it of a 
needle, which enters the sound skin about an eighth of an inch 
away from the edge of the blister. The skin should first be 
cleansed with Alcohol, and the needle passed through flame to 
prevent infection. If the whole blister has been torn away, the 
underlying skin should be protected by a wet dressing or a cotton- 
collodion dressing or a simple ointment. 

If a blister contains pus, all of the raised epithelium should 
be at once cut away and a wet antiseptic dressing applied. 

Hematoma. The description and treatment of hematoma of 
the bead (p. ~2) is applicable to bematoma of the arm. There 
are, however, two special forms of hematoma peculiar to this 
region, 

Hematoma Beneath the Nail. If the blood is poured out be- 
neath the nail, this is wholly or partly lifted from its bed, and 
even then the unrelieved pressure may cause the patient great 
pain. As the bluish red of the clotted blood shows through the 
translucent nail the diagnosis is unmistakable ( Kin. 111). 

Treatment con-i>ts in cutting away a narrow traiisver-e strip 
of the nail near its base to relievo the pressure and prevent sup- 
puration (Tig. 1 !">). If Ibe base of the formed nail has been 



326 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

separated from the matrix, it should be freed from the overlying 
skin with the point of a knife and removed. If the whole nail 





FIG. 144. HEMATOMA BENEATH THE NAIL. 
The skin is lifted by the formed nail, the 
outline of which is readily seen. 



FIG. 145. INCISION FOR EVACU- 
ATION OF THE BLOOD IN HEM- 
ATOMA BENEATH THE NAIL. 



has been loosened, it should be thus freed from the skin and re- 
moved. In any case a dressing should be kept over the finger for 
a few days to prevent dirt from making its way beneath the loos- 
ened nail and to protect the tender bed of the nail. 

Cutaneous Hematoma or Blood-blister. Small hematomata are 
produced in the palmar skin by pinching or by continued rubbing, 
as of an oar. They usually contain bloody serum and are called 
blood-blisters. The contents of these blisters should be pressed out 
through the channel made by passing a clean needle through sound 
skin into the blister. This evacuation may have to be repeated 
once or twice. 

A blow upon the olecranon or upper part of the ulna may pro- 
duce a large hematoma. The circulation in this region is not very 



in I'll i;i; <>! mi.; HICKI-S .MCSCIJ-; 327 

active, ami it' the skin is broken ami the wound neglected the hema 
tomsi may suppurate, even when there is no apparent connection 
between the superficial wound and the hematoma. The treatment 
is then that of an abscess (see p. 408). 

Rupture of the Biceps Muscle. The biceps muscle may 
be partly or completely torn, usually by an attempt to lift a too 
trreat; weight This accident occurs almost exclusively in men, and 
usually in those who have passed their prime, or in those whose 
muscles have been weakened by alcoholism or disease. 

The history given is that of sudden pain in the arm during a 
strain, followed by muscular weakness. If the muscle is only par- 
tially torn, the patient is able to flex his forearm, but with nothing 
like the usual power. 

Physical examination confirms the statement of the patient as 
to the loss of muscular power of flexion, especially when the fore- 
arm is supinated. Careful palpation will usually reveal a depres- 
sion at the site of rupture. This may be in either the tendinous 
or muscular portion of the biceps. Moreover, when the patient 
attempts to contract the muscle it remains flabby, although he 
may move it to a certain extent. If only a part of the muscle 
or one of its heads is ruptured, this part will remain flabby 
while the remaining portion is firmly contracted. Sometime- 
the retraction of the torn portion of the muscle forms a notice- 
able bunch. 

TREATMENT. The treatment may be operative or non-opera- 
tive. In young and healthy subjects the rupture in the muscle or 
tendon should be exposed by a longitudinal incision, the torn ends 
sutured by fine silk or fine catgut chromatized to resist absorption 
in the tissues for twenty days or more. The skin should be sutured 
without drainage, and the forearm kept in a flexed position by a 
broad sling, or, if the patient cannot be trusted, the arm should 
be h'xed in this position by a light gypsum or starch bandage. 
This should be kept up for two or three weeks, after which passive 
motions, and later active motions, may be resumed* 

If the rupture is slight, or if the general condition of the pa- 
tient makes an open operation seem useless, non-operative treat- 
ment is indicated. The forearm should be flexed at a right angle 
and carried in a sling. Massage may be employed every day or 
every second day, pressure being so directed as to approximate the 



328 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 



torn ends of the muscle. Bandages or strips of rubber adhesive 
may also be employed toward this end. 

Wounds. Punctured wounds of the hand or fingers rarely 
give rise to troublesome hemorrhage, but they are often followed 
by suppuration. 

Bites of men and animals should 1x3 regarded as punctured 
wounds, and should receive the same treatment. 

COMPLICATIONS. Incised wounds are significant because un- 
derlying structures are often injured, even though the superficial 




FIG. 146. POSITION OF THE RADIAL AND ULNAR ARTERIES AT THE FRONT OF THE 
WRIST. The curve of the ulna toward the center of the wrist, as it passes the 
head of the ulna, is often more pronounced than it is here represented. Some- 
what diagrammatic. 

wound is small. This is especially true if the instrument causing 
the wound is very sharp, as a chisel or a pointed fragment of glass. 
The possible complications of such a wound are incision or division 
of an artery or nerve, or one or more tendons, or the opening of 
a joint. The radial and ulnar arteries are superficial in the wrist, 
and are often injured. One is wont to think of the ulnar artery 
as lying close to the ulnar side of the forearm, forgetting that in 
the wrist where this vessel is superficial it makes a sharp curve 
toward the radial side to clear the head of the ulna and the pisi- 



form bom* ( M'C Fig. 1 Hi). Hence it is often opened in iraiiM. 
cm-, which are, roughly shaking, in the middle of the \\ri-t. 

The ulnar nerve may be cut at the elbow liet \veen the inner 
condyle (.(' the hmnerus and the olecranon. Thi- produces paral- 
ysifl <>f the flexor carpi ulnaris, inability to separate the fini: 
lose of >ens;ition of (he outer half of the ring tinker and of the 
little linger in front and behind. Division of the iilnur nerve at 
the wrist gives the same symptoms in the hand. 

If the radial nerve is divided at the wrist, sensation i.- lo-i in 
the hack of the thumb and index-finger. There is no muscular 
paralysis, 

If the median nerve is divided at the wrist its muscular 
branches to the flexors of the forearm are, of course, not affected. 
There will be inability to abduct the thumb and loss of sensation 
in the palmar surface of the thumb ami index-finger. 

The symptoms here given are not all the changes which fol- 
low these nerve injuries, but they are the nio.-i striking our- 
and are sufficient for diagnosis. Jt is best to disregard -eiisa- 
tion in the middle finger, as anastomosis may ^i\-e misleading 
symptoms. 

The tendons most often divided in wounds of the arm are tlio^- 
of the muscles which have their origin in the forearm and their 
insertion in the baud. Twenty-three such tendons pa-s through 
the annular ligament. They may be cut either in the wrist, hand, 
or fingers. Most of them are easily palpated when put on the 
stretch by resisted voluntary motion, and a comparison with the 
other hand will usually show whether any one of them i< divided; 
but if in doubt, the medical attendant will do well to post pom- 
suture of the wound in the skin until he has refreshed his anatom- 
ical memory. 

The action of the deep and superficial flexors of the fingcr- 
may be distinguished as follows: If both are divided, the finder 
cannot be flexed with any considerable force. The lumhricalc- 
and interossei have only a feeble action as com parcel with tin- nor- 
mal flexors. If the tendon of the flexor profundus to any finger i- 
divided, the patient cannot flex the terminal phalanx when the 
oud phalanx is held extended by the surgeon ( Kig. 1 17). If the 
tendon of th<- sublimis is divided, the patient cannot flex th 
olid phalanx when the first i- held extended, or at least not until 



330 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 




FIG. 147. TEST FOR DIVISION OF THE PROFUNDUS TEN- 
DON. When the second phalanx is held extended the 
terminal phalanx cannot be flexed voluntarily if the 
profundus is divided. 



after the third lias 
been well flexed on 
the second. With 
division of the sub- 
limis, the test posi- 
tion shown in Fig- 
ure 148 cannot be 
assumed. 

Joints of the 
arm and hand are 
most exposed to in- 
cision on their pos- 
terior aspect. The 
metacarpo - phalan- 
geal joints are 
opened far more 
frequently than the 
others. 

TREATMENT. 
The treatment of 
wounds of the arm 
and hand consists 
in the removal of 
any dirt, the con- 
trol of hemorrhage, 
the approximation 
of the tissues by 
suture if necessary, 
and a dry dressing, 
or, if the cleansing 
is doubtful, a wet 
dressing. (For the 
details of such 
treatment see p. 
13.) The skin of 
the hand or finger 
should not be cut 
away simply to obtain a straight line of suture. It is well sup- 
plied with blood, and heals rapidly. 




FIG. 148. TEST FOR DIVISION OF THE SUBLIMIS TEN- 
DON. When the first phalanx is held extended, the 
patient cannot flex the second; certainly not until the 
terminal phalanx has been flexed in cases of division 
of the sublimis. 



\V<>r.\|)S 331 

It' ;i portion of skin has been destroyed in -uch a manner that 
the edges 1. 1' tin- wound cannot |>c sutured, an ulcer will result. 
It' ihi.- U s<> shallow that islands of epithelium an- left in it- l.a-e 
it will quickly become ci)vcrc<l with new skin. It' the whole thick- 




]'!<;. 149. TRAUMATIC ULCERS OF THE HAND; DCRAIION Si \i\iii\ DAYS; ACTIVE 
GRANULATIONS. In good condition for skin-grafting. Patient aged fifty years. 

ness of skin is destroyed, the gap should he covered \vith skin 
Drafts if it is more than one inch in diameter. The diameter of 
an nicer left to close by marginal growth will diminish only by 
ahoiit one-quarter of an inch a week, and the epithelium in a large 
scar thus produced is inferior to that of a Thiersch graft. Tin- 
grafts may be applied to a fresh \vound, after it has l>eeu cleansed 
and the hemorrhage stopped, or to the resulting nicer, when its 
base is thickly covered with granulations ( Fiir. 1 P.O. 

Treatment of Minute Wounds of the Fingers.- -A pin-prick or 
other wound of the tinker or hand, insienifficanl in itself, mav vet 



332 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

be the starting-point of a serious inflammation. Indeed, most of 
the suppurations of the upper extremity begin in such minute 
wounds. Their proper treatment is, therefore, a matter of no 
small importance. Probably no method of treatment can afford 
infallible protection from infection, but in a rather extensive ex- 
perience with this class of wounds the author has never known 
infection to extend beyond the immediate area of the wound,, and 
rarely to manifest itself even there when the following rules have 
been observed : 

1. Make the wound bleed promptly by pinching it, sucking it, 
and, if necessary, enlarging it. 

2. Cleanse the adjacent skin by vigorous scrubbing with strong 
antiseptics, such as turpentine, ether, or bichlorid solution. 

3. Shave away any surplus dead epithelium. 

4. Apply a wet antiseptic dressing for a few hours. 

5. If the wound contains visible foreign material, e. g., rotten 
wood from a splinter, or has been made by something probably 
covered with pyogenic germs, e. g., an old fish-bone, it should be 
laid open and drained if its track can be followed. 

6. The wound should be inspected on the following day, and 
if it is indurated and tender, an incision should be made through 
the indurated area only. A minute drop of pus may escape. 

liigaticn of Vessels. If a wound has opened a vessel of 
sufficient size to require ligation, the incision, if such is necessary, 
should be made in the long axis of the limb, even though this 
makes an irregular wound. Before the vessel is tied with No. 1 
or No. 2 catgut it should be entirely isolated, so that no nerve 
may be included in the ligature. A local anesthetic is satisfac- 
tory, but some patients prefer a general one in order to avoid the 
nervous shock. Suture of the skin with horsehair or fine black 
silk, and a dry dressing, together with a splint and sling if the 
wound is serious, complete the treatment. 

Suture of Tendons. A recently divided tendon should be 
sutured with fine chromic catgut (JSTo. or 1). Some surgeons pre- 
fer fine silk, believing that the catgut makes a rougher suture and 
may be absorbed before the ends of the tendon have firmly united. 
The sheath should then be sutured with plain catgut. The skin 
wound should be closed entirely, or with drainage if infection is 
feared, and the part bandaged in such a position that the sutured 



SI Tl !!!; M| II.M.nNS 333 

tendon shall IK- relaxed. It is well to begin passive moiion.- in a 

week or ten days, to prevent adhesions between the tendon and 

heath. Active motions, very gentle at first, should be begun 

within two weeks of the suture. 

If the ends of the tendon come together without tension a 
simple stitch will snfliee ( Fi".. 150 B). If the proximal part ha- 





FIG. 150. TKNDON , SUTURE. A, Mattress FIG. 151. TKM>\ Si uni. One 
stitch ; B, simple stitch, more likely to method of elongation to fill a gap 

cut out than a mattress stitch. between tin- end.-. There an- many 

other methods. 

retracted so that the stitch is likely to be pulled upon, a mattr- -- 
stitch is better, as less likely to cutout (Fig. 150 A). IJoth stiiche.- 
shonld be passed with a fine needle about one-quarter of an ineh 
from the cut end of the tendon. If the gap between the ends is 
too great to permit of direct suture, one or both ends of the ten- 
don may he elongated, as shown in FiiMire 1 .M . This method j-; 
at he- 1 a clumsy one, and a- it nece^iiai.- splitting the tendon 
sheath for a considerable distance, operator- have hem -earchinir 
for a better method. 



334 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 



Another way of overcoming a gap in a tendon due to retrac- 
tion, or due to sloughing of the tendon from suppuration in its 
sheath, is to unite the separated ends by a long silk stitch, making 
no attempt to bring the ends of the tendon together, but leaving 
the thread to act as a part of the tendon (Fig. 152). The silk, 
like all aseptic foreign bodies of small size, becomes encased with 
fibrous tissue, and if the patient persists in passive and active 
motions as soon as the skin has healed, more or less use of an 
otherwise totally helpless finger will result. The reports in the 

few cases in which this method has 
been tried indicate that it is far supe- 
rior to the splitting and elongation 
of the tendon itself. It is easy to 
split a recently divided tendon, but 
in the course of weeks or months the 
ends often atrophy so that there is 
is scarcely enough left to be recog- 
nized. On the other hand, nature is 
capable of filling a gap in a tendon 
if the sheath has not been closed by 
inflammation and if the ends are not 
constantly pulled apart by muscular 
action. 

Suture of Nerves. If a nerve 
is divided in a recent wound it should 
be at once sutured with very fine cat- 
gut or with silk. Three or four sim- 
ple sutures should be inserted in the 
sheath of the nerve (Fig. 153). The 
skin should be sutured and the arm 
kept for two or three weeks in such 
a position that the nerve is relaxed. 
Motions should then be gradually re- 
sumed. It takes from three to nine 
months to restore function in a di- 
vided nerve. Sensation is usually re- 
stored before motion. During this 
period the condition of the muscles supplied by the nerve should 
be kept good by massage and electricity. 




FIG. 152. TENDON SUTURE. A 
long silk stitch left in place to 
act as a tendon. It becomes 
covered with fibrous tissue 
growing out from the cut ends 
of the tendon. 



wor\i >> 



JOIN ra 






If the division of a nerve i- an old one, it- liber- have prob 
:dil\ BO degenerated ihat re|iair i- mil of i|,, question. 

It' the <livided nerve has retracted, or if a part of it ha- been 
destroyed, it may be split and turned down. The operation is 
similar to thai upon a tendon t \'"\n. 1 .'. 1 ). This operation is still 
in the ex|H-rimental stai^e. 

If a nerve i- injured by a blow, or by 
continued pre--niv, lo-- of -ens : iti<.n and of 
motion may follow. If the paralysis i- to 
tal, and shows no signs of disappearing in a 
few days, the essential part of the nerve i- 
probably divided. If so, the reaction of de- 
generation in the muscles supplied by it will 
appear in about fourteen days. The nerve 
should be exposed, ragiied ends trimmed oil'. 
and sutures inserted. A contn-ion of a 
nerve may give a partial or complete paral- 
ysis, but its activity -will gradually return, 
until after some weeks <r months there is 
a complete restoration of function. This 
should be aided by exercise, massage, and 
electricity. This 'accident frequently fol- 
lows prolonged anesthesia if the patient's 
arm is allowed to rest on the edge of the 
table (musculospiral), or if the arms are 
too tightly held over the head (brachial 
plexus). 

"Wounds of Joints. A punctured <r 
incised wound may open a joint. Tnis acci- 
dent is very important because of the infec- 
tion which may follow, and may de-troy the function <>f the joint. 
Under such circumstances the opening in the joint capsule should 
not be sutured entirely, but enough -pace -honld be left for drain- 
age. The skin suture should allow a small wick of rubln-i- tissue 
to extend to the opening in the capsule. Either a dry or \\et 
dressing may be used. 

If manifest impurities have entered the joint the opening in 
it should be so enlarged that free irrigation with -terile normal 
saline solution is possible. The drain of rubber ti--u<- should in 




I'u;. l.i:{. Si M i 

I III- lllflllf 
slinlllil In- | 
tlirniii:li UK- slu-uth 
only. 



INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

this case extend through the capsule of the joint. This drain 
should be withdrawn from the joint in twenty-four hours if there 
are no signs of increasing inflammation. A wet dressing should 
be employed. 

In both classes of cases the joint should be immobilized by a 
splint applied, when possible, to the opposite side of the limb. The 
drain through the skin should be left in place two or more 
days, until it is evident that no more fluid is coming from the 
joint. 

If the joint suppurates, the treatment is that given on page 42f>. 

Foreign Bodies. Splinters of wood, bits of glass, and parts 
of needles are the objects commonly found in wounds of the hand 
and arm. Bullets and shot are less common. 

There is a popular belief that certain objects are especially 
likely to produce a suppurating wound. Brass filings and the 
slivers of yellow pine have this bad reputation. The former are 
often covered with grease or oil. The latter, on account of their 
strength and sharpness, penetrate more deeply than the ordinary 
splinter. Splinters usually lie obliquely. A small deeply placed 
splinter of new wood may become encysted like a piece of glass, 
and give the same symptoms. 

Fragments of glass are often left in an incised wound because 
the physician is careless in inspecting so clean a wound, or be- 
cause the transparent glass is not easily seen. Such wounds do 
not usually suppurate, and they often heal primarily. If a bit 
of glass is left in the wound it becomes surrounded by scar tissue, 
and may not be noticed until the main scar has atrophied. Then 
it is revealed as a hard object in or beneath the skin, giving a 
slight sharp pain when pressed upon or when certain motions are 
made. If the examiner cannot feel the foreign body distinctly, 
and if he does not cause pain every time he makes a certain pres- 
sure, he will do well to postpone operation until more definite 
symptoms are present or until a radiograph shows the exact situa- 
tion of the object. Sometimes a patient, feeling pain in a scar, 
attributes it to the presence of a foreign body, although it is really 
due to pressure of the scar upon some nerve-fibers. 

A needle is often driven into the hand or forearm while the 
patient is scrubbing, or dusting a curtain. The needle is broken, 
and the doctor is consulted if it breaks below the surface of the 



i"i;i,H,\ BOOT 337 

skin. S 'limes the end is in pl.nn -i-lil, or it can h< fell 

beneath the skin. Tlm^e ca>es arc iimn- dlfficull in which the pa 
tient ivcei\ed a punctured wound supposed t<i be due to a needle, 
although net needle was seen. There is pain on making certain 
mot inns, and pressure causes pain. The.-e symptoms indicate tliat 
;i fragment of needle, p< rhaps less tlian half ;in inch Innir, i-, buried 
in the tissues. A search for it \vitlmut nmre delinitc knuwl- 
of its situation is rarely successful. One should resm-t to a tlum-o 
scopic examination or, better still, radiographs should he taken in 
two planes. 

Bullets and shot may be touched with a probe passed through 
the wound of entrance and so diagnosticated. If this is not \<- 
sible they should be located by means <.f the X-ray. 

The fate of a foreign body embedded in the tissues depends 
partly upon its nature and partly upon the entrance with it of 
pathogenic organisms. Most foreign bodies are capable of r- 
ing disintegration in the tissues for an indefinite time. They will, 
therefore, either become encysted or produce a suppuration and a 
sinus, through which, sooner or later, they will be expelled from 
the body. Powder grains and the ink of the tattooer are familiar 
examples of the first class. Needles and splinters of glass, beini: 
practically free from germs, are frequently included in an a-ept it- 
scar. Splinters of rotten wood, fish-bones, greasy metal lilin^-. 
etc., are almost always cast out by the suppuration. 

TREATMENT. The treatment in all these cases should be to 
enlarge the wound of entrance sufficiently to render certain the 
removal of the foreign body and to provide for drainage. The 
skin, if grimy, and the wound should be thoroughly scrublx'd with 
soap, turpentine, and ether. In cleaner cases, soap and hot water, 
followed by alcohol or an antiseptic solution, will suffice. It is 
well to reduce the pain as much as possible by the use of a local 
anesthetic. A splinter usually enters the skin obliquely : then-fore 
the incision should be so made as to expose the whole splinter, in 
case the wood is rotten. With new wood a short incision may 
suffice. 

If the wound has been caused by glass, its edges should be 
fully retracted, so that no portions of the glass shall be overlooked. 
These wounds are often oblique, or even irregular, due to the con- 
traction of the muscles at the time the accident occurs. Hence 
24 



338 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

there is a greater necessity for a thorough exposure, even though 
the wound in the skin has to be made larger. 

A portion of a needle is often a difficult foreign body to locate. 
If the needle appears in the wound, it can be grasped with forceps 
and extracted. If one end of the fragment is felt just beneath the 
skin, its removal is likewise simple. In many cases, however, it 
can neither be seen nor felt by the doctor, although the patient is 
certain of its presence. In these cases plenty of time should be 
given 'to determine the exact location of the needle before the 
search for it is made with a knife. The best single guide to its 
position is the sensation of the patient when pressure is made upon 
the tissues in which the needle is embedded. The operator should 
make the most. of this before administering a general anesthetic. 
Even after a local anesthetic this sensation may be lost. Incision 
for^search has to be made in the long axis of the limb, and yet it 
is desirable to so direct the plane of incision, if possible, that the 
needle shall lie across it. 

A bullet is often more readily reached through an incision 
made somewhere else than at the wound of entrance. 

The decision to suture the wound, or to drain it, must rest 
upon the probability of infection. In doubtful cases it is well to 
suture the wound and to drain it with flat gutta-percha drains, 
which can readily be extracted in a few days, if there is then no 
sign of suppuration. In this manner the healing of the wound is 
scarcely interfered with. 

If there is a possibility that all of the foreign material has 
not been removed, a drain should be employed to facilitate the 
casting out of small fragments or the extraction of larger ones. 

Sprain. A sprain is an injury of the joint caused either by 
a too great strain upon some ligament or by crowding together 
the bones of the joint. It will be seen, therefore, that the lesions 
produced may be either a rupture of some of the ligamentous 
fibers or a separation of the same from their bony attachments ; 
or, on the other hand, a contusion of the cartilaginous end of one 
or both bones. Often these different lesions are associated. They 
can usually be differentiated by carefully pressing the ends of 
the bones together and by drawing them apart, and by overflexing 
and overextending the joint. If the bones are contused, pain will 
be excited when they are pressed together. If the ligamentous 



SPRAIN 

fibers arc broken, or li;i\v been pulled from tin- hone i,, which 
they were attached, pain will lie cviie'l when the ligament of 
which they are a pan is put upon the stretch. Besides these 
symptom-, there will be noted a certain amount of swelling, dis- 
ability, and pain without manipulation according to the .-< verity 
of the injury. Then.' is sometimes effusion of serum or hi...,.) into 




Fid. I")!. SritAiN (M I'i\(;i:it WITH SI.KKI-S ! IN JOINI. 

the overlying soft parts; but in general the ecchymosis caused by 
a sprain is far less than that caused by a fracture. There is often a 
considerable effusion of serum into the cavity of the joint, increas- 
ing the swelling, and giving rise to fluctuation if the capsule of 
the joint is accessible to palpation (Fig. 154). 

TREATMENT. The treatment of a sprain is threefold: To 
prevent strain upon the injured ligaments ; to facilitate the absorp- 
tion of the exudate; to prevent adhesions and stiffness of the joint. 
The first indication is met by a splint which shall hold the joint 
in a position most comfortable for the patient. Such a position 
is usually between flexion and extension. The second object of 
treatment is accomplished by massage and passive motion. Light 
rubbing of the joint should be begun either immediately or after 
a day or two, according to the severity of the lesion. Pa- 
motion is next in order of application. Active motion should be 
delayed in severe case- fr a few <\;\\< in order to give the : 
symptom- time to subside. Ii i<, however, the I*--! means at our 
command to prevent adhesion- in a joint. 

A dres>inir which fulfils very well the tir-i ami second indi- 
cations and allows active motions to a safe limited extent consists 



340 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 



of strips of rubber plaster from half au inch to an inch in width, 
put on alternately from right to left and from left to right, so 
that they shall cross each other at nearly a right angle. In this 
manner irregularities in outline of the part may be smoothly cov- 
ered (Fig. 155). If the wrist joint or one of the interphalangeal 




FIG. 155. ADHESIVE PLASTER STRAPPING FOR SPRAIN OF THE METACARPO- 
PHALANGEAL, JOINT. Drawn from a photograph. 

joints is sprained, the strip of plaster may be wound directly 
around the part. 

If this dressing causes venous congestion, it may be slit longi- 
tudinally on the side opposite the sprain. In case of the larger 
joints it is only necessary to apply the strips through two-thirds 
of the circumference of the limb. 

Sprain of the Shoulder (Subdeltoid Bursitis*). A common in- 
jury of the shoulder is partly a contusion, partly a sprain. It fol- 
lows falls either upon the hand or upon the shoulder itself, and 
sometimes the effects of exposure are added to those of the trau- 
matism. This condition of the shoulder is in some cases associ- 
ated with neuritis, and in others is accompanied by a paralysis 
due to overstretching or pressure upon some part of the brachial 
plexus or of the circumflex nerve. Paralysis of the affected mus- 
cles then becomes a prominent symptom. 

Anatomically it is to be noticed that the shoulder is more 
thoroughly covered with muscular tissue than any other joint in 
the body. The large muscles about the hip-joint do not overlie 



SIM;\I\ ;;j| 

the great trochanter, and are therefore n..| |il,.-|\ to |>e injured 
b\ direct fall- upon the hip: while tin- joint M-e|| i- - lirm lli;it 

-pram- are liul likely l'> follow indirect \ iolelice. < )|i the oilier 
hand, lax joints, Mich as the wri>t, an- constantly exjK)8ed to 
lence, lioth by direct Mow and by sudden over-l retching but then- 
is no muscular tis-ue in the vicinity to lie injured. The shoulder- 
joint then is peculiar in its ninscnlar covering ; and while the joint 
itself is so freely movable that it is not likely to sutTer from over- 
stretching, the ninscnlar and fibrous planes and l.nr.-a- and n 
about it are exposed to injury either from overstretching or from 
a direct blow. 

DIAGNOSIS. A patient who has injured his -hoidder by fall- 
ing on the hand, or on the shoulder itself, either presents him- 
self within a day or two after the accident on account of the 
pain and disability, or else he seeks advice in a week or two 
because improvement under home remedies has been so slow 
that he fears that the injury is more serious than he at iir-t 
supposed. 

Examination of the shoulder after all clothing has been re- 
moved from both shoulders and arms shows an absence of bony 
deformity; and only a slight swelling over the head of the hnmerns 
anteriorly and exteriorly. Direct pressure is not painful, nor is 
pressure made upon the elbow in such a manner as to crowd the 
head of the humerus against the scapula. Both active and pa--ive 
motions are limited by pain, and usually to about the same extent. 
Internal rotation is not very painful, and the patient can often 
put his hand behind his back. External rotation and abduction 
cause pain in the anterior portion of the deltoid muscle. If the 
elbow is fixed at the side and the forearm tlexed at a right am:le. 
the patient may be able to rotate the arm outward sutiiciently t> 
bring the hand directly forward, though even this is usually quite 
painful. If asked to abduct the arm, the patient rai-cs the scap- 
ula and hnmerus together, not chan^'mir the an-le Ix-tweru them. 
He cannot usually raise his hand as hiiib as the top of his head. 
When the elbow is at the side it can he pushed backward with far 
less pain than it can be pushed forward. In other words, the 
lesion seems to be located in the anterior portion ,,f the deltoid 
muscle, or immediately leneath it, -ince contract ion of this nni-de 
or passive motion of the arm made in such a manner a~ to stretch 



342 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

it over the head of the bone causes pain. Other signs of inflam- 
mation are wanting. 

If two weeks or more have elapsed since the accident, there 
will be noticed the additional symptom of atrophy of the deltoid, 
apparently from disuse, and the humerus will stand ovit more 
prominently on the affected side, so that without a careful exami- 
nation one might think 'some bony deformity was present. Such 
an accident occurring to a patient who is a regular whisky drinker 
is usually sufficient to produce a neuritis of the circumflex nerve. 

Neuritis of the shoulder or arm, whether alcoholic or other- 
wise, may occur without traumatism. The pain then exists when 
the limb is at rest as well as when it is moved. The pain, too, will 
probably not be limited to so small an area. Acute articular rheu- 
matism, gonorrheal arthritis, suppurative arthritis, tuberculosis, 
and syphilis of this joint all have such marked symptoms due to 
temporary or permanent derangement of the joint that they can 
hardly be mistaken for simple sprain. 

The effects of sprain last for some weeks or months, and in 
the alcoholic, " rheumatic," old, and neglected, complete use of the 
joint may never be regained. 

TREATMENT. The best treatment for sprain of the shoulder 
is bathing the shoulder twice a day with very hot water, follow- 
ing this with vigorous rubbing. Two or three times a week the 
surgeon or some other responsible person should perform abduc- 
tion and external rotation of the arm, as fully as the patient can 
bear it, to prevent permanent limitation of motion. The patient 
himself should make full active motions of the joint several times 
a day. Counter-irritation may be required to allay pain. 

Neuritis. Neuritis of the arm occurs spontaneously, or from 
exposure to cold, or as a complication of sprain and other injuries. 
Long rides in automobiles is a fruitful cause of neuritis, espe- 
cially in those unaccustomed to severe muscular exercise. If the 
history of the attack is confusing a differential diagnosis can usu- 
ally be made by the existence of pain along the nerve trunks 
and their branches, when the arm is at rest as well as when it is 
moved. Sometimes paralysis, complete or partial, is the striking 
symptom. This is the case when the brachial plexus is injured 
by too violent attempts to reduce a dislocation of the shoulder ; 
or by prolonged elevation of the arms above the head in sleep 



\< I II V>.\ Sll'l'l IIATIVE rENOBYNOVl I Ifi 



>r anollie.-ia : or when the mnscnlospiral is caught anil pr< 
14)011 by I IK- callus in fracture of the shaft of the- hnmeni-. 

The local treatment of neuritis consists in the application 
of heat or cold or counter-irritants to relieve pain ami imp: 
local circulation, with rest of the affected parts. Later hat him:, 
massage, and electricity are beneficial, and still later .-ictivc motion. 
It is in these cases that the daily use of a mechanical vibrator 
proves very satisfactory. If there is continued pr< mv upon, the 
nerve, as from a broken bone or callus, this should be removed 
early. If there is reason to think that the nerve may have 
been ruptured, it should be exposed for suture. In most o 
occasional passive motions should be made from the first, to 
prevent the formation of adhesions, limiting the free motions of 
the joints. 

Acute Non-suppurative Tenosynovitis. This cumber- 
some title is used to indicate a condition which a traumati.-m 
may produce in any tendon sheath, but which is most common 
in those of the extensor tendons of the thumb and radial -idc of 




FIG. 156. DIAGRAM OF THE BACK OF THE RIGHT Wi;i-r TO Snow THK Hi : \TIONS 
OF THK TENDONS TO THE RADIUS AND TO ONE AM>IHI K. N..te that tin- ten- 
dons of the extensor carpi radialis longus and brevis lie between the tendons of 
the extensors of the thumb and the shaft of the radius. When in violent action 
each pair saws on the other, and also on the bone. 

the hand. It is marked by tenderness and swelling, and a peculiar 
fine crepitus or creaking which is due apparently to a 1"<- of polish 
of the tendons and inner lining of the -\novial sheaths, e 
cially where they lie close to the radius about two inches above 
the plane of the joint (Fig. 1 ."<>). The slightest motion of the 



344 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

thumb or hand, whether active or passive, -will produce this 
creaking. 

The history given by the patient is almost invariably as fol- 
lows: After a period of comparative idleness, he went to work at 
moving furniture or polishing wood or some occupation requiring 
equally severe muscular effort. Next day his arm was sore, but 
he kept on working until the pain compelled him to stop. This 
nvpitus may persist for five days or a week after work has been 
given up, although if the hand is kept absolutely at rest on a 
splint, it usually disappears in a day or two. In slight cases it 
may wear off in a few minutes during the" diagnostic manipula- 
tion by a class of students, for example. In some workshops this 
tenosynovitis is of common occurrence among the new men em- 
ployed. 

While the above mentioned cases represent the usual type of 
tenosynovitis, the writer has known this lesion to be produced 
in the sheath of the extensor tendon of the index-finger, the cor- 
responding metacarpal bone having been fractured some weeks pre- 
viously, and the patient having returned to work while there was 
still a sharp projection posteriorly at the site of fracture, due 
partly to displacement and partly to callus. Pulling the extensor 
tendon backward. and forward over this bony prominence set up 
the dry tenosynovitis. 

TREATMENT. The treatment of these cases is comprised in 
two words rest and counter-irritation, the former of which is 
far more important, while the latter will relieve the acute pain 
which exists in the first few days. A light splint, compound 
iodine ointment, and a gauze or starch bandage make up the dress- 
ing which should be left in place for four or five days. If symp- 
toms persist, the dressing should be repeated. The patient should 
be advised to begin very gradually to use the hand. 

Serous Synovitis. The joints of the upper extremity are 
not so prone to fill with fluid after a traumatism as are the 
joints of the lower extremity. Still such serous effusions occur. 
Figure 157 shows distention of the right shoulder- joint fol- 
lowing an unrecognized dislocation. Six ounces of the flr.id 
which was slightly bloody, was aspirated. Note the flattening of 
the outline of the shoulder which resulted from the aspiration 
(Fig. 158). 



SKROUS SYNOV1T1S 



345 



Fluid in the el- 
bow-joint distends 
the arm posteriorly 
on either side of 
the olecranon. A 
small amount of 
fluid will give fluc- 
tuation. 

Injuries of the 
joints of the wrist 
and fingers usually 
cause so much swell- 
ing of the overlying 
skin and subcutane- 
ous tissue that the 
outline due to fluid 
in the joint is ob- 
scured. In a chron- 
ic synovitis the fluid 




I Hi. l~>7. EFFUSION OF BLOODY SERUM INTO THE RIGHT 
SHOULDER-JOINT IN DISLOCATION, WITH FREQUENT 
MANIPULATION. 




FIG. 158. RIGHT SHOULDER AFTER ASPIRATION OF Six OUNCES OF BLOODY 
SERUM. Same subject as Fig. 157. 



346 INJURIES TO THE SOFT PARTS OF THE ARM AND HAND 

in the joint is readily recognized. It is generally of a tubercular 
character (p. 440). 

The treatment of serous synovitis is that of the injury, of 
which the effusion is only a symptom. The amount of fluid will 
rarely be so great as to require aspiration. 

Bursitis. The olecranon bursa may fill with serum as the 
result of a single severe blow or after repeated slight traumatisms 
(miner's elbow). It forms a smooth, tense, somewhat tender, 
fluctuating tumor between the skin and the olecranon process. If 
the skin is broken by the injury, the bursa is likely to become in- 
fected, and then redness and edema of the skin will be added, and 
the tenderness will be greatly increased. If the bursa is punctured 
there will be a discharge of thin mucous or purulent fluid. For 
infected bursitis see page 427. 

Other bursoe of the arm are rarely affected by an injury. 

TREATMENT. The treatment of an uncomplicated case of 
olecranon bursitis consists in rest to the joint and pressure, wit.li 
wet dressings if the skin is abraded. In a later stage of the trou- 
ble, counter-irritation, then aspiration and pressure, may be tried. 
If these measures fail, the bursa may be opened longitudinally., 
and its cavity drained with gauze, so that it will heal by granula- 
tions. A better plan is to dissect out the bursa and suture the 
wound. This requires a general anesthetic, and takes longer, but 
it does away with a tedious period of recovery. (Compare the 
paragraphs on diagnosis and treatment of the prepatellar bursa.) 



CHAPTER XIV 

DISLOCATIONS AND FRACTURES OF THE 
ARM AND HAND 

DISLOCATIONS 

THE records of a large hospital for a period of years show 
that two-thirds of the dislocations treated there involved the shoul- 
der-joint, and that three-fourths of all dislocations treated were of 
some joint of the arm or hand. 

A dislocation of a joint is an injury by which one of the 
articulating bones has been pushed out of its normal relation 
to the other. The dislocation may be partial or complete. It 
may be reduced spontaneously at the time of injury, in which 
case only the symptoms of a sprain will persist. In other cases 
reduction is easily accomplished ; while in still others it is diffi- 
cult, and may even be impossible without an operation. 

The symptoms of dislocation are those of a sprain of the joint, 
viz., pain, swelling, tenderness, and possibly ecchymosis, and in 
addition marked deformity, and great limitation of motion. But 
these last named symptoms, which are so characteristic in many 
cases, may in others be obscured by the swelling. Axial deviation 
of the bones is another symptom which is often of great diagnostic 
value. 

General Remarks on Treatment. There are two gen- 
eral methods of reducing a dislocated bone. One is to make trac- 
tion until the distal bone slips into its true relation to the proximal 
bone. The other plan is to swing the lower end of the distal 
bone toward the side on which it is displaced ; for example, flexion 
in case of an anterior dislocation of the finger, overextension in 
case of a backward dislocation. 

Redaction is interfered with by muscular contraction, by the 
irregular shape of the bones, by intervening ligaments or other 
tissues. 

347 



348 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

Muscular contraction may be overcome by an anesthetic or 
by long continued traction in such a manner as to tire out the 
muscles or by dexterity 011 the part of the surgeon, so that manipu- 
lation is made when the patient's attention is distracted, and his 
muscles are off their guard. The various motions made for reduc- 
tion should never be violent nor powerful. That which one can 
accomplish with great force can almost always be accomplished 
with little force if properly directed for a sufficient time; and 
permanent injury is likely to follow the use of violence. 

Manipulation of the bones at the joint, while an assistant 
makes traction at a distance, will favor reduction by guiding one 
bone past the other, and through the rent in the capsule if the 
bone has protruded. Such action may well be compared to draw- 
ing a shoe-button through the buttonhole by means of a button- 
hook. 

If all other measures fail to reduce a dislocation, an incision 
should be made for this purpose. The risk of infection and a 
subsequent stiff joint is not great when the operation is properly 
performed. It is better to assume this risk than to suffer the 
permanent disablement of an unreduced dislocation. 

A common mistake is to give too favorable a prognosis after 
a dislocation has been satisfactorily reduced. Except in cases in 
which the capsule of a joint is abnormally loose, the bones can- 
not be dislocated without producing at least as much injury 
to the surrounding parts as exists in a severe sprain. While 
such injury is many times perfectly recovered from, the con- 
valescence may be most tedious, and in many cases the func- 
tions of the joint are never fully regained. This is especially 
true if the interval between dislocation and reduction is a 
long one. 

The question is sometimes asked, How long after the occur- 
rence of a dislocation is it possible to replace the bone? ~No defi- 
nite answer can be given. My own experience tends to show that 
manipulation is rarely successful if the interval is more than four 
weeks. Furthermore, if a reduction is then accomplished, it is 
less complete than when accomplished promptly, and extra pre- 
cautions are needed to keep the bone in place. Before attempting 
to replace the bone, the surgeon should move it about in all direc- 
tions, to break up adhesions, overcome stiffness of the muscles, 



GENKl.'AL 1! KM AUKS ( )\ TKKATMENT 



349 




Fio. 159. DISLOCATION OF THE THUMB OF SEVEN YEARS' DURATION. Patient a 

boy aged twelve years. 

and so to gain as much freedom of motion as possible. Not until 
this has boon done should the specific motions of reduction be per- 




Fid. 100. RAniocuAi'ii ni Sunn- Hi .1. vn<>\s OF HONES IN DISLOCATION OF THE 
THUMB OF SEVEN YEARS' DURATION. Same subject as Fig. 159. Note the 
formation of a new bony articulation on the back of the metacarpal. 



350 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

formed. In these late cases a general anesthetic is absolutely indi- 
cated. 

The condition of an unreduced dislocation improves some- 
what as months go by. The ends of the bones form imperfect 
sockets for themselves, so that the functions of the joint are par- 
tially restored, but its use is more or less painful. The deformity 
is of -course permanent. These points are strikingly illustrated in 
Figures 159 and 160. The radiograph shows both the bony out- 
lines and the contour of the dislocated thumb. In this case subse- 
quent growth of the bones has increased their abnormality. 

By operation in a case of long standing dislocation one may 
reasonably hope to secure a correct alinement of the bones and 
some improvement of function with less pain. A normal joint 
may be hoped for, but should never be promised. The ultimate 
success depends not a little upon the faithful performance of 
active and passive motions of the joint, massage, and hot bathing. 

Dislocations of the Shoulder. The humerus may be dis- 
located upon the scapula in any direction excepting upward. An 
upward dislocation can only take place if the acromion process is 
broken off, and this accident rarely happens. The form of dislo- 
cation which exists in more than ninety-five per cent of the cases 
is downward and forward beneath the coracoid process. The in- 
jury is usually produced by a fall on the outstretched arm or 
hand. The capsule of the joint is torn anteriorly in its lower 
part. 

The signs peculiar to dislocation of the humerus are absence 
of the head of the bone from its socket, flattening of the shoulder, 
projection of the elbow, and the impossibility of bringing it to 
the side of the body, and most important of all, the presence of 
the head of the bone in an abnormal situation, usually below the 
coracoid process. There is also a difference in the length of the 
two arms, measured from the tip of the acromion to the external 
condyle of the humerus. There is a shortening on the affected 
side, which is increased by abduction of the arm. 

TREATMENT. Reduction of the bone by a direct pull upon 
the arm is a difficult procedure, often requiring great force, and 
exposing the patient to injury of the axillary vessels or nerves; 
but a long continued, slight pull will often accomplish the end 
in view without great pain and without serious risk. Stimson 



DISLOCATIONS OF THE ELBOW 

;irries 1liis diil by allowing the patient \<> lio upon a high canvas 
cot, with his arm hauling through a hole in the canvas. To his 
\vri.-4 is attached a two pound weigh). The trad ion will grad- 
ually overcome the muscles and will bring the head of the bone 
back into position in less than ten minutes. 

The usual method of reducing a dislocated humerus is to 
place the patient upon his back on a firm table; to flex, extend, 
abduct, and rotate the humerus for several minutes, in order to 
break up adhesions, and to partially tire out the muscles. The 
next step is to flex the forearm on the arm, and to forcibly rotate 
the latter outward for two or three minutes until the muscles yield 
to the steady tension. With the arm still rotated, the elbow is 
carried up\vard across the chest, and as the head of the bone slips 
into its socket, the hand is brought over to the opposite shoulder, 
and fixed there by a strap of adhesive plaster or a bandage. This 
simple manipulation, known as Ivocher's method, will usually suc- 
ceed in reducing a fresh dislocation. It can be performed either 
with or without an anesthetic. 

In other cases inward rotation of the arm, followed by a sud- 
den hitch outward of the upper arm, will throw the head of the 
bone back into plade. 

When the dislocation has been reduced the arm should l>e 
kept in a sling, but it need not be firmly bandaged to the body 
unless the patient is very untrustworthy. Such close confine- 
ment tends toward stiffness of the shoulder, and this should i>e 
avoided when possible. The shoulder should therefore be bathed 
and massaged daily, and slight passive and active motions allowed 
(see treatment of sprain, p. 339). The elbow should not be 
raised to the level of the shoulder for two or three weeks, lest 
the dislocation be reproduced. 

Dislocations of the Elbow. Dislocation of the elbow is 
not a common accident, for the reason that the ulna is so closely 
articulated with the humerus that an injury is more likely to break 
the lower part of the humerus than it is to produce a dislocation. 

The head of the radius may be dislocated either backward or 
forward (Fig. 161) or to one side. 

The commonest form of elbow dislocation is the backward 
dislocation of both radius and ulna (Fig. 162), with or without 
fracture of the coronoid process. If no fracture exists, the dis- 



352 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

location is of necessity an extreme one, since the coronoid process 
is carried behind the articular surface of the liumerus. This 
produces a deformity which should not be overlooked. The tendon 




FIG. 161. RADIOGRAPH OF FORWARD DISLOCATION OF THE HEAD OF THE RADIUS, 
FIVE MONTHS' DURATION, AND FRACTURE OF THE ULNA OF THREE WEEKS' 
DURATION. Patient a girl aged seven years. 

of the triceps is tightened when an attempt is made to flex the 
forearm j and the whole olecranon portion of the ulna is posterior 
to the condyles of the humerus when the forearm is at right angle 
with the arm. Normal motions of the joint are considerably 
limited. The head of the radius, recognized by palpation and 
rotation of the wrist, may be felt to the outer side of the olecranon. 
In case the ulna alone is dislocated, the head of the radius will 
remain in its natural position. The dislocation of the forearm 
in this case will not be directly backward, but the forearm will 
swing round upon the head of the radius as a pivot, so that if 
the forearm is held at right angles with the arm in the position 
of supination, the hand will be considerably nearer the median 
line of the body than it ought to be. If the radius is dislocated 
with the ulna the forearm may be carried directly backward, or 
it may be more or less laterally displaced. In every case of dis- 
location or other injury about the elbow, it is of the greatest im- 
portance to determine the relations of the two condyles of the 
humerus, the tip of the olecranon and the head of the radius. 



DISLOCATIONS or THI-: 



353 



Dislocation at the elbow is often ruinliim-d with fracture of 
sonic hone. In this case the characteristic signs will lie more or 
less obscured. Indeed, injuries of the elbow-joint afford some 
of the most difficult diagnoses, and the surgeon should not miss 
the aid offorod by radiographs made in the anteroposterior and 
bilateral directions. 

TREATMENT. Backward dislocation of the elbow-joint, if of 
recent occurrence, can usually be reduced without difficulty. The 
patient should be fully anesthetized. The range of motion of the 
forearm on the arm is then to be increased by repeated gentle 
manipulation in all directions, and then, while an assistant fixes 
the upper arm, the surgeon makes an attempt to unlock the ulna 
from the humerus and bring it forward. Sometimes this is easily 
accomplished ; sometimes a number of efforts must be made before 
success is obtained. As in all dislocations, strategy rather than 




Fio. 102. RADIOGRAPH SHOWING BACKWARD DISLOCATION' OF Horn RADIUS AND 
ULNA OF FIVE MONTHS' DURATION. Patient a man aged fifty-eight. An opera- 
tion was necessary to reduce this dislocation. 

great force should be employed. It is sometimes possible to slide 
the ulna toward the inner side of the humerus, and then to bring 
it forward. When one bone has been reduced, or in case only one 
of the bones is dislocated, the bone which is in place acts as a 
lever to drag the other one into place if a firm lateral motion, 
either abduction or adduction, is combined with the forward trac- 
tion upon the forearm. 

25 



354 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

It is said that reduction by manipulation is rarely possible 
in dislocation of the elbow-joint which has lasted a month or more. 
In every case the manipulation should first be tried, and tried 
most thoroughly, not only on account of the possibility that it may 
succeed, but because the added freedom of motion thereby obtained 
is of the greatest help to the operator in case he has to expose the 
bones through incisions. The best incisions to employ in this in- 
stance are two lateral ones, linear longitudinally when the fore- 
arm is extended, but more or less curved in the semiflexed position 
of an old dislocation. 

When the elbow has been reduced by manipulation or opera- 
tion, the forearm should be flexed to a right angle and kept so 
by a sling, or a gypsum bandage, or molded splints. As soon as 
possible passive motions and massage and hot bathing should be 
instituted. Such treatment should be begun within a week if a 
fresh dislocation has been reduced by manipulation, and as soon 
as the wounds will permit in cases reduced by an open operation. 
It is well to remember that oft-repeated slight motions have a 
far greater curative value than a few violent ones. For this rea- 
son active motions made by the patient himself are especially to 
be encouraged. He should be given certain definite motions to 
practise several times daily which will tend to increase the exist- 
ing range of motion. 

Subluxation of the Radius. Dislocation downward of the 
head of the radius, or subluxation, as it has been called, may be 
produced in young children by jerking them or lifting them sud- 
denly by one hand. The head of the radius is pulled downward 
out of the coronoid ligament, usually without other injury. Ex- 
amination will show a certain amount of tenderness at the seat of 
injury and loss of function, especially in the matter of pronation 
and supination of the hand; but these signs are frequently ob- 
scured by the fact that a young child will refuse to make any 
motions of an injured joint through fear. Hence the symptoms 
elicited may differ in nowise from those of a sprain of the elbow. 
The only characteristic sign, therefore, is the absence of the head 
of the radius from its normal position, and its presence slightly 
below this point. Careful measurement from the external condyle 
of the humerus to the styloid process of the radius will show that 
the distance is slightly increased upon the injured side. A differ- 



DISLOCATION OK rill, I'll! MM 355 

ential diagnosis between this injury and fracture of the neck of 
the radius can best bo made by an X-ray cxaminai i<>n. 

TREATMENT. This dislocation is easily reduced, either with 
r without an anesthetic. The upper arm should be grasped firmly 
near ils lower end at the same time that the hand and lower end 
of the radius is also (irmly held. The forearm should lie extended, 
and the radius pushed steadily upward at the same time that it is 
rotated slightly to right and left. In this manner it can be slipped 
back into place much as a peg is worked into a hole. 

Dislocation of the Wrist. Dislocation of the wrist is a 
rare occurrence, owing to the fact that the lower end of the radius 
is broken by an injury which might otherwise cause a dislocation. 
The deformity, whether anterior or posterior, is extreme, resem- 
bling that of Colles's fracture with marked displacement of the 
lower fragment. Motion at the. wrist-joint is greatly limited. The 
normal relation of the tips of radius and ulna is preserved 1 and 
measurements of these two bones will show them to be of normal 
length. After reduction of the dislocation the hand -lioiild be kept 
for two weeks or more upon an anterior splint. 

Dislocation of the Thumb. Dislocation of the carpo- 
metacarpal joint 'of the thumb occurs rarely. Fracture of the 
metacarpal bone is common. If the fracture is near the base it 
may be difficult to differentiate it from a dislocation without the 
u- of the X-ray. Crepitus, a difference in measurements, and 
the impossibility in making a perfect reduction will indicate frac- 
ture; but in the presence of considerable swelling these signs may 
not be clearly obtained. 

This dislocation is easily overcome by manipulation. Adhe-ive 
plaster strapping will prevent it< recurrence (see Fig. l.V>, p. -'510), 
or a starch bandage may be applied to the thumb and wri<t. 

The proximal phalanx of the thumb may he dislocated hack- 
ward. The anterior portion of the capsule is torn from the nieta- 
carpal and the thumb rests upon the posterior surface of the meta- 
carpal, sometimes forming an angle of ninety degrees with its 
shaft. It is evident that such a dislocation, if unreduced, will 
render (lie thumb nearly useless (Figs. 'I.V.I ; ind 1 ',<>, p. -".10). 
This condition i- easily recognized, A fracture may ! followed 
by posterior displacement of the distal portion, but it does not give 
such an axial deviation as dislocation. 



356 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

TREATMENT. Reduction is sometimes made difficult by the 
interposition of the torn capsule or the outer sesamoid bone, or by 
the position of the head of the metacarpal between the two heads 




FIG. 1G3. FULL EXTENSION OF ADULT THUMBS. Right thumb normal; left thumb 
abnormally overextended. 

of the flexor brevis muscle. To avoid these hindrances the sur- 
geon should first bring the metacarpal into the center of the palm 
so as to relax the flexor brevis muscle, should flex the distal pha- 
lanx to relax the flexor longus tendon, and should increase the 
dorsal flexion of the proximal phalanx and rotate the bone slightly 
from side to side in order to dislodge any structures which have 
intervened between the bones. The base of the phalanx is next to 
be pushed along the posterior surface of the metacarpal until it 
is partly beyond it. Not until then should flexion be attempted. 
If 'reduction is not accomplished, the patient should be anes- 
Jhetized, and another attempt at reduction should be made. If 
this is not completely successful, the joint should be exposed by a 



DISLOCATION o| A FINGER 






radial incision and normal relation established. Perfect restora- 
tion of function slionlil follow. 'I'liis operation should al.-o hi- 
performed in cases of dislocation of |ou^ >landinu'. 1'nder such 
circumstances resection of the head of the metacarpal will usually 
lc necessary. The results are then not as perfect, l>ut the n.-e of 
the thninh is far greater than if it is allowed to remain perma- 
nently displaced. 

In either operation the wound may he closed at once or a horse- 
hair drain may be used. This should extend only as far as the 
capsule of the joint and should he removed in forty-eight hours if 
there is no suppuration of the wound. The thumh should he hand- 
aged in a slightly flexed position. If the joint suppurates it should 
be treated by drainage through the incision, and a wet dressing 
and a splint should be applied, as described on page JL'.". 

Overextension of Thumb. Overextension of the liist phalanx 
of the thumb, simulating a dislocation, is possible in many per- 
sons. It is due to an abnormal laxity of the anterior ligaments, 
either the persistence of an infantile condition or the result of 
traumatism in childhood (Fig. 163). 

Dislocation, of a Finger. Dislocation of the metacarpo- 
phalangeal joint of a ringer may occur, but this is not common, on 
account of the strong ligaments; consequently fracture of the head 
of the metacarpal is the usual result of injury in this locality. A 
differential diagno- 
sis between the two 
can usually be made 
by taking exact 
measurements and 
comparing them 
with those of the 
opposite hand. A 
pair of calipers is 
convenient for thi- 
purpose. A differ- 
ence may also be 
observed in the 
knuckle when the 

finders are Hexed. 1<ia ' 164 -~ I >(>s ":"""< DWXXUTIOM <>K THE TKRMIN u 

PHALANX OF THE FOHKI i\<;i it, AMI RADIOGRAPH or 
In this position the THE SAME. Patient ;i man :ip-<l twi-nty-tliree years. 




358 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

knuckle is wholly formed by the head of the metacarpal, and will 
not, therefore, be altered in a dislocation, whereas in fracture it 
will be less prominent. 

Dislocation of one phalanx of the finger upon another may be 
anteroposterior (Fig. 164) or lateral (Figs. 166 and 167). The 




FIG. 165. REDUCTION OF POSTERIOR DISLOCATION OF THE TERMINAL PHALANX OF 
THE FOREFINGER BY OPERATION. Photograph two weeks later. Same patient 
as shown in Fig. 164. 

cause is usually a blow upon the finger-tip or a fall upon the out- 
stretched hand. Sometimes the finger is caught between two mov- 
ing hard surfaces, which, in the lateral dislocation here illustrated, 
were the teeth of a horse. 

The diagnosis of these dislocations is readily made unless there 
is great swelling. The eye can detect the error in the bony aline- 
ment, which cannot be corrected, while the range of motion of the 
joint will be distinctly limited. 



DISLOCATION <>| A FINGEB 






If tin di.-located bone is allowed to remain in ii.- abnormal 
position the finger will not be entirely useless, but the range of 
motion of the affected joint will never be fully regained and the 
deformity will be permanent. Hence, treatment is indicated in 
most cases, even of an operative character, if reduction cannot 
otherwise be obtained. 

TI.-KATMKNT. Red uction of a partial d isloeal i<>n is simple. :uil 
is usually accomplished by a bystander or by the patient himself'. 
In some cases, however, torn ligaments intervene between the ends 
of the bones, making perfect reduction impossible. The reduction 
of a complete dislocation is 
more apt to be interfered 





FIG. 166. LATEKAL DISLOCATION 
OF LITTLE FINGER DUE TO THE 
BITE OF A HORSE. 



FlO. 167. K.\m<>t;uAPii "i I.AILKAI. I>i>n>- 
CATION OK I.ITTI.K KiMa.ic. Same patient 
as shown in Fig. 166. 



with by the interposition of the ligaments, and the various pulls 
and twists of sympathetic friends will in such cases merely in- 
crease the traumatism and its resulting swelling. 



3GO DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

As in all dislocations, the simplest measures should first be 
tried. Extension should first be made upon the distal portion at 
the same time that the dislocated bone is manipulated. If this 
fails, the axial deviation of the displaced distal bone should be 
exaggerated, and while traction is made upon it in this direction 
an attempt should be made to crowd its base past the head of the 
proximal bone. Unless this last effort is successful it is useless 
to swing the shaft of the bone into a correct line. If these efforts 
fail, continuous traction may be employed. A pound or two pound 
weight should be fastened to the finger by adhesive strips, and the 
hand allowed to hang vertically downward. If this method is not 
successful in fifteen or twenty minutes, it should be abandoned. 

If all these methods fail, it is necessary to expose the joint 
by two lateral incisions, to remove intervening ligaments and new 
formed cicatricial tissue if the dislocation is an old one, and to 
pry the bones back into place. When this has been accomplished 
the wounds should be closed, by suture with horsehair or fine 
black silk (Fig. 165). 

Whatever the treatment, when the dislocation has been reduced 
it is not likely to return. It is only necessary to apply an anterior 
splint of wood to the finger, or its motions may simply be confined 
by strips of adhesive plaster wound about the finger spirally or 
circularly. 

In any case in which a bone is used as a lever in manipula- 
tions the risk of fracture should be borne in mind. 

If a dislocation remains unreduced for some weeks, fibrous tis- 
sue forms about the ends of the bones, so that reduction will be 
impossible without operation. The X-ray may show no trace of 
this tissue, but may give the impression that reduction will be 
very easy, as was the case in the patient whose finger is shown in 
Figures 166 and 167. 

If the patient is a child, and the dislocation remains unre- 
duced, continued growth will alter the shape of the bones, and 
may even establish a new joint, as shown in Figure 160, 
page 349. 

Drop-finger. A blow upon the end of the finger may rup- 
ture the posterior part of the capsule of the distal joint. As this 
part of the capsule is the extensor tendon of the finger spread out 
flat, it is impossible in such circumstances to extend the distal pha- 



PINQBB ;;;! 

laux, which drops forward (Figs. K' s :ind Hi!i). Thi- deform- 
ity is known MS drop-finger or niidlct-Hnger or " !>a.-e-lwll-nnger." 
TsBATMENT. If seen Ml once MIK! kept coniinnon-|v in exten- 
sion for two or three weeks l>v M light Miiterior splint, union of the 




FlG. 1 (IS. I >i;ni'-l i\.,i i; c>:; M \ 1.1.1. i -1 IN. .i.u. On MOOUOt of niplurrut I IK- c\ tensor 
tendon which forms the posterior ligament of the terminal joint, extru>ion ia 
impossible. 

tendon to the bone will often take place. If the deformity is 
neglected for some days the same trentmeiit may be tried, but 
with less probability of success. If no union re>nlN nfter several 
weeks of treatment, an attempt should be made to sew the end 
of the tendon to the l>nse of the hist pliMhmx with fine silk. The 
incision should be a U-shaped one, the opening of the U directed 
upward, the base of the U crossing the finger alnmt midway be- 
tween the joint and the point where the skin is reflected to the 




FIG. 1C)',). TitAT'MATic DROP-FINGER OF TIIUEK MONTHS' IM i:\nns. I'jitu-nt aged 

sixty years. 

nail. Tn turning this flap upward care should IK- taken not to 
disturb the Ix-d of the nail. In such an operation the finest in- 
struments an- es-ential to BUGQ6B8. In other COSBfl the posterior 
part, of the base of the phalanx is pulled off with the insertion 



362 DISLOCATIONS AND FRACTURES OF THE ARM AND HANI) 



of the tendon (Figs. 170 and 171). The "drop" of the tip of 
the finger is then less marked, but even when the finger is forcibly 
extended there will still be some deformity. Treatment by an- 
terior splint will give a somewhat thickened finger with good 






FIG. 170. RADIOGRAPH OF TRAUMATIC DROP- 
FINGER, ANTERO-POSTERIORVIEW. A portion 
of the terminal phalanx has been torn off 
with the posterior ligament. 



FIG. 171. RADIOGRAPH OF TRAU- 
MATIC DROP - FINGER, LAT- 
ERAL VIEW. Same patient as 
Fig. 170. 



function. In order to avoid deformity the loosened fragment 
of phalanx should be removed through a transverse incision. The 
periosteum should be saved if possible. This or the termination 
of the tendon should be stitched to the periosteum of the third 
phalanx or kept in place by pressure. An anterior splint should 
be worn for two weeks, and the patient should avoid complete 
flexion of the distal phalanx for some weeks more. 

In some cases the terminal phalanx of the finger is overex- 
tended and bent directly backward. The term " baseball-finger " 
is applied by some writers to this condition exclusively. It is the 
result of force suddenly applied to the tip of the finger and in most 
instances the permanent deformity is due to fracture of the ter- 
minal phalanx, and not simply to rupture of the anterior ligament. 



I :: \TI i;i 8 i\ GENERAL 

FRACTURES 

Fractures in General. DIAGNOSIS.- The dia.iio-ii.- p,,int- 
of ;i fracture arc well known to be: 
1. Piiin and tcnderii> 
Swelling; 

3. Keel i vinos is ; 

4. I >efo rniit v ; 
f>. Shortening; 

(!. Results of examination with the X ray; 

7. False point of motion : 

8. Crepitn>: 

9. Altered percussion note: 

10. Loss of function ; 

11. Results of examination under general anesthesia. 
It is not to be expected that all signs of fracture will l>e pres- 
ent in any given case. Most of the signs may also lie due to an 
injury to the soft parts, or possibly to a bruise of the bone itself; 
but they have a relative value, and if certain of them exist to- 
gether, and the history of the injury is such as to presuppose a 
fracture, a sufficiently por-itive diagnosis can often be made, even 
though the pathognomonic signs of false mot ion and crepitus are 
not obtained and an X-ray examination is out of the question. 

Some further explanation of the relative value of these signs 
is desirable. 

1. Pain is one of the least valuable signs, because it varies so 
in different cases. Its absence is no proof that a fracture <i 
not exist. Tenderness, that is, pain produced by pressure or 
manipulation, is a far more valuable, sign. In almost all frc-h 
fractures pain is caused by pressure directly upon the line of 
fracture. If it is produced at the point of fracture by pressure 
made upon the injured Ixme at some other point, the sign has a 
greater significance. Take, for example, the ca-e of the ulna, a 
bone which is often bruised. Pressure on the bruised spot natu- 
rally causes pain, whereas pressure on the ends of the bone, made 
by crowding together the olecranon and hand, will cause no pain. 
In a case of fracture such pressure will probably caii-e pain if 
the solution of continuity is complete. The same difference exi-ts 
when attempts are made to U-nd a bone at the suspected point of 



364 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

fracture. In making these tests one must be careful not to -make 
direct pressure upon the contused area. 

2. Swelling of the soft parts is such a common sign after all 
injuries that its diagnostic value is not of great importance. If 
the swelling is out of proportion to the apparent damage to tlio 
soft parts, or if it persists longer than such apparent damage 
would warrant, it has some value in establishing diagnosis of frac- 
ture. If a deep swelling persists after the edema of the skin has 
disappeared, its diagnostic value is greater, as it is then probably 
due to displaced bone or to callus. 

3. Ecchymosis has also a relative value in establishing the 
diagnosis of fracture. If it occurs within a few hours its diag- 
nostic value is slight. If the area of ecchymosis extends for three 
or four days, the value of the sign as indicating fracture is far 
greater. This fact indicates positively that some deep blood-ves- 
sels have been ruptured, and in case of suspected fracture such 
blood-vessels are usually in the bone itself. It is unusual to have 
a fracture without ecchymosis. 

4. Deformity, if one can be certain that it is true bony de- 
formity, is a positive sign of fracture or dislocation. The value 
of thia sign rests, therefore, on the completeness of the examina- 
tion. If the patient is seen immediately after the accident, before 
the soft parts have had time to swell, even a slight bony deformity 
is readily made out. On the following day the deformity may be 
massed by the edema of the soft parts. In a week or more, after 
the swelling of the soft parts has more or less subsided, the bony 
deformity will again be more apparent, but from this time for- 
ward it will be more or less obscured by the callus. 

Deformity due to fracture may be either angular or due to 
overlapping of the broken ends. Angular deformity is usually 
easier to make out, especially if the fracture is in a shaft of a long 
bone. As such fractures are rarely impacted, the angle can gen- 
erally be increased or diminished by manipulation (sign IsTo. 7). 

The deformity due to overlapping, or to driving one fractured 
end into the other, is easily made out, provided there is no swell- 
ing of the soft parts and the bone lies near the surface. If the 
fracture of the shaft of the bone is transverse, or nearly so, over- 
lapping of the fractured ends will produce a marked deformity, 
and one that is easily recognized in spite of swelling. This often 



.s i\ <;KM;UAL 

happens ill fractures of tin- shaft of one of the pliahinp-s ;ml of 
the hunieni-. Most fractures are, however, oblique. This is par- 
ticularly true of fractures near the joints, and it is in ji 
ca>es that swelling is great and diagnosis is more ditiieiilt. 1 ). 
mination of the long axis of the portion of the hone \vhieh can be 
felt, and its projection, in the mind, beyond the site of fracture, 
will help the examiner to decide whether deformity exists, 

Marked deformity is, of course, produced by dislocation, but 
a dislocation can in most cases be differentiated with certainty 
from a fracture by the other symptoms which exist, and which are 
given in the description of the special fractures and dislocations. 

5. Shortening is also a positive sign of fracture, if one is sure 
of his measurements. Many bones have such definite prominence 
that accurate measurements can be made and compared with thox- 
of the uninjured side. In other cases it is better to extend the 
measurements beyond the particular bone in question until well 
marked prominences are reached. Thus, in cases of suspected 
fracture of the femur, it is customary to measure from the ante- 
rior superior spine of the ileum to the internal maleolus. 

In some cases -a previous injury or deformity of the affected or 
non-affected side will render comparative measurements worthless. 
If a false point of motion exists, measurements of the l>one 
may show a difference when traction is made upon the limb so as to 
overcome any shortening which exist-, and when the ends of tin- 
bone are crowded together so as to increase the shortening. This 
difference in many cases amounts to an inch or more. Measure- 
ments are of value not only as proving the exi-teiice ,,f fracture, 
but also to show that reduction has been effected. In all e 
comparative measurements should be made upon the sound side. 

6. Examination with the X-ray has added more to our knowl- 
edge of fracture- than all other methods combined. The technic 
of such examinations is fully explained in social books upm the 
subject, at least one of which should IH> in the hands of any one 
who takes up thi> method of examination. There are three gen- 
eral points which may well be borne in mind by every one who 
sends a patient to have an X-ray examination made. The first 
point is that a negative examination with the tliior,,^,-,,^' -lioiild, 
if possible, be confirmed by a radiograph, since fractures \\iih 
slight displacement may not be apparent to the eye. The second 



366 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

point is the necessity of making radiographs in both the antero- 
posterior and lateral planes, in order to show how much deformity 
exists in both directions. The third point is this, that many cases 
of supposed sprain will be shown in a good radiograph to be cases 
of fracture. 

7. A false point of motion is positive proof of fracture. Its 
absence does not prove the absence of fracture, since the fracture 
may be incomplete (green stick fracture), or it may be impacted, 
or it may be so situated that one cannot grasp both portions of 
the fractured bone in such a manner as to demonstrate their lack 
of continuity. This is the case in many fractures about a joint. 
Sometimes the false point of motion can be demonstrated by the 
abnormal motion which one of the bones making up the joint has 
upon the other, even though the shorter fragment is quite inacces- 
sible. This is seen after fracture of the so-called anatomical neck 
of the humerus and fracture of the neck of the femur. 

In testing for a false point of motion the bones should be 
grasped firmly above and below the suspected plane of fracture. 
Gentle manipulation should then be made, calculated (a) to bend 
the affected bone in an anteroposterior direction, (&) to bend it 
laterally, (c) to slide one broken end on the other in an antero- 
posterior direction, (d) to slide it laterally, (e) to rotate one end 
upon the other, and (/) to increase and diminish any existing 
overlapping by alternately pushing up and then making traction 
upon the bone in the direction of its long axis. These general 
tests may be varied to meet the requirements in any particular 
case. They are especially applicable to fractures in the shaft 
of a long bone. Emphasis is laid on the firm grasp combined 
with gentle manipulation, for in this way the best results are 
obtained. 

Sometimes, if a small portion of the bone has been broken off, 
its mobility may be demonstrated by making pressure first on one 
end or side of the fragment and then upon the opposite one. In 
this manner it may be tilted back and forth. 

If the fracture is near a joint the best result is sometimes 
obtained by grasping with one hand the main portion of the frac- 
tured bone, and with the other hand the bone or bones with which 
it articulates, thus allowing the small fractured portion to move 
with the bones beyond the joint. A good example of this is found 






FRACTURES IN GENERAL 
in fracture of one malleolus, especially when combined with l;i . 

lion (if the ligaments of the opposite side. 

S. Civpillis or ; rating del ween tin- broken SUffftOefl "I' a bollO 

is, of course, a po-iiive proof of fracture wlicii found. It should 
!> tcslcd for with licntleness, according to the direct ion- ui\cn in 
the preceding paragraphs, under the heading " Fal-e I'oim of 

Motion." Failure to ohtain crepitus when a fracture existfl may 
he due to impact ion of the fragments, or to lack of mobility, or 
to the interposition of soft ti--lies or clotted blood, which allow 
the hones to move on each other without ^ratiiii;-. 

A soft or false crepitus is often produced in a joint by an 
unnatural slipping of one bone upon the other. Thus, the shoul- 
der-joint in many persons habitually gives out a crepitus when 
manipulated, and any joint may do so following an injury. This 
source of possible error can usually be eliminated by a comparison 
with the corresponding joint of the other side. 

A hlood dot in the vicinity of a suspected fracture will some- 
times givn a soft crepitus when pressed upon. There is aU<- a 
possibility of iibrinous crepitus produced by the slipping of a ten- 
don through an acutely inflamed tendon sheath (see p. " I-'I). 

9. An altered percussion note was at one time heralded as a 
sure sign of fracture. A stethoscope is placed over one end of 
the bone Avhile the other end is tapped. If the Ixme is intact the 
sound is transmitted clearly; if the bone is broken the sound is 
muffled. The difference is noted by comparing the results ob- 
tained on the two sides of the body. This test has a limited appli- 
cation. It is obvious that there must be no swelling of the 
parts over the points where the stethoscope is placed and where 
the bone is tapped, as otherwise a different sound will IK> pro- 
duced. Practise has shown that, the sound is frequently uudi- 
minished, even though a fracture exists, presumably hecaii-e the 
fractured ends of the bone are in intimate contact with each other. 
If the ends are separated there is a distinct difference in the tone. 
For this reason some observers claim that this percUBsion-aUBCni- 
tation is a reliable sign of the exigence of >oft tissues In-tween 
the fractured ends of a bone, and that if the ends cannot l>e so 
approximated that a clear tone will be produced non-union may 
be expected. Further testimony is needed ujxm this subject In-fore 
accepting this statement as final. 



368 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

10. Loss of function is a valuable sign of fracture, though not 
an absolule one. The function of a bone is to remain rigid while 
allowing motion in its associated joints. In a sense, most of the 
symptoms mentioned above indicate a loss of function of the part, 
but the term " loss of function," as ordinarily employed, means 
that the normal use of' the portion of the body affected is impos- 
sible. For example, after fracture of the tibia the patient cannot 
bear his weight on the foot. After fracture of the humerus he 
cannot hold a ten pound weight at arm's length, etc. It is worthy 
of note that loss of function is usually only partial ; thus,- after 
fracture of the fibula alone, the patient can w r alk upon his hcd, 
but cannot bear his weight upon the ball of the foot. The special 
limitations of function which follow various fractures form an 
important part of the knowledge necessary for an accurate diag- 
nosis and treatment of the same. 

Loss of function frequently exists without a fracture. Pres- 
sure upon contused areas, tensions of damaged muscles and nerves, 
motion of inflamed joint surfaces, and so forth, may all cause 
pain, and thus interfere with the normal uses of the body. The 
exact limitations of function can often be better determined if 
the patient's attention is directed away from the injured part. 
The administration of an anesthetic, but not to full anesthesia, is 
frequently a valuable help in determining loss of function. 

11. General anesthesia is of great assistance in the diagnosis 
of fractures. The patient is thereby spared much pain, the sur- 
geon is put at his ease, the muscles are relaxed so that much less 
force is necessary in manipulation, and the existence of positive 
signs of fracture and the relation of the fractured ends to one 
another are made out with an accuracy which is quite impossible 
in most cases if no anesthetic is employed. Furthermore, anes- 
thesia is a great help toward the reduction of displacement, but it 
should be borne in mind that, with the return of consciousness, 
muscular contraction will again take place, and the fragments may 
again be drawn out of relation. 

TREATMENT. Successful treatment of any fracture accom- 
plishes three things: 

1. Reposition of the fragments; 

2. Immobility of the fragments; and 

3. Restoration of function. 



FRACTURES IN >,l.\l !<AL 

The patient should l>c ane.-lheliy.ed whenever for the pun 
of diagnosis or reposition of (he fragments the surgeon is obliged 
to use force or cause p;iin. A simp reposition, like ;i snap diag- 
nosis, may be correct, but is never justifiable. Before giving an 
anesthetic, and before reducing the fracture or bandaging the 
part, sensation and motion in the part of the limb beyond the 
break should always he tested. Otherwise a subsequently observed 
paralysis may be ascribed to the surgeon. 

1. The fragments are best replaced by manipulation while 
traction is exerted by an assistant. 

Impaction between the fragments should never be broken up 
if they are in correct line. It should always be broken up if the 
alinement of the fragments is so bad as to interfere with the 
proper use of the limb. Whether an impaction should be broken 
up when the alinement is bad, but the function is not seriously 
interfered with, depends upon the age and nutritive condition of 
the patient, the probability that a better alinement can be obtained, 
the possibility of non-union, etc. 

Measurements of the length of the injured bone as compared 
with those of the opposite side are valuable as showing the amount 
of shortening and also the success of reduction. Generally speak- 
ing, if the shortening is more than a half inch reduction is unsat- 
isfactory. The fragments have not been restored to their normal 
relations, or the muscles do not allow them to remain in proper 
relation. In the former case a better reduction should be brought 
about under an anesthetic. In the latter case extension should be 
employed. 

2. Immobility is secured by splints and extension. The best 
splints for most fractures are made of plaster of Paris bandages 
molded directly on the limb. "\Yhon dry they may be trimmed, 
if necessary, and covered with canton Hannel or some similar mate- 
rial (Figs. 174 and 175, p. 382). 

3. Restoration of function can be aided by massage, passive 
motion of neighboring joints, active motion, hot bathing, dry heat, 
and electricity. 

Massage may be employed with benefit on the day following a 
fracture, and every day afterward until there is complete restora- 
tion of function. For the first few days the limb should be rubbed 
lightly above and below the seat of fracture. Then one splint may 
26 



370 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

be removed to permit gentle stroking of the injured portion. After 
two weeks both splints may be removed and more force employed 
in the rubbing. The splints are of course reapplied immediately 
after the treatment. By this means the disappearance of the swell- 
ing is hastened, the formation of adhesions is kept at a minimum, 
and the surgeon is given an accurate knowledge of the positions 
of tile fragments at a time when a faulty position may be easily 
corrected. 

Passive motions of the neighboring joints should be made 
every two or three days, beginning at the expiration of -a week. 
The patient's sensation is the best guide to the extent of the 
motions, but no motions should be made which will disturb the 
fragments. 

The amount of active motion allowed will depend upon the 
nature of the fracture. In general, active motion at the nearest 
joints should not be attempted until the union is sufficiently firm 
to allow the surgeon to handle the injured portion of the limb 
readily without fear of displacement. Active motions of more 
distant joints may be allowed somewhat sooner than this. 

Hot water applications, hot packs, and baking in a hot air 
apparatus are powerful stimulants to circulation, and are service- 
able in restoring mobility to stiffened joints after the bony union 
is firm. The mobility thus gained must be kept up by massage 
and active and passive motions, or the stiffness will be likely to 
recur. 

Mechanical vibration is a form of massage which is of very 
great service in the later treatment of fractures. 

Electricity is employed with benefit to keep up the tone of 
muscles grown flabby by some weeks of disuse, and also in cases 
in which the nerves have been injured at the time of fracture or 
afterward, by manipulation or by pressure caused by splints or 
bony fragments or callus. 

Separation of the Epiphysis There are two special forms of 
fracture occurring in children, viz., separation of the epiphysis 
and green stick fracture. An epiphyseal separation is virtually 
a transverse fracture. Tn order to avoid deformity, and to favor 
the proper growth of the bone such a fracture should be reduced 
most exactly. An anesthetic is desirable in many cases. When 
such reduction is accomplished union takes place very quickly, 



I i;.\< 1 1 i;i.s en- mi; in MI.KI 8 :*71 

there is absolutely no deformity nor >hor!ening of tin- limb, ami 
the restoration of function is perfect. 

Green Stick Fracture A green stick fracture is one in which 
the bone is partly broken, partly bent, as when force is applied 
to a living sprout. It is not necessary in all cases to complete 
the fracture. The rule should l>e to correct the deformity so com- 
pletely that there is no tendency for it (<> recur when the force 
of the surgeon's fingers is removed. Once corrected the deformity 
does not tend to recur. 

Fractures of the Humerus. Fractures of the humerus are 
divided into those of the upper extremity, those of the shaft, and 
those of the lower extremity. Those of the upper extremity of 
the humerus are again divided into those of the anatomical and 
those of the surgical neck of the bone; while those of the lower 
extremity are often spoken of as fractures of the internal condyle, 
external condyle, T-shaped fractures, etc. The use of the X-ray 
in the diagnosis of fractures has shown that such classifications 
have only a general value, and that there is by no means a regular 
type of fracture of each of the kinds mentioned; but that, on the 
contrary, the plane of cleavage may run in almost any direction; 
it may be too irregular to be spoken of as a plane at all, and that 
often there is more than one break, so that the bone is separated 
more or less completely into three or more pieces. ITence the 
great importance of studying each case by itself. The use of 
the X-ray, both for diagnosis and as confirmatory of reduction of 
displaced fragments, is greatly to be advised, and should be in- 
sisted upon by the surgeon in all doubtful ca- 

In almost all cases the fracture is due to a fall. 

Fractures of the Upper End of the Humerus. Fracture of the 
upper end of the hunierii- is not a dith'cnlt dia^n---!- to make 
out, provided the tnherositic- ;nv Separated from the shaft of the 
hone. Then, if the arm is grasped at the elbou- and rotated by 
the surgeon the tuberosities do not rotate with it, and a certain 
diagnosis of fracture can be made, even though crepitus is not 
elicited. This fracture has been spoken of as fracture of the 
surgical neck of the humerus, as distinguished from fracture 
of the anatomical neck. In the latter case, the tnlM-rositi.-< being 
attached to the shaft, rotate with it. The diagnosis is then more 
difficult. Even if crepitus is attained, it may be simply the 



372 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

grating so often produced by rotation of the humerus, especially 
in people who have reached middle age and whose joints have 
suffered previous inflammation. If crepitus can be obtained by 
pushing the arm directly up and down, it is more significant of 
fracture than if it is produced simply by rotation. 

The other customary signs of fracture are well marked. 
Ecchymosis is greater if the fracture involves or passes below the 
tuberosities than it is if the fracture is through the anatomical 
neck. The effused blood, directed by gravity and fascial planes,, 
is often most prominent at the elbow. 

There is about one-half inch shortening, if the fracture is 
between the points measured. Crowding the elbow upward will 
sometimes increase the shortening, and will give pain at the frac- 
ture. 

False point of motion is often demonstrable, and if the frac- 
ture is below both tuberosities, there is often an inward angulation 
of the shaft. 

If the fracture is impacted, the tuberosities will rotate with 
the shaft, even though the line of fracture is below them. In 
such a case the diagnosis must be made from the shortening, ten- 
derness, loss of function, ecchymosis, angular deviation of the 
shaft, if such exists, and the direct palpation of the bone at 
the fracture. It will be noticeably thickened as compared with 
the opposite side. 

TREATMENT. In fracture of the anatomical neck of the 
humerus the arm should be supported and kept close to the scapula 
by plaster strapping or by a body bandage and a sling. After 
ten days or two weeks, gentle passive motions should be made to 
prevent the formation of firm adhesions in the joint. If the bone 
fails to unite, a painful or much impaired joint results, and an 
open operation is necessary, either to remove the head of the bone 
or to fasten it to the shaft by sutures or pegs. 

In fracture of the surgical neck the deformity may be cor- 
rected by the weight of the arm if the hand be kept in a sling; 
or additional extension may be obtained by a light weight, two to 
five pounds, hung at the elbow. A shoulder cap should be made 
from a plaster of Paris bandage applied in the form of a spir-a, 
including the shoulder and extending around the chest (N"o. 34, 
Chapter XXI). When dry, all of this bandage should be cut 



i i:\rii i;i:s OF Tin: in \n:i;i s 373 

auay except an external shoulder cap. Tins mid a short internal 
splint ..honld he bandaged in place by a soft haiidar. and the hand 
placed in a sling. Massage and passive motion .should he he-un 
in two weeks or less to prevent if possible the adhesions which 
often form in and ahont flu- joint. 

Fracture of the Shaft of the Humerus. Fracture of the shaft 
of the Innneriis is a common accident, and one which is ea-ily 
diagnosticated hv the false point of motion, which can always 
lie made out. The direction of the displacement will vary accord- 
ing to the site of the fracture above or below the attachment of 
the deltoid and the origin of the brachialis anticus. 

Essential treatment consists in the application of coaptation 
splints to the arm, with extension at the elbow to overcome short- 
ening, and support of the hand in a sling. As soon as the tendency 
to deformity or displacement of the broken ends is overcome the 
extension may be omitted, and passive motions be made at the 
elbow and shoulder. The hand should be carried in a sling until 
firm union results. 

While fracture of the shaft of the humerus is easily and suc- 
cessfully treated in most cases, it is of all fractures of the body 
the one most likely to result in non-union. As reasons for this 
may be mentioned the fact that the bone is a single one of small 
size, and the further fact that the fracture is usually transver-c. 
Thus muscular traction may cause overlapping. If non-union 
results the case should not. at once he given np as ho]>eless, nor an 
immediate operation be advised. There should first he tried abso- 
lute rest in a correct position as obtained by a plaster of Paris 
splint of the whole extremity and shoulder, applied under ether 
if necessary. If no stiffening of the break is evident after two 
or three weeks of this treatment, the ends of the fractured bone 
should be vigorously rubied together twice a week, the arm lx- 
inir kept at rest in the intervals. Sometimes it is ,,f advantage 
to omit all dressing, except the coaptation splints, and to allow 
the patient to use the hand and forearm. This improves the cir- 
culation of the limit, and if judiciously dfmed out, need not 
increase displacement of the fractured bone. These ami similar 
measures calculated to stimulate the ends of the bone, while pre- 
venting an undue amount of motion, may result in a cure, even 
though union he delayed for six months or more. Should these 



374 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

simpler measures fail, an incision should be made, any soft tissue 
which is found lying between the fractured ends of the bone 
should be removed, the ends of the bones should be freshened 
and shaped to each other as well as possible, and fixed firmly to- 
gether by a drill passed' obliquely through both, and left in posi- 
tion for two or three weeks, or by means of a suture, preferably 
of materials which will become absorbed in two weeks or more. 

Even though no bony union follow fracture of the humerus, the 
arm is far from useless. 

Another complication of fracture of the shaft is involvement 
of the musculospiral nerve, and paralysis of the extensor mus- 
cles of the hand and fingers. The nerve may be injured at the 
time the bone is broken, or it may be pressed upon later by a 
splint, or it may be involved in the forming callus. To avoid 
unpleasant accusations, the surgeon should always test the sensa- 
tion and circulation of a limb, a bone of which has been broken, 
both before and after the application of splints. If the func- 
tion of the musculospiral does not return with the help of bath- 
ing, massage, and electricity, the nerve should be exposed and 
freed. 

Fracture of the Lower End of the Humerus. Fracture of the 
lower end of the humerus is very common, especially in child- 
hood. The exact line of fracture may extend transversely across 
the bone, or may separate either condyle, with or without the 
articular portion ; or the injury may be a still more complex one. 
An exact diagnosis of injuries about the elbow-joint is often 
impossible. The use of the X-ray is of the greatest benefit under 
such circumstances, and the surgeon for his own protection, as 
well as for his own satisfaction and for the benefit of the patient, 
should insist that a radiograph be taken. The use of an anes- 
thetic is also of the greatest assistance in clearing up the diagno- 
sis, especially in determining how much the normal motions have 
been interfered with by the injury. Deformity may at the same 
time be overcome, and the limb placed in a plaster of Paris splint. 
Whatever the injury, the limb is usually best treated with the 
forearm flexed at a right angle and held in a position midway 
between pronation and supination. Either the plaster of Paris 
or starch bandage should include the hand, or a sling should 
support the hand, and save the patient from the pain caused by 



i i; M 1 1 i;i 8 <>! Tin, MI MI.I.-I a ;i7. r ) 

tlu- constant si retching of the r;ili:il ligaments of the wrist The 
arm should be inspected at least three times the first week and 
twice a week for a month or longer. Alter the first week pas- 
sive motions (rotation of the hand and arm, flexion and extension 
of the forearm) should be begun. These motions, combined with 
light massage, should be slight at first, and grow more extensive 
as the union of the fragments progresses. 

Deformity follow ing fracture of the lower end of the humenis 
is not uncommon, owing to the fact that the lower fragment has 
united at a vicious angle. Such deformity is most noticeable 
when the arm is fully extended, and the forearm and hand will 
then appear to be bent abnormally backward or to one side. If 
the deformity .is not too great, and especially if the motions of the 
elbow are free and painless, operative interference should be 
advised against. 

Another common after-effect is limitation of flexion and ex- 
tension. Flexion is usually affected to a greater extent than 
extension. If motion in the joint is prevented 1>\ swelling merely, 
this may be overcome by use of the arm and massage. But in 
other cases there is a mechanical obstruction t<> flexion or exten- 
sion, which will not yield to such simple measures. I'nder such 
circumstances an anesthetic (preferably nitrous oxid) should be 
given, since if the motion is limited by adhesions, these may be 
broken up. In many instances the limitation of motion is due 
to the formation of callus and new bone at or near the line of 
fracture; so that the function of the joint, instead of increa-in::. 
may grow less as the weeks go by. This bony irregularity is due 
to imperfect reduction. If recognized early by an X-ray examina- 
tion it may be corrected by manipulation. At a later date, if the 
limitation of motion is still considerable, sufficient say to ; 
vent the patient from putting the hand up to the head, and con- 
tinues in spite of a thorough course of treatment by massage, 
and active and passive motions, extern ling over several w<vk>, and 
if under an anesthetic the forearm cannot be flexed much Iteyond 
the point to which it can !>< flexed without the anesthetic, an 
operation is indicated. 1'. iUy the l>ony outgrowth may be 
chiseled away, so that an inciva-e ,,f flexion is jmssilile. If anky- 
losis seems inevitable, the surgeon mn-t choose In-tween fixing 
the elbow at the most favorable aiiiile, a little less than a right 



376 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

angle, or resecting the elbow-joint. The effect of this is to 
give a fibrous flail-like painless joint at the elbow, which enables 
the patient to do far more with the hand and arm than is pos- 
sible with a fixed joint, no matter at what angle. 

Fractures of the Ulna and Radius. Fracture of the Ole- 
cranon Process of the Ulna. Fracture of the olecranon is due to 




o 



tf 

II 



g 



S " 3 

Hi 

P3 (*. 4) 
I & 



falls upon the elbow. The diagnosis is easily made, since the 
olecranon is movable upon the ulna, often with crepitus. The 
fragments may be separated in flexion of the forearm, so that 
the injury is best treated by placing the extended arm on a splint 



I KA( I I RES "I I III. I I.XA AM) i; \1HI > 



for h-ii days nr two weeks, and then lie^iiiiiiii^ po->il,| t . motion 
to prevent adhesions in the elliow- joint. 

Fracture of Head of Radius Fracture of tin- head of the 

radius, or of its neck, is due to falls upon the hand i Ki--. 17:.' 





FIG. 173. SAME SUBJECT AS FIG. 172. Rftdiograpb giving lateral view of fractured 

radius. 

and IT-')). Tlie rarity oi' this fracture i- a matter for surprise. 
Donlilless it has often heen overlooked, ami the diann-'-i^ made 
of sprain of the elbow-joint or fracture of the external eoiidvle 
of the humerns. 

The symptoms of fracture of the head of the radius are the 
general ones of fracture everywhere. Tain is al-o produced by 
crowding upward the palm of the overextended hand; pr<>nation 
and siijiination are ;\\^> extremely painful, and may he imp. 
ble. This fact, together with the fact that the maximum -well 
ing and tendern.-- i- I. -low the plane of the elbow-joint, and the 
further fact that pressure upon the two eondyles does n.-t elicit 
pain, will serve ! differentiate an uncomplicated fracture of 
the head of the radius from fracture of the external omdyle. 
An X-ray examination is often necessary to e-tahlish the d 
iosis. 



378 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

TREATMENT. Deformity should be overcome if possible, and 
the forearm immobilized at an angle of ninety degrees, midway 
between pronation and supination, for two weeks. Then passive 
motions, both flexion and extension and rotation (very gentle), 
should be commenced and gradually increased, the arm being 
kept in a sling for at least two weeks longer. In some cases per- 
manent limitation of motion, especially of pronation and supina- 
tion, makes it necessary to remove some of the displaced bone. 

Fracture of the Shaft of the Ulna or Radius. Fractures of the 
ulna or radius, or of both of these bones occurring in the shaft, 
are usually made out without difficulty. The ulna lies so close 
to the skin that a break in it can be easily determined by direct 
palpation, while the attachment of the hand to the radius helps 
in the diagnosis of a fracture of this bone, in cases in which the 
ulna is not broken. The hand and lower fragment of the radius 
can be moved independently of the ulna to a short distance, and 
hence a false point of motion in the radius can be made out almost 
as easily as it can be in the humerus or femur. When both 
bones are broken the diagnosis is extremely simple in adults. In 
young children it sometimes happens that one or both bones are 
partially broken as the branch of a living tree breaks on one side 
and bends, hence the term "green stick" fracture (see p. 371). 

TREATMENT. If a green stick fracture exists, in order to get 
the bone to remain in a correct position, it is often necessary to 
overcorrect the deformity. In so doing, the remaining portion 
of bone may be broken through. This in itself is not a serious 
accident, and is preferable to allowing the deformity to remain 
only partially reduced. 

In other respects fractures in the middle of the forearm are 
easily treated. When the deformity has been overcome by manipu- 
lation, the hand should be placed midway between pronation and 
supination, and the bone should be kept quiet by means of light 
anterior and posterior splints, or a light plaster of Paris bandage. 
If the plaster is fresh and is applied before it has time to set there 
is no need for such a bandage to be more than an eighth or a 
twelfth of an inch in thickness. The heavy cumbrous bandages 
which are sometimes applied are by their very weight, not only 
uncomfortable, but injurious to the patient. 

The position of the hand has been a matter of considerable 



FRACTl i;i:s OK TIIK II.NA \\it i; AIHI > 579 

dispute. Sonic writers have said (hat the hand >h..nld I,.- t'ulJv 
supiuatcd in order to prevent the eallns from unitiii- || H . radiu- 
and ulna. They have stated that the bone-, were most widely 
separated in extreme supination. Others have denied this, claim- 
ing that the separation is greatest in a position between pronati>n 
and Stipulation. An examination of any cadaver, or of the fore- 
arm in life liy means of the X-ray, will show that the distance 
between the bones is almost the same whether the hand be held 
two-thirds supinated or be fully supiiiated. Since this is the case, 
the comfort of the patient demands that the hand be placed with 
the thumb directly upward, the elbow being flexed at a right angle. 
This is the natural j>osition of the forearm, and to hold the hand 
for a long time fully supinated when the forearm is flexed at a 
right angle is a tiresome procedure in health, and well-nigh impo-- 
sible if the arm is broken. 

In fracture of the radius there is a chance of the interposi- 
tion of muscle or fibrous tissue between the broken end-, while 
the numerous strong muscles cause overlapping if both bones are 
broken. The possibility of non-union should always be borne in 
mind if crepitus is not elicited when the fracture is fresh, or if 
there is still motion at the line of fracture in a month or six 
weeks. But the surgeon should not be too impatient nor turn 
too quickly to an open operation, the results of which are by no 
means invariably good. Moreover, it sometimes happens that 
union which has been delayed for six or eight weeks will never- 
theless take place sjxmtaueously under the more favorable condi- 
tions of massage, and an occasional rubbing together of the ends 
of the bone. 

If both radius and ulna are broken, and non-union iv-ult<, 
pronation and supination of the hand are impossible. If a single 
bone is broken, pronation and supination is at tirst impossible, but 
later is possible to a certain extent, even though only a fibrous 
union exist between the fractured ends. 

Pronation and supination are also limited by angular de- 
formity of one or both bones, and are absolutely prevented by a 
bony union of radius to ulna. A complete crossed union of radius 
and ulna, i.e., the union of the lower fragment of the ulna with 
the upper fragment of the radius, and rirr rrrxn, pn.bahly never 
occurs, but any bony fn<ion of these bones is equally destructive 



380 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

of the function of rotation of the hand, and is an absolute indica- 
tion for operation. To prevent such fusion, some authors advise 
the use of splints, the center of each of which is elevated in a 
ridge, intended to press between the radius and ulna, so as to 
keep the bones apart. This device is theoretical rather than prac- 
tical. 

Fracture of the Lower End of the Radius (C Giles's Fracture}. 
Fracture just above the wrist-joint, always involving the radius 
and sometimes the tip of the ulna, and known as Colles's fracture, 
after the surgeon who accurately described it, is one of the com- 
monest fractures which the surgeon is called upon to treat. The 
study of radiographs of this injury is most instructive. Such 
pictures show that the line of fracture may extend in almost any 
direction. The lower end of the radius may be broken into sev- 
eral pieces, or there may be a single break either involving the 
joint or extending across the bone in a more or less oblique direc- 
tion wholly above the joint. The radiographs also show that the 
lower end of the ulna is involved in about a third of the cases, 
a fact which is rarely made out clinically, and which has little 
bearing on the treatment. 

In Colles's fracture the lower end of the radius may be dis- 
placed in any direction. The common displacement is upward 
and backward. This, with the fact that the plane of the articular 
surface is often bent a little backward, causes what is known as a 
silver fork deformity, the hand assuming something of the curves 
of an ordinary table fork. The other signs of this fracture are 
a displacement upward of the styloid process of the radius when 
compared with the styloid process of the ulna, tenderness, ecchy- 
mosis, and possibly abnormal motion and crepitus. 

TREATMENT. Owing to the breadth of bone and its spongy 
character, and to the fact that the injury is received usu- 
ally by a fall upon the hand, the lower fragment of the radius 
is often impacted in the shaft. False motion and crepitus will 
then be absent, but an abnormal thickening and irregularity of 
the bone may mark the plane of fracture. If no deformity exists, 
there is no need of breaking up this impaction. The injury is 
much simplified thereby, and in two or three weeks the patient 
will begin to have free use of his hand. Such a fortunate condi- 
tion is rare. The impacted fragment is almost always set into 



i I;.\<TI i;i:s OK TIII-; U.MHUS :M 

the shaft at a false anule, hence (he neces.-iiy for breaking up the 
impaction and restoring the normal relation of the parts. Thi- 
can best be done under the influence of a general anesthetic, 
nitrous oxid being well suited to the purpose. It is extremely 
important that any existing deformity should be thoroughly re- 
duced. I nder no circumstances should the surgeon trust to \ 
sure obtained by splints to reduce the deformity. Tin- strength 
of the structures forming the wrist-joint and the nearness <>f the 
plane of fracture to the joint itself make it almost imjtossiMe 
to overcome deformity by pressure, and a firm pressure easily 
causes necrosis of the skin overlying the back of the wri>t. If 
impactioii has been broken up and the deformity has been thor- 
oughly reduced, there will be little tendency to recurrence except 
through muscular contractions. To avoid this the hand should 
be kept at rest by anterior and posterior plaster splints extend- 
ing at least to the metacarpophalangeal joints. In difficult 
these should be applied while the patient is thoroughly am- 
thetized and muscular contraction eliminated. 

If there is any doubt as to the diagnosis and perfect reduc- 
tion cannot be obtained and kept up, a good X-ray picture of tin- 
injury in the anteroposterior and lateral planes should be insisted 
upon. If the patient refuses this aid to diagnosis and treatment. 
there will be little ground upon which to rest a suit for malprac- 
tice in case the function of the hand is not fully restore* 1. 

A great many different forms of splints have been advocated 
for this injury. Good results have been obtained with all of 
them, and indeed in many cases with no splint whatever, the hand 
being merely carried in a slin^ with a broad strap of rubln-r plas- 
ter about the wrist to support the broken bone. Others have 
advocated carrying the forearm <>r hand in a slin<;-, the ed^e of 
which reaches only to the line of fracture, and thus |H-rmits grav- 
ity to prevent the recurrence of the deformity. Such an, appa- 
ratus is needlessly simple and places too great responsibility up-:i 
even an intelligent patient. The advantages claimed for it are 
the avoidance of stiffness in the wrist joint and a hastening <.f 
the time of repair by means of ma<-a^e and pa<-i\v motion. The-e 
advantages are very ^real. especially in per-oiis past middle ae. 
but they can be readilv obtained by the frequent removal of well 
fitting anterior and posterior splints, while the splint* JIP-- 



382 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

the patient against possible accident and are far more comfortable 
than the sling alone. They are made as follows : 

A two or three inch crinoline gypsum bandage should be wet 
and drawn back and forth on a board or marble slab for a dis- 
tance of fifteen inches- until twelve or fifteen thicknesses are 
made to overlie each other. .They are thoroughly rubbed together. 
A second - bandage is used to make a 'second strap, splint. The 
fracture is reduced, and -the Jiahd of the patient put in whatever 
position of flexion, extension, abduction, or adduction best keeps 
the reduced radial fragment in correct position. The .skin is 
anointed, "and the moist plaster strap splints are then applied and 
approximated' with a gauze bandage (Figs. 174 and 175). The 
hand and forearm^ are held for ten or fifteen minutes: till the 
plaster has partially set. In this manner two: light rigid splints are 
obtained which are accurately molded '.to the .part, and which can 
be applied and removed at pleasure, and which fit far better than 
any wooden or metal splints can" possibly do. In three days the 
splints should be removed for light massage, and reapplied. This 
treatment should be repeated every two or three days until three 
weeks have passed. After the first week gentle passive motion 




FIG. 174. MOLDED GYPSUM SPLINTS FOR FRACTURE OF THE LOWER END OF THE 
RADIUS. Photographed after removal from the limb. 

may be made at the wrist, and the fingers flexed and extended 
by passive motions several times. If the deformity caused by the 
fracture has been fully reduced at the start, an arm treated in 
the manner described will be pretty nearly well in three weeks. 
There will be no pain and very little tenderness and swelling of 



FRACTURES OF THE RADIUS 



the wrist, and llic patient may !.< allowed I.. go without a splint 
and to begin active motions of his hand while rout inning daily 
balhing and massage, and resting the forearm and hand in a sling 
when he is not using it. Cases which ".ive trouble are tho-e in 




FIG. 175. SAME SPLINTS AIMM.IKD. This position of the hand is desirable in many 
cases, to prevent n-curreiKM; of deformity. 

which the deformity is not thoroughly reduced soon after the 
accident. 

Cases of Old Colles's Fracture The surgeon is often called 
upon to treat cases of Collos's fracture in which the injury oc- 
curred some weeks or possibly months previous. 1'uder such cir- 
cumstances the first, question to IK- answered is ihc desirability 
of an attempt at reduction of any existing deformity. The 
patient will complain either of pain or of limitation of motion 
or of deformity, -possibly all three. It is hard to say in ju-t how 
long a time the union In-tween the fragments will become >o firm 
that it will not be possible to separate them without a cutting 
o I )eration. This will depend to a considerable decree upon the 
amount of impaction produced by the injury. In doubtful c 
it is better to give the patient an anesihetic and to make an attempt 
to reduce existing deformity, even if it does not succee.l. It i- 
a satisfaction to the patient to know that a fair attempt has IKVII 
made to reduce the deformity without, an operation, and, more- 
over, while under an anesthetic, adhesions Ix-tween the various 
bones of the wrist may 1x3 broken up, and thus a greater amount, 
of movement be obtained. In considering the question of an pn 
operation, the accessibility of the radius ami the probability "f 



384 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

a reduction of the deformity are the favoring conditions, while 
the scar and the risks incident to operations upon bones, espe- 




FIG. 170. OLD FRACTURE OF RADIUS (COLLES'S) WITH MARKED DEFORMIT.Y, BUT 

GOOD USE OF HAND. 

cially in the vicinity of a joint, are to be considered as against 
operation. 

The extreme deformity of an old unreduced fracture of the 
radius is shown in Figure 1YC. Yet this patient had good use 
of the hand. 

Fracture of the Carpus. Fracture of one or more carpal 
bones is not a very common accident. It has to be differentiated 
from sprain. In a recent state this diagnosis cannot usually be 
made without the help of the X-ray. Later the marked limitation 
of motion, pain, and abnormal thickness of some portion of the 
wrist may suggest the true diagnosis. The os magnum and semi- 
lunar bones are most often broken. 

The treatment is the same as that of a severe sprain. If a 
portion of a bone is so displaced as to interfere with motion, it 
should be removed. 

Fracture of a Metacarpal. Fracture of one or more of 
the metacarpals is a very common injury. It results almost always 
from blows with the fist, the force coming against the knuckle 
that is, against the head of the metacarpal. The line of fracture 



! ,\ 



. 



is usually just above the head of tin- lion.-, although it ma\ !* 
higher up. There is almost invjirial.lv an anterior displacement 
of the distal fragment, thus causing a <lepn i,,n ,,f the knuckle 
at the back of the" hand. This looks at first "lance like a <1M. 
cation of the phalanx until one considers that the knuckles are 
formed entirely by the metacarpals, if the fingers are ll.-xe.l. 

If the injury has been recently received the. diagno-i~ i- 
ehai-aeteristic signs of pain, false point of motion, and crepitu- 
being present 

The deformity is best reduced in most cases by flexing all 
the fingers over a ball of yarn or a gauze bandage placed in the 
hollow of the palm (Fig. 177). The fingers should be strapped 
or bandaged in this position, and the dressing should be removed 
and massage two or three times a W(vk. 1'niou take- 





FIG. 177. KRAI- 1 1 i. OOMD UH.MI MII.M \KP\I.. IMormily c-urrwUtl l.y 

flexing the hand over a bandage lu-hl in tin- palm, with :nlln-.-ivf plaster strap- 
ping. 

place in these small bones very rapidly, and in yonnir ^'il 
two weeks is generally sufficient to produce a callus stmnir enough 
to prevent displacement. The bandage may then !* omitted, and 
the patient simply cautioned again-t B0VBN n-e of the hand for 

two or three weeks more. 

Fracture of a Phalanx. In fracture of the tir-t phalanx 
it is* sometimes ditlieult to prevent recurreiie* ..]' th<- deformity, 
27 



386 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

owing to the constant pull of the anterior and posterior tendons, 
and the further fact that the web between the fingers prevents the 
application of a circular bandage. This, of course, does not apply 
to the thumb. It is the fifth finger in which the first phalanx is 
most often broken, on account of its small size and exposed position. 
It should be treated on a splint, preferably of tin, curved to fit 
three sides of the finger and hand. (Cf. Fig. 211, p. 426.) The 
deformity may be overcome by allowing the splint to extend be- 
yond the end of the finger, and by making extension by means 
of longitudinal strips of plaster fastened to the finger and reach- 
ing out beyond it to- the end of the splint. Counterextension to 
hold the splint in place is obtained by similar adhesive straps 
about the wrist.. 

Fracture of the second or third phalanx is easily treated. The 
pull upon the distal fragment is slight, and the deformity may be 
kept down by winding rubber plaster around the finger while 
extension is being made by an assistant. 

COMPOUND FRACTURES 

Compound fractures of the upper extremity should be treated 
from the very first aseptically, if possible. If the materials for 
a thorough cleansing of the wound are not at hand, a compress 
and bandage should be applied and one or two splints to keep 
the parts quiet until preparations can be made for a proper surgi- 
cal dressing. When the wound has been cleansed and drained 
and the deformity reduced, the treatment of the fracture does not 
differ materially from that of a simple fracture, provided that 
no suppuration ensues. The splints should be so arranged that 
they may be easily removed to permit dressing of the wound, or 
a window may be cut for this purpose. If the wound heals- asep- 
tically, a longer time is required for bony union than is the case 
with simple fractures. Hence massage and passive motion cannot 
be begun usually until the third week. 

Suppuration occurring in a compound fracture will show itself 
locally by increased edema and tenderness near the wound and 
a discharge of pus; or if the discharge is interfered with, by 
extension of the pain up the arm, swelling and tenderness of the 
regional lymph-glands above the elbow or in the axilla, and by the 
general symptoms of fever, headache, and malaise. These gen- 



CR1 SI 1 1. 1) MM,, 



eral symptoms ;iiv iiahirallv mmv notin-ahlc in cases of 
fracture of the larger bones, l>nt they also exist in fracture of 
the hand and fingers with infection. Tin- local signs are u-ualK 
sufficient to show the sureon whether repair i> progressing favor- 
ably, but it is well to note the "em-mi symptoms ev-n in these 
minor forms of fracture. 

Crushed Fingers. The typical case of coinjxHiud fractun- 
in which ambulant treatment is demanded is a crush or nit of one 
or more fingers (Fig. ITS). The treatment to be follow,-,! in such 




FIG. 178. COMPOUND FRACTURE OK THE SECOND PHALANX or 

A simple caae. 

a ease is: Cleansing of the skin with soap and hot water, tur|*-n 
tine, and either alcohol or ether; clean-iiii; of the wound with sa- 
line irrigation and sponging; control of hnuorrhai:e by pn tn 
ligature; inspection of the wound; removal of any fop-inn -nb- 
stance and of detached bits of bone; adjustment of the fnu-tun-d 
bone, and suture with chromic gut if the fragments cannot ! 
in place by splints. Whether the wound is sutured or drained vill 
depend upon circumstances. The circulation of the hand is so good 
that compound fractures often heal without suppuration; but ft* 



388 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 



rubber tissue drains do not cause pain or irritate, their use is to be 
recommended in this class of wounds. They should be removed 
in two days, and not reinserted if there are no signs of infection. 
The skin sutures should -be of fine plain catgut or of very fine silk. 
They should not be placed too close together, since there is con- 
siderable oozing of blood and serum for a day or two. The hand 
and fingers should be dressed with dry sterile gauze or with gauze 
moistened with some mild antiseptic, such as borolyptol, 1 : 10, 
or creolin, 1 : 200, and placed on a palmar splint. Individual 
splints to the fingers are not usually needed. A moist dressing 
favors the escape of secretions from the wound and adds greatly 
to the comfort of the patient. It should not be covered by oil-silk 
or anything which prevents evaporation, but should be wet sev- 
eral times a day with 
si ( 'rile water. Never 
use carbolic acid for 
a continuous wet 
dressing. 

If the fingers are 
badly crushed or torn, 
nice judgment is often 
needed to get the very 
best result for the pa- 
tient. The temptation 
is great to amputate 
and sfritch up the 
wounds completely. 
The neatness of a 
stump covered by well 
shaped flaps appeals to 
the surgeon, but not to 
the patient, whose at- 
tention is wholly fixed 
on the lost member. 
The extra time re- 
quired for complete 
cure is not considered 

by most patients, if a longer finger is thereby secured. It is 
true that some laborers find a stiff finger, either flexed or ex- 




FIG. 179. INJURIES TO FINGERS FROM CONTACT 
WITH A BUZZ-SAW. Compound fracture, com- 
pound dislocations, and traumatic amputation. 



AMPUTATION OF A FINGER 



880 



tended, so much in the way that they ask to have it removed. 
The finger in such cases is generally tin- middle or ring finger, 
in which there is ankylosis of the first phalan^eal joint and loss 
of the long flexor tendon. No one e\er asks to have his thumh 
shortened for ankylosis. r rhe fact, therefore, that a Qflelefli linger 
is sometimes voluntarily sacritieed has a very limited application 
to the treatment of trauniatisms of the lingers. 

It is far hetter to pursue a conservative course, and never to 
sacrifice a flap of skin, no matter h"\v -lender it- attachments, 
which can be used to cover a bone, and never to remove a phalanx 
which can be covered or nearly covered hy normal skin. If only 
the base of a phalanx is left, it is better to remove it in order to 
avoid tenderness in the stump. 

There are many recorded instances of the reattachment of a 
finger or part of a finger which was almost severed from the hand 
hv a traumatism. Such a ease is shown in Figure IT'.i. A buzz- 
saw wounded the sec- 
ond digit, disjointed 
the terminal phalanx 
of the third, dividing 
most of the soft parts, 
amputated the fourth, 
and disjointed the ter 
minal phalanx of the 
fifth, while the soft 
parts of this finger 
were stripped from the 
middle phalanx and di- 
vided by spiral cuts 
which almost encircled 
the finger. Measured 
at right angles to the 
cuts, the undivided 
pedicle was about one- 
third of an inch wide. 
The wounds were 

Stitched loosely and the FI,;. ISO. -AMITTATK-N THKor<;n nu MII\.\H 

li-mil l-pnt lino' milint POFHAUUwmAJ .I..IVT. Tin- i.h,.i,. K r:i,.li tak.-u 

hand kept upoi ^^ ^.^ J;ii(>r _ shows |h| . | . nilsllll . llt wl ,| e gap 

and dressed daily with between the rtatainiog fingers. 







390 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 




FIG. 181. AMPUTATION OF THE 
FOURTH RIGHT DIGIT WITH THE 
HEAD OF THE METACARPAL BONE. 



to cover the end of the bone, 
a racket shaped flap, prefer- 
ably from the palmar sur- 
face, is best. But, whatever 
the end of the stump at first, 
it invariably becomes smooth 
and rounded from constant 
use. The chief point, there- 
fore, is to have the flaps long 
enough so that the skin may 
move easily over the bone. 
Tendons and nerves should 
be cut off short. Horsehair 
is an excellent suture mate- 
rial for the skin. A few 



moist gauze. The pho- 
tograph was made the 
day after injury. Af- 
ter four weeks' con- 
servative treatment, 
the only loss was the 
terminal phalanx of 
the third digit and a 
small portion of the 
skin of the fifth. 

AMPUTATION OF A 
FINGER 

In amputating a 
finger, if there is plen- 
ty of skin with which 




FIG. 182. SAME SUBJECT AS FIG. 181, Pos- 
TEHIOR VIEW. 



\Mirr\Ti<\ 01 \ i [N< 






hairs (wined 
;iiid then doubled and 
allowed to twist on 
themselves, make an 
excellent drain. This 
should lie passed from 
side to side of the fin- 
ger, between til,; skill 

flaps and the end of 
the bone, to permit tin- 
escape of serum and 
blood. If suppuration 
is feared, a wet dress- 
ing is preferable. A 
small amount of sup- 
puration can usually 
be overcome by irriira- 



184. POSTERIOR VIEW or SAME SUBJECT 
Tia. 183. 



183. Am > 
Two CENTRAL FINOKRS 

WITH THEIR Mr.TACAR- 

i- A i s . 'lli<- photograph 
taken many yeans later 
shows tin- nppriixiiiiHliun 
of flu- ri'iiiaiiiinjr fingpnt. 
as well a-s tin- gr-:t <!<>- 
\clopnictit of tin- littlo 
finger. 

tion tliroiiiili the drain 
opruiiigs with j-r..\id 
of livdrom-n and I 

without rntirr 
separation ,,f the \\n\. 

I f ampiitati.-n i 
bo performed as lii^'h 
up as flu- metaMrj*- 
pliahiugDnl joint, tin- 
n must decide 
whether or iiot he will 
remove somo portion 



392 DISLOCATIONS AND FRACTURES OF THE ARM AND HAND 

of the metacarpal bone. The strongest hand is gained by leaving 
it intact; so, if appearance is not to be considered, the decision 
should be to leave the whole metacarpal (Fig. 180). 

The deformity caused by the loss of the finger is, however, 
less conspicuous if the head of the metacarpal is removed (Figs. 
181 and 182). While this is true for a single metacarpal in the 
center of the hand, it is an open question whether the heads of 
the third and fourth inetacarpals should be removed for esthetic 
considerations, since a depression thus caused would be very con- 
spicuous, as, indeed, is the deformity no matter what the treatment. 

Another plan is the removal with the phalanx of the greater 
portion of the metacarpal, or even the whole bone. This is prob- 
ably the best method to pursue if the fifth, or fourth and fifth, 
fingers are lost, since in this manner the ulnar side of the hand 
can be made more smooth. The result of the application of this 
principle to the loss of the two central fingers is shown in Figures 
183 and 184, taken many years after the operation. This was 
the hand of a hard working woman, as may be inferred from the 
strong development of the little finger. 



CHAPTER XV 
INFLAMMATIONS OF THE ARM AND HAND 

EFFECTS OF HEAT AND COLD 

Burns. The li;m<ls and anus arc e-j.ecially e.\|M.>ed t., burns 
by steam, boiling water, llame, electricity, and ilie rmjl "t" the 
sun. The treatment is such as indicated .n p If the 

burned surface overlies a joint it is desirable t<> keep the limb in 
such a position that the motion of such joint shall not !* inter- 
fered with by contraction of the resulting .-car. Hence a single 
splint is often of great value in the treatment f burn-, e-p-cially 
in children. If the burn be a deep one, and situated over a joint, 
skin i:ra ft s should be applied in order to hasten the healing and 
prevent contraction of the scar. The grafts should l*> large and 
should comprise a considerable part of the thickness of the skin. 
They should not "be applied until granulation is \vell established. 
For the teehnie sec Chapter XX. 

Mangle Injury.- An injury ptvidiar to cities is pro.: 
by a laundry machine called a steam mangle, which has two large 
steam heated rollers through which clothing is passed in order to 
dry and smooth it. H the girl who feeds the machine has the 
misfortune to press her fingers lietween the rollers, the hand will 
IK- drawn forward and crushed and burned at the same time, 
a result of this accident the lingers or the hand, or even the hand 
and a part of the forearm, will IK- ironed out Hat and at the same 
time severely burned. The disfiguration is, of course, vet 
but the rule holds good, none the less, to >acriticc no |*.rtion of 
the hand or finger in which the vitality is not absolutely de>tro\ed. 
Skin-grafts may be used to take the phuv of skin which has been 
burned or torn away. Unfortunately, function is destroyed by 
this accident to a considerably greater distance than vitality, ao 
that, even though the fingers or a considerable part of them be 

393 



394 INFLAMMATIONS OF THE ARM AND HAND 

preserved, the hand may be stiff and nearly useless. But even 
such a deformed hand is far better than an artificial substitute. 

Frost-bite. Exposure of the hands to cold not severe enough 
to actually freeze the tissues may produce a condition marked by 
congestion and edema and analogous to chilblains of the feet. 
There will be symptoms of numbness, alternating with burning 
pain. Those who are exposed to cold should protect their hands 
by heavy leathern mittens, and should stimulate the circulation in 
the fingers by dipping the hands alternately into hot and cold 
water. Similar treatment should be employed daily in the case of 
hands already chilled, and following this the skin should be well 
rubbed with a mildly stimulating ointment, such as ichthyol. 

In the usual frost-bite of the fingers the action of the cold has 
been sufficient to shut off all circulation until some of the tissues 
have died. When the hands are thawed out slowly, by rubbing 
with snow or rubbing in cold water, it will be seen that no blood 
circulates in parts of the fingers. Such parts remain cold and 
dark when the rest of the hand becomes warm. The color passes, 
in a day or so, from a dark red to reddish black or greenish black, 
and it is evident that dry gangrene exists; or, if there is plenty 
of moisture, blisters may form under the skin. 

TREATMENT. In no part of the body is it more important to 
preserve as much of the tissue as possible. Hence, from the be- 
ginning, treatment should be directed toward that end. After the 
hands have been slowly brought to a normal temperature they 
should be kept warm and dry by wrapping them in cotton, so as 
to favor the efforts of the circulation to keep up the vitality. This 
is perhaps best accomplished by an ointment spread upon gauze, 
or applied directly to the finger and covered with gauze, outside 
of which a thick layer of non-absorbent cotton should be placed 
and bandaged without much pressure. Such an ointment often 
contains tannic acid or other astringent for the purpose of keep- 
ing down the edema in the tissue which has been injured but not 
destroyed. 

Immediate amputation is strictly contraindicated. It often 
happens that the apparent gangrene is merely superficial and that 
a finger may live and remain useful an inch or more beyond the 
line of demarcation of the skin. Even if such a happy result does 
not follow delay, nothing is lost by conservative treatment, and 



GANGRENE FROM CARBOLIC ACID AND OTHER ' UJBBB . 



flic patient i.< more easily reconciled i,, tlu- removal of a 
of a finger after he Sees licit all attempts tn p reserve it have failed. 
Compare what is said upon this in the following paragraphs on 
carbolic gangrene. 

Gangrene from Carbolic Acid and Other External 
Causes. Gangrene of the finger is still frequently caused by 
the injudicious use of carbolic acid, in spite of all that has been 
written on this subject. Sometimes the responsibility for this 
rests with the patient, sometimes he acts at the suggestion of a 
friend, sometimes a druggist is at fault, and sometimes, sad to 
tell, a doctor applies the deadly lotion. 

If carbolic acid is spilled upon the skin accidentally, \\< <-aiH- 
tic action may be prevented by promptly bathinir the part with 




FIG. 185. PARTIAL GANGRENE OF FINGER DUE TO ('AKIH.I.H \< u>. There was low 
of the true skin over a part of the circumference of tin- finger only. No opera- 
tion was performed. Recovery with perfect function of joint* and tendons, but 
with a permanent scar. Notice the swelling of the living tissue adjoining the 
gangrene. 

alcohol; but in most of the cases in which gangrene is produced 
a solution of the acid is employed, and the destruction of the -kin, 
taking place slowly and often painlessly, i- not ivcogni/.ed until 
hours have elapsed. It is then too late for relief to IK- obtained by 
bathing with alcohol. 

Gangrene has frequently been produced by the application of 
a five per cent solution of carbolic acid in water, and in some in- 
stances by the use of a watery solution of only one ]>cr cent. Ex- 
periments show that a similar gangrene may follow the application 



396 



INFLAMMATIONS OF THE ARM AND HAND 



of five per cent solutions of caustic potash, acetic acid,, or mineral 
acids. 

Carbolic gangrene is dry and usually painless. The affected 
part is at first dark gray or brown, and as the tissues dry and 

shrivel they grow 
darker, so that they 
become almost black 
(Fig. 185 and. Fig. 
186). In a few days 
a line of demarcation 
is established between 
the dead and living 
parts, and there is 
some swelling of the 
latter, due to absorp- 
tion of septic mate- 
rial along the Hue of 
separation. Tu a few 
cases this absorption 
may lead to a well 
marked cellulitis 
with the formation 
of pus pockets (Fig. 
187). 

The termination 
of the gangrene varies 
according to its ex- 
tent. Thus there may 
be loss of the super- 
ficial skin only, with- 
out permanent scars, 
or a part of the cori- 
um may be destroyed, or the deeper tissues, including the 
bones. The line of demarcation becomes established, granula- 
tions spring from the proximal side of the line, and attempt 
to close the wound. The bones and tendons will resist disinte- 
gration longer than the other tissues, but they, too, must yield 
in time, so that in favorable cases a spontaneous cure may 
take place. 




FIG. 186. CARBOLIC GANGRENE OF DISTAL HALF 
OF FINGER, PHOTOGRAPHED ONE WEEK AFTER 
THE APPLICATION. When first seen the gan- 
grene extended beyond the web of the finger. 
It was superficial over the proximal phalanx, and 
the sloughing of the gangrenous epidermis ex- 
posed the living skin beneath, as can be seen in 
the photograph. Two weeks' delay in perform- 
ing the amputation enabled the surgeon to save 
the proximal phalanx, and to cover it with good 



GANGRENE KUo.M CAKI'.OLIC \CI1) AM) nTHI.Ii < 397 



TREATMENT. The treatment of carbolic gai - at first 

conservative. As in frost-bite, and other forms of gangrene from 
c.i-lcrnal cause, the parts should be kept warm and dry, and ampu- 
tation should be postponed until the line of demarcation through 
the true skin is established. Not until then is the surgeon able 
to decide positively how much of the finger can be preserved with 
benefit This delay of ten days or two weeks also increases tin' 
vitality in the partially damaged skin, so that it can IK; used 




\ 




FIG. 187. CAHH. .i.ic (;AN<;IU:M. Of mi: TIU:MB, COMIM.ICAI KM \MIII 

OF TIM. TIU.MH AND HAND. Sero-pus escaped through the incisions made to 
relieve tension. 

cessfully for a flap after two weeks, when the same flap would 
certainly not have been viable if amputation had been performed 
as soon as the gangrene was noticed. 

Sometimes the gangrene is complicated with ccllulitis. 



398 



account, while waiting for a distinct line of demarcation, the 
surgeon should inspect the affected finger daily. If tension due 

to swelling interferes 
with the circulation, 
or if abscesses form, 
incisions should be 
made, so that the gan- 
grene may not extend 
(Fig. 188). 

For the treatment 
of cellulitis see page 
402. 

Cellulitis in the 
hand does not often 
lead to gangrene, even 
when it develops in 
diabetics or individ- 
uals otherwise enfee- 
bled. Yet it may do 
so. Hence, the neces- 
sity for free incisions 
whenever swelling 
within the restricting 
skin of the finger 
threatens to cut off 
the circulation from 
the damaged part. Figure 192, on page 403, shows a finger 
which was lost by neglect of this precaution. Such gangrene 
is moist. 

Whenever a cellulitis which is well drained does not progress 
satisfactorily, and gangrene is threatened, the urine should be 
examined for sugar and albumin. If either is present the 
treatment should be prompt and radical, as delay in amputating 
a finger under such circumstances may lead to loss of an arm 
later, or possibly of a life. Gangrene due to diabetes or nephri- 
tis is far more common in the foot than in the hand. (See 
Chapter XVIII.) 




FIG. 188. SAME SUBJECT AS FIG. 187. Recovery 
with no loss of bone, but the skin was so tightly 
stretched over the distal phalanx that its tip 
was later resected. 



ANAToMK \|. '1 | |'.|.l;i II 



INFLAMMATIONS 

Infection in Wounds. Although tin- hand is exj>osed to 
frequent injuries, large and small, repair u-ually take- place with- 
out inflammation sufficiently marked to demand -iir^i.-al treatment. 
Such inflammation as does occur usually follows a punctured 
wound, or a wound into a preformed -pace, such as a joint or 
bursa or synovial sheath. Tin- very fact that the wound is small 
favors the early closure of its mouth, and thru, as tin- intrude. 
germs multiply in it, they find it easier to jM-uetrate tin- d. < 
tissues than to escape to the surface. 

The form and extent of the inflammation are determined by tin- 
nature of the wound, by the nature <>f the introduced germs, l.y 
the health of the individual, etc. We shall consider here only 
the forms which occur with frequency in the up]>er extremity. 
There are clinically. seven such forms, the It-ion- in four U-imr 
chiefly local, that is in the immediate vicinity of the wound ; while 
iu three they are chiefly regional, developing at a distance from tin- 
wound in structures which are ;i i with the wounded part 

by means of the lymphatics. 

These four types of local inflammation are anatomical tub. 
acute dermatitis, eellulitis, and abscess; and the regional f- 
lymphangitis, lymphadenitis, and secondary a: nns 

of inflammation are variously combined, but one or the other 
type usually predominates in any ^ivi-n CMa li i- not safe 
infer from the form taken by the inllammatiou that it is dii. 
a certain germ, for, according to Welch, "all of the affection- 
caused by one species of the pyogenic cocci may be caused by any 
of the others." 

Anatomical Tubercle. This is an old term used to 
the reaction in wound- in the dittectillg-room, whieh were 
before the use of ant i-.-pt i.--. The term i< >till of U-M- to d --rile 
a form of inflammation without suppuration limited to the imme- 
diate vicinity of the wound, last in-: many days, and tcrmiuutiiii: 
in resolution, without or with a local neONMUl of the skin ( 1 
189). This wound, as all others, may IK- the starting-point for a 
more wide-spread inflammation. Anthrax ( Fiir. T9, 1 !' 1 '- 

ilis (Fig. 21:., p. 1 '. i. ainl tnlM-n-ulo-is all form similar le-i..iH. 
so that a bacteriological examination should In- made, if possibUv 



400 



INFLAMMATIONS OF THE ARM AND HAND 



Anatomical tubercle should be treated by wet dressings. If 
a malignant character of the infecting organism is proved or 

suspected, the tubercle 
should be excised. 

Dermatitis ; Ery- 
sipelas. - - Dermatitis 
produced by germ inva- 
sion is marked by ede- 
ma, redness, tenderness, 
and pain, and a constant 
daily extension of the 
involved area. Erysip- 
elas is the typical der- 
matitis of this charac- 
ter. It spreads rapidly, 
often as much as an 
inch a day, more rapid- 
ly in the direction of 
the lymph current than 
against it. It may also 
be known by the gener- 
al symptoms of an ini- 
tial chill and a high 
fever, but as a rule the 
symptoms are less se- 
vere when the erysipe- 
las occurs on an extremity than when the face is involved. Moist 
antiseptic dressings, applied and allowed to evaporate, give the pa- 
tient some relief from the pain, but they do not seem to have much 
effect upon the spread of the dermatitis. Fortunately, the inflam- 
mation tends to become less and less active the further it spreads, 
and so gradually dies out, and the patient recovers. In a minority 
of cases the inflammation extends to the deeper tissues, producing 
cellulitis, lymphangitis, and abscesses, which may prove fatal. 

A good application is formalin, one per cent solution, or a solu- 
tion of carbolic acid one part in sixty parts of alcohol and sixty 
parts of water. This is weak enough not to produce gangrene, 
and the anesthetic action of the carbolic acid is advantageous. (See 
also erysipelas of the face, p. 35.) 




FIG. 189. ANATOMICAL TUBEKCLK, DURATION ONE 
WEEK. The patient was a butcher, aged twen- 
ty-two years. 



ERYSIPELOID 

Erysipeloid. An equally typical infective dermatitis occurs 
on the hands of those engaged in handling meat. It is often spoken 
of as an erysipeloid to distinguish it from the more active erysip- 
elas. It does not usually produce an initial chill, and is accom- 
panied by only a slight rise in temperature. There is redness and 
edema of the skin, with a distinct edge to the affected area, which 
spreads outward in all directions very slowly, averaging one-quarter 
of an inch a day (Fig. 190). There is considerable local pain, 
sufficient at times to disturb sleep. After a few days the infection 
dies out in some parts of its growing edge, while still advancing 




FIG. 190. i:itvsi]'i:i.cii> DI.KMA n -is DKVKI.OI-IN.; IN A \V<>r\i> <>K HAM> <u Si \ t \ 
DAYS' DUHATION. Erysipeloid di-rmutitis noticed for three days. I'utii-nt :i 
butcher aged t\\&enty-one years. 

in others, so that it terminates in a number of separated and s6me- 
what faded red spots, which gradually disappear in t\\< or three 
weeks. Treatment consists in applications to ivlicve the pain. 
Ichthyol ointment has some advantages. 
28 



402 



INFLAMMATIONS OF THE ARM AND HAND 



Cellulitis. Cellulitis is a diffuse swelling of the skin and 
deeper soft tissues, due to infection. The lines of the skin are 
obliterated, the outline of the part is changed, its functions are 
limited, and it is held in a position of relaxation so that the painful 
pressure upon inflamed nerves may be as little as possible (Fig. 
191). 

Cellulitis is so often an accompaniment of an abscess that in 
every case of cellulitis search should be made for suppuration. It 
may be concealed under the dried crust of an abrasion. A small 
collection of pus beneath sound skin gives greater resistance to the 
palpating finger than the remainder of the inflamed area, and it 
is also much more tender to the touch. If the quantity of pus is 
larger and near the surface, fluctuation can be obtained by making 

sudden slight impres- 
sions with one finger, 
while another rests 
quietly upon the sus- 
pected surface. Pus 
also gives a whitish or 
} r ellowish tint to the 
skin over it as com- 
pared with the sur- 
rounding skin. This 
is a confirming sign, 
which sometimes ap- 
pears early enough to 
be of value to the sur- 
geon, and which con- 
vinces the patient as 
no other sign can, that 
the abscess is " ripe 
enough to cut." 

TREATMENT. Cel- 
lulitis "of the hand or 
arm should be treated 
by the application of 
gauze wet with an 
evaporating lotion, and the part should be kept at rest and mod- 
erately elevated by means of a sling. Evaporation should not be 




FIG. 191. CELLULITIS or FINGER WITH ABSCESS OF 
Six DAYS' DURATION. Patient a man aged 
thirty-one years. 



CELLULITIS 



in- 



prevented by oiled silk or any iinjK-rvions material. The cnWi 
of the fluid is greater if it contains some alcoh.,1. It mav be 
applied either hot or cold. The use of antiscptie. j,, ,| 1( . ,! m . 




I 



FIG. 192. GANGRENE OF FINGER FOM.<>\M\<. Cnxvuru, uro \MM 

TO UNRELIEVED TENSION. The details arc statiil in tin- 
Very common, but probably has n. effect whatever if tin- >kin 
is not broken. The fluid chosen should not product- jH-nnaiient 
stains on the clothing; for this reason lead and opium wa.-h, and 
aqueous solutions of ichtlmd arc u.t to !. recommended. 

If pus is present it should IM- evacuated throiidi a suitable in- 
cision, as mentioned bdo\v. Tin ..f pus arc l<H-al ten- 
derness on pressure, and increased local ten-ion. Kven it' there ! 
no visible collection of pus, marked in<-n av of ten-ion and pain 
are sometimes sufficient indication-^ for ipci-i..n. Tliu-. the gan- 
grene of the finger shown in Figure I'.'L' might have U-en avoid*-.! 
by an early incision. The history of this case is so instruct ivo that 
it is worth giving in detail. 

A healthy man, aged thirty-two, scratched the back of liis 
fourth digit with the wire on a bale of hay. For five days, be 



404 INFLAMMATIONS OF THE ARM AND HAND 

noticed no especial change in the finger. Then it began to swell, 
and he presented himself for treatment on the ninth day. There 
was moderate cellulitis of the whole finger, with puffiness at both 
phafepageal joints, but no especial tenderness at any point. A wet 
dressing of aluminum acetate was applied. The next day the finger 
was in about the same condition. The patient had slept well, had 
a good appetite, and little if any fever. The wet dressing was 
reapplied. The next day the condition was about the same. The 
question of incision was discussed and decided against for the 
reason that the process was not extending, there was no lymphatic 
affection either in the vessels or glands, the general health of the 
patient was undisturbed, and no local point of tenderness or fluc- 
tuation could be made out. The following day was Sunday, and 
the patient was not seen. On Monday the epithelium, anteriorly 
and posteriorly, was lifted by \vatery blebs and the underlying 
skin of the finger was discolored, although there was no sharp 
line of demarcation. There were still no constitutional symp- 
toms, and, no cause for gangrene being evident, the hand was 
airaiu dressed and put on a splint. The next day there was 
fluctuation in the posterior tendon sheath, and the demarcation 
between living and dead tissue was more apparent. The photo 1 
graph, of which Figure 192 is a reproduction, was taken; the pus 
was evacuated through a wide posterior incision, and the inflam- 
matory process rapidly subsided. ]STo carbolic acid had been" used ; 
the infection, as shown by its course and by cultures made from the 
pus, was not especially virulent, and one is forced to the conclusion 
that the gangrene of the finger was the result of excessive tension 
and that an early longitudinal incision made anywhere through the 
skin of the finger, by relieving this tension, might have avoided 



Boil ; Furuncle. Suppuration in the arm and hand is some- 
what rout rolled by existing structures so that it presents several 
well marked forms. The pus may be in the skin in the form of 
a pimple or a boil (Fig. 193). These lesions may have the same 
characteristics as similar lesions in other parts of the body, but it 
s worth noting that the epidermis of the palmar surface of the 
fingers and hand is so thick that pus may collect in it, raising the 
superficial portion like a blister. This is insensitive and can be 
cut away with forceps and scissors, exposing the deeper layer of 



BOIL 



ID:, 



epidermis. This should be sponged and inspected, for it often con- 
tains a sinus lending to :i second abscess underneath the skin, the 
so-called " collar button " abscess. For the opening of the deeper 
part of such an abscess, local anesthesia is required. Great care 
should be taken not to carry the incision beyond the abscess cavity 
so that operation may not spread the infection Ix-yond its existing 




FIG. 193. BOIL OF WRIST WITH SECONDARY PIMPLES. Original infection from a 
corpse; secondary infection from the discharge from the first boil. 

limits. (See also p. 411.) A small wick of gutta-percha tissue 
make- an excellent drain. 

When the pus is situated in a finger deeper than the true skin, 
the development of the abscess will be determined to a considerable 
extent by the peculiar anatomical relations which exist in the fin- 
gers, and especially in the finger-tip. Figure 194 shows in a 
diagrammatic way how pus may form in four different spaces, and 
the symptoms will be more or less different in each case. These 
four spaces are: A, the space between the dorsal skin and the 
matrix; J5, the space between the matrix and the formed nail; 
C*, the space between the formed nail and the underlying skin ; 




Fio. 194. SECTION OF TERMINAL SEGMENT OF FINGER. An abscess may form 
lift ween the dorsal skin and the matrix of the nail at A ; or between the matrix 
and the formed nail at B; or between the nail and the underlying skin at C ; or 
bi-tween the skin and the front of the phalanx, as shown in D. 

and D, the space between the skin and the front or side of the 

phalanx. These are not pre- 
formed spaces, but with the de- 
velopment of pus in the tissues 
they become abscess cavities. 

An abscess of the type D 
usually following a prick with 
a pin or splinter, situated in 
the distal segment of the thumb 
or finger, may " point " at the 
very tip of the finger. If not 
properly relieved it may extend 
deeper, causing necrosis of the 
tip of the last phalanx, or it 
may extend upward into the 
hand or into the flexor tendon 
sheath. Fortunately these com- 
plications are relatively late in 
occurrence, so that if the abscess 
is drained within a few days of 
its origin they are usually avoid- 
ed. The flexor tendons do not 
extend further than the base of 




Fio. 195. ABSCESS TIP OF THUMB OF 
THIRTEEN DAYS' DURATION, WITH 
SPONTANEOUS RUPTURE; TYPE D, 



Fid. 194. Note that the swelling 4.1 j- . i i i ,1 

does not pass the interphalangeal tllG dista j P lialanx I Consequently 

suppuration which is limited to 



joint. 



r \KO.NYCHIA 407 

tin- distal segment of the digit cannot involve the tendon sheath; 
yet this type of suppuration is often wrongly spoken of as a 
"felon," a convenient term for purulent thecitis or suppura- 
tion in a tendon sheath. Fig. 105 shows a thumb with an 
altsccss df type D of thirteen days' duration, which ruptured 
spontaneously. 

Abscesses of types C and D should be opened by a transverse 
incision at the tip of the digit, following one of the natural lines 
in the skin. This incision gives good drainage, and leaves far 
less deformity than a longitudinal incision. The nail should not 
be removed. 

Paronychia. Paronychia, or " run-around," is suppuration 
about the root of a nail. In order to understand its development 
and the treatment which will afford relief, one should know how 
a nail grows. The epithelium of the back of the finger is folded 
in upon itself and thickened. This double layer of actively multi- 
plying cells reaches nearly to the terminal joint, and is called 
the matrix of the nail, Figure 194, C and -D. The lower part 
of the matrix is thicker than the upper and forms the greater 
part of the nail. The distal edge of the underlying part of the 
matrix forms the whitish semilunar line visible in most finger- 
nails. A nail which is thick and strong, like the thumb-nail, has 
a more extended matrix than the more delicate nails on the ulnar 
side of the hand. 

If a splinter or a pin passes between the nail and its matrix, 
above or below, the tissues are damaged, blood and serum col- 
lect in the wound, and an abscess may result. Such an abscess 
may result from infection entering through a break in the skin 
at the side of the nail a hang-nail. The pus will at first be 
confined between the half formed nail and its matrix, and it will 
spread more easily transversely than in any other direction; but 
before much pus accumulates in the situation B, Figure 194, it 
will also travel beyond the matrix and enter the space C. The re- 
verse also happens, but the space C is much larger and an abscess 
starting beneath the nail in C is often some distance from the 
proximal edge of the nail. The spontaneous rupture of a parony- 
chia is usually posteriorly between the nail and the reflected skin 
(Fig. 196). The drainage thus obtained- is not sufficient to effect 
a cure, but usually prevents the suppuration from extending to 



408 



INFLAMMATIONS OF THE ARM AND HAND 



the front of the finger, or upward into the hand, though these 
complications do occur. 

TREATMENT. This naturally varies according to the situ- 
ation of the pus. If the pus is beneath the formed nail, a suffi- 




FIG. 196. ACUTE PARONYCHIA OF THREE WEEKS' DURATION, WITH SPONTANEOUS 
RUPTURE OF ABSCESS. Pus in spaces marked A and B, Fig. 194. Patient a 
woman aged twenty-one years. 

cient part of the latter should be cut away to give free exit. Such 
a condition often follows the passage of a splinter beneath the 
nail, even though it does not extend as far as the edge of the 
matrix. 

If the pus is in space B and has not yet extended to space A 
a transverse incision should be made through the reflected skin 
the whole width of the nail. In doing this the scalpel should be 
kept flat upon the nail and close to it, so that the incision does 
not appear on the surface of the finger at all. IrTmany cases it 
is no incision at all, simply a bloodless separation of the nail from 
the posterior part of the matrix. 

If the pus is in the space B, reaching toward (7, a transverse 
incision should be made clear across the nail at the semilunar 
line, and the proximal portion of the nail removed. It will be 



PARONYCHIA 409 

found adherent only at its lateral margins. If the distal portion 
of the nail is still attached to the tender skin beneath it, it may 
be left as a protector. In many cases it will have been lifted up 
by the pus. The upper and lower portions of the matrix should 
be kept apart for two or three days by a folded piece of rubber 
tissue, and a wet dressing applied. 

A longitudinal incision is less satisfactory, since it does not 
properly drain the pus cavity. Multiple longitudinal incisions 
have been advised by some, but they are unnecessarily mutilating, 
and require constant care, lest they close prematurely and fail to 
drain. Moreover any longitudinal incision which is made deep 




FIG. 197. ACUTE PARONYCHIA TEN DAYS AFTER REMOVAL OF Oi-n NAII,, AND ONE 
MONTH AFTER THE BEGINNING OF THE SUPPURATION. Same subject as Fig. 196. 

enough to pass through the whole matrix is likely to produce a 
permanent ridge in the nail or a split nail. Drainage carried 
out as indicated above will invariably be followed by a perfect 
nail. 

Figure 197 shows the finger ten days after removal of the 
nail to secure proper drainage. All suppuration has subsided, and 
the uninjured new nail is already showing. 



410 



INFLAMMATIONS OF THE AKM AND HAND 



If drainage is secured as already indicated by removal of the 
proximal portion of the nail, while the older portion is left to 
protect the finger, the new nail by its growth must push the old 
nail off from the finger. Its thin edge may be crumpled up by so 

doing, and this may cause the patient 
some pain. The removal of the rem- 
nant of the old nail will give the pa- 
tient relief, and make it easier for the 
new nail to grow out smooth and 
straight. The tenderness of the fin- 
ger resulting from removal of the old 
nail quickly subsides. 

Chronic Paronychia. Portions of 
formed nail, which are partly loosened 
and partly attached, may act as foreign 
bodies and keep up suppuration. This 
gives a chronic form of paronychia 
(Fig. 198). Treatment consists in the 
removal of every bit of formed nail 
and the application of a wet dressing 
for a few days. The two layers of the 
matrix should be kept apart by the in- 
terposition of rubber tissue, or a probe 
may be passed between them every two 
or three days until the new nail ap- 
pears. This method of treatment will 
insure a nail without deformity unless 
the matrix has been previously dam- 
aged. 

A patient will usually wish to know 
how long it will be before the appear- 
ance of the finger is restored. It is 




FIG. 198. CHRONIC PARONY- 
CHIA, FOUR MONTHS. Note 
that the edges of the old 
iiiiil interfere with the new, 
Leading to local recurrences 
of suppuration. Patient a 
woman aged twenty - two 
years. 



to say that it will be three months before the new nail grows 
out to the tip of the finger, and at least another two months 
before the irregular part of the new nail has grown off and has 
been cut away. 

There is still a fifth type of suppuration in the last segment 

of the finger. This type of suppuration often starts in a torn 

' hang-nail," and is situated generally at the side of the finger. 



SUPPURATIVE THECITIS 



411 



It may be drained llm-iidi ;IH incision made by keeping the knife 
flat on the nail, or else by a longitudinal incision made through the 
skin. The latter is parallel to the natural lines of the skin at the 
side of the finger. 

Suppuration in the proximal or middle segment of a finger 
may he simply subcutaneous, or in a tendon sheath, or in a joint. 
It is of the greatest importance to recognize the fact that many 
abscesses of the finger are simply in the subcutaneous fat, and 
do not involve the special structures of the digit. In opening such 
an abscess the skin only should be divided, great care being taken 
not to spread the suppuration by the careless incision of a hitherto 
not infected tendon sheath or joint. If the situation of the pus 
warrants it, it is best to make the incision a little to one side of 
tin- 1 1 ie< li an line. 

Suppurative Thecitis. Suppuration in a tendon sheath is 
called purulent thecitis, or felon, or whitlow. The infective agent, 




FIG. 199. ABSCESS IN THE TENDON SHEATH OF THE THUMB FROM A SPLINTER, OF 
Two WEEKS' DURATION. Compare the shape of this thumb with that shown 
in Fig. 195 on page 406. Fifth digit contracted thirty-five years from infection. 
Patient a man aged forty years. 



412 

which in the serious cases at least, is usually a streptococcus, is 
generally carried by a pin, needle, or sliver into the tendon sheath 
of the flexor side of the finger or thumb (Fig. 199). Suppuration 
does not immediately distend the whole length of the sheath, so 
that a timely incision may prevent its spreading so far as the palm 
of the hand. Its extension from the tendon sheath of one digit to 
that, of another is rarely seen, although mentioned as an anatom- 
ical possibility in the case of the thumb and little finger. 

The symptoms of suppurative thecitis may not be sufficiently 
distinct to enable one to say positively whether the pus is inside 
of the tendon sheath or merely subcutaneous. This distinction is 
the less important, since in either case it is necessary to divide 
the skin for drainage, and when this has been done it will be 
evident whether the sheath is or is not distended with pus. 

In both cases there are edema of the finger, great tenderness, 
and possibly tense fluctuation. Motions of the joints are inhibited 
by the tenderness, so that the inability of the patient to flex the 
finger is not of much assistance in a differential diagnosis. Pain 
caused by contraction of the flexor muscles when the finger is so 
held that no motion of the bones is possible, is significant of sup- 
puration within the sheath. If there is pus in a joint, pressure 
on the tip of the finger will cause pain. If the pus is inside 
or outside of a tendon-sheath, sudi pressure will not be especially 
painful. 

TREATMENT. Fus in a tendon sheath, like pus everywhere 
else, demands evacuation. In general, incisions for this purpose 
sljould be longitudinal, in order to avoid unnecessary injury of 
vessels and nerves; and while the incision should be deep enough 
and long enough to afford free drainage, in no case should it be 
made deeper than the pus. The old rule to cut every felon to the 
bone is a barbarity which has no place in modern surgery. 

The close relations of the tendon sheaths to many important 
structures in the hand makes it desirable that some more exact 
rules should be given for their drainage. In every case of sup- 
puration in the hand, unless it is evident that the case is one of 
the simple types already described in which the pus cavity is situ- 
ated within or just beneath the skin, a general anesthetic should 
l>e given. Furthermore the parts should be rendered bloodless by 
elevation of the arm and application of a tourniquet around the 



SUPPURATIVE THECITIS 413 

upper arm. The best form consists of five or six turns of an 
elastic rulilu-r bandage. In no case should the bandage be wound 
spirally around the whole arm from the hand upward, lest the 
suppuration be spread in this way. 

The first incision should be made through the point of infec- 
tion. Even if a previous incision has been made at that point, 
it will often be found to be insufficient to afford free drainage. 
If the case is seen at an early stage, this digital incision may 
sulHce. 

In making the incision one should divide one tissue plane after 
another for u distance of about an inch. As each plane is divided, 
it should be fully retracted, so that the operator may see exactly 
what lie is doing. 

It is important to remember that in some cases of deep suppu- 
ration of the finger, as well as of the hand, the pus lies outside 
of the tendon sheath. One should never hunt for pus with a probe, 
in this portion of the body at least, as it may spread the infection. 
\Vhen an abscess has been opened, its extent may be determined by 
a probe, provided the latter is not passed into the tendon sheath. 

If incision is made in the finger or the thumb, it should be 
made either in the median line or slightly to one side of it. It 
should be carried deeper, step by step, with the flaps retracted, in 
a good light, until the pus is evacuated. If the tendon sheath is 
exposed and is not distended with fluid, it should in no case be 
incised. If it is distended with fluid, the character of the same 
may be ascertained by aspiration with a hypodermic syringe. If 
purulent or seropurulent, the tendon sheath should be drained by 
an incision from half an inch to an inch long. 

If the whole tendon sheath is distended with pus, it will be 
necessary to drain also its upper end. Incision for this purpose 
in case of the index, middle, and ring fingers should be made in 
the palm of the hand directly over the tendon involved. An in- 
cision about one inch long, with its center opposite the metacarpo- 
phalangeal joint will usually suffice (Fig. 200, D). The tendon 
sheath should never be laid open from end to end, as this pro- 
cedure is almost certain to cause sloughing of the tendon. 

One word of caution in regard to palmar suppuration: The 
tendon sheath of course lies beneath the palmar fascia. This lim- 
its the swelling of the palm. On the back of the hand there is no 



414 



INFLAMMATIONS OF THE ARM AND HAND 



such strong fibrous tissue to limit swelling, and it sometimes hap- 
pens that the back of the hand will be more swollen than the 
front, although the suppuration may be wholly confined to the 
space between the metacarpal bones and the palmar fascia. 

One should not be misled by this swelling into making a pos- 
terior incision, for at this stage of the process posterior incision 
is useless. Such was the series of events in the case shown in 
Figures 200 and 201. The patient, a nurse, noticed a soreness 
in the end of the left index-finger. There was no history of in- 




Fiu. 200. SUPPURATION IN THE INDEX-FINGER EXTENDING INTO THE PALM (PuRU- 
LKNT THECITIS). A, The point of infection and the original incision, probably 
insufficient in depth; D, incision at the upper end of the tendon sheath which 
stopped the infective process; E, an incision into the abscess cavity outside of 
the tendon sheath. There are small drains in incisions D and E. Patient a 
woman aged twenty-five years. 

jury, and no abrasion in the skin could be discovered. An hour 
later the finger began to ache and throb. Two hours after that 
there was a chill and a temperature of 102, and the pain had 
extended into the hand and arm. Five hours after the first 
symptom the finger was tense, swollen, and extremely sensitive, 



SUPPURATIVE THECITIS 



415 



and there was a small yellow spot near the tip on the palmar sur- 
face. It was cocainized and incised by a physician, but no pus 
was found (Fig. 200, A). A wet dressing was applied. The 
following day the swelling had extended to the hand and arm, 




FIG. 201. SAME SUBJECT AS FIG. 200. Posterior view. Incisions B and C, which 
failed to reach the cavity of the abscess on account of their wrong situation. 
The drain at C extends through the hand from D. 

and the general symptoms were more severe. On the second day 
after the first symptoms another physician chloroformed the pa- 
tient, and made a lateral incision in the finger and a posterior 
incision in the hand, being misled by the great amount of swell- 
ing in these two places. Cloudy serum, but no pus was found 
(Incisions B and C, Fig. 201). Two days later, as the swelling 
in the hand and arm continued, I saw the patient, and under ether 
made a palmar incision into an abscess cavity (Incision D, Fig. 
200), and also a second incision at the outer limit of the abscess 
cavity (Fig. 200, 77). There seems no reason to doubt that the 
palmar incision would have terminated the suppuration if it had 
been made on the second day, just as readily as it did when it was 



416 



INFLAMMATIONS OF THE ARM AND HAND 



made on the fourth day. A temperature chart is appended, Fig- 
ure 202. 

The photographs, which were taken some days later, do not 
show the amount of swelling that existed at the time of incision, 



104 



103 



102 



101 






98 






97 



PULSE 



RtSP 



DAY OF 
DISEASC 



o 



o 



<> 



FIG. 202. TEMPERATURE CHART OF THE PATIENT WHOSE HAND is SHOWN IN 

FIG. 200. 

and are introduced to show the correct and incorrect sites of 
incision. The suppuration at the tip of the finger involved the 




I-'HI. 203. SAME SUBJECT AS FIG. 200. Ultimate result three months later. 



, a part of which disintegrated and came away in granular 
form. The ultimate result is shown in Figure 203. The patient 
obtained a movable finger. 



8UPPURATIVE THECITIS 417 

Tn ease the suppuration involves the tendon sheath of the 
thumb or little finger, the situation is much more complicated, 
since these tendon sheaths usually extend into the wrist. 

Three incisions may therefore be necessary to afford sufficient 
drainage: First, the digital incision at the point of infection, usu- 
ally near the tip of the thumb or little finger; second, the incision 
in the palm; and third, the incision in the wrist. 

In the case of the thumb, the palmar incision should be made 
along the inner border of the outer head of the flexor brevis pol- 
lieis. This incision is almost in line with the inner surface of 
the thumb when the first phalanx is fully extended on the meta- 
carpal bone. It should not be carried further upward than the 
second carpometacarpal joint, for fear of dividing branches of 
the median nerve going to the short muscles of the thumb. 

The incision in the wrist may be made either to the inner or 
outer side of the tendon of the flexor carpi radialis, a landmark 
which is easily recognized. It should extend from the lower trans- 
verse crease of the wrist an inch or inch and a half upward. One 
comes more directly upon the tendon of the thumb by making the 
incision to the inner side of the flexor carpi radialis, but drain- 
age in this situation sometimes inflames the median nerve. It is 
therefore probably better to make the incision outside of the ten- 
don of the flexor carpi radialis, and if the radial artery is exposed 
to contact with the drain, it should be li gated in two places and 
divided. Otherwise its wall may become eroded, and fatal hem- 
orrhage result. 

When the infection starts in the little finger, the palmar in- 
cision should be placed between the digital branches of the median 
and ulnar nerves. In order to avoid these nerves, it should be 
made directly over the fourth metacarpal bone, beginning a little 
above the head of the bone and extending upward to the annular 
ligament. The superficial palmar arch must be ligated and 
divided. 

The incision in the wrist must be so situated as to expose the 
flexor sublimis and flexor profundus tendons, as the pus sur- 
rounds or separates these when it extends above the annular liga- 
ment. This large bundle of tendons is easily felt in the normal 
wrist. The incision should be along the inner border of the 
bundle. If the tendons cannot be felt, a linear incision should lie 
29 



418 INFLAMMATIONS OF THE ARM AND HAND 

made from the lowest transverse crease of the wrist upward for 
an inch and a half, and in a line one-half inch to the outer side 
of the tendon of the flexor carpi ulnaris. This tendon, it will be 
remembered, terminates in the pisiform bone. If even these land- 
marks are obscured, the line selected for incision should be placed 
one-third of the distance from the ulnar to the radial side of the 
wrist. The sublimis tendons are quickly exposed. Pus may lie 
superficial to them or between them and the profundus tendons, or 
between the profundus tendons and the pronator quadratus. If 
the pus is in the last named space, it may be well to make a second 
incision along the ulnar border of the wrist, o as to obtain drain- 
age behind the tendon of the flexor carpi ulnaris. The only two 
structures which one need fear in making these incisions are the 
ulnar nerve and the ulnar artery. The nerve lies close to the 
outer (radial) side of the flexor carpi ulnaris tendon and Ili<> 
artery just outside of the nerve, next to the sublimis tendons. 
The artery may be divided and ligated, if necessary. 

As stated above, the tendon sheath should never be opened 
if the pus lies only outside it. If the sheath has to be opened on 
account of pus within it, no probe or director should be pushed 
upward along the sheath, lest it carry the infection further than 
it has already gone. The operator should rely on the external 
appearance of the finger, on the feeling of tension, and the pain 
caused by pressure to guide him in making his incision. When 
the pus cavity has been opened, and the edges of the wound are 
retracted, the eye is the safest guide to the extent of the cavity; 
but there is not the same objection to the use of a probe in abscess 
cavities which extend away from the tendon sheath. Such cav- 
ities, especially when situated near the base of the finger and out- 
side of the tendon sheath, frequently extend from front to back, 
or from back to front of the finger, and so need to be opened on 
both sides in order to be properly drained. 

The abscess cavity should be washed and sponged clean, but 
not curetted a most cruel procedure and absolutely useless. The 
whole extent of the wound superficial to the tendon sheath should 
be lightly filled with gauze to prevent its surfaces from adhering. 
A gauze dressing should be applied and kept constantly moist with 
a mild antiseptic or water. Some doctors seem to have a passion 
for stuffing a wound full of iodoform gauze and covering it with 



SUPPUKATIVE THECITIS 419 

a dry dressing. In the case of a clean wound this does very little 
harm ; in a suppurating wound, unless the outflow of pus is very 
free, the plug may suffice to keep most of the pus within the 
wound, while a little escapes and dries in the dressing. This may 
seal up the wound and literally reproduce the abscess, one side 
of which will then be formed by the gauze and inspissated pus. 
Pus will then reaccumulate under pressure, and the usual signs 
of an abscess swelling, heat, pain, etc. will reappear. It is 
needless to say that such treatment retards the healing of the 
wound, even if no more serious result follows. If the gauze is 
placed loosely in the wound, and the dressing is kept constantly 
moist, the pus will soak into the dressing as fast as it forms. Its 
accumulation under pressure is impossible, and the absorption of 
further infectious material is at least not favored. 

If drainage is required in the deeper portion of the wound, 
gutta-percha tissue presents many advantages. Being more flexible 
tlmn rubber-tubing, it conforms to the shape of the wound, and 
therefore exerts a minimum of injurious pressure. Unlike gauze, 
it never adheres to a wound, and as it does not soak up the dis- 
charge, it cannot by evaporation become dry and prematurely seal 
the wound. If it is desired to keep a larger opening, the gutta- 
percha tissue may be rolled loosely around a wick of gauze, making 
a flabby cigarette drain (Fig. 306). 

The part should be kept at rest. If the inflammation is slight, 
it is sufficient to place the hand in a sling. If the inflammation 
is more severe, a splint should also be employed. 

The hand should be dressed once or twice a day. A good plan 
is to soak it in a hot, weak, antiseptic solution for half an hour, 
before or after removing the dressing. This stimulates the circu- 
lation, and greatly favors the exit of pus. If irrigation is em- 
ployed, the fluid used should be mild in character, and injected 
with great gentleness. One should never use a strong solution of 
peroxid of hydrogen, as the rapidly forming bubbles of gas dis- 
tend the sinuses, causing the patient pain, and possibly spread- 
ing the infection. One part of peroxid to six of water is suffi- 
ciently strong for such use. An abundance of a weak fluid is a 
far better cleanser than a little strong antiseptic. 

In most cases nothing is gained by an early removal of the 
gauze which has been placed in the wound. Unless there are 



420 



INFLAMMATIONS OF THE ARM AND HAND 



signs of insufficient drainage, i. e., continued or increasing swell- 
ing, tenderness and heat, it is better to leave the gauze packing 
for' three or four days until it loosens. As granulations form, 
the dressing, need not be changed so frequently, and in a week 
or more a balsam of Peru, gauze may be inserted, and a dry 
dressing employed. When the wound has become superficial, mas- 
sage and passive motions should be added to the treatment, so as 
to maintain the mobility of ' 
joints and tendons. 





FIG. 204. SUPPURATION IN TENDON 
SHEATH FOUR WEEKS. Drainage 
sufficient to reduce the swelling, but 
not to effect a cure. 



FIG. 205. BACK OF SAME FINGER. 
Note the absence of characteristic 
swelling. 



Sometimes the patient does not apply for treatment until the 
abscess in the tendon sheath has ruptured externally, or has been 
evacuated through a minute incision. This relieves the acute 
swelling (Figs. 204 and 205), and changes the shape of the finger, 
as is easily seen by comparison with Figure 191, page 402, but 
leaves an imperfectly drained sinus. Proper drainage may then 
be obtained by a longer incision or a second incision opposite the 
proximal phalanx. 



SUPPURATIVE THECITIS 



421 



COMPLICATIONS. Suppuration in a tendon sheath if not too 
violent or too long continued may subside and leave a movable 
tendon. If more 
severe, the tendon 
is adherent, but 
will usually become 
movable in time. 
If the process is 
still more severe, 
the tendon sloughs, 
1 1 ic wound heals by 
granulation, and 
the scar ultimate- 
ly contracts, giving 
a useless finger, 
whose joints are 
movable, but which 
cannot 
as the 
don is 

cannot be extend- 
ed on account of 
the scar. This 
was the condition 
of the little finger 
in the hand shown 
in Figure 199, on 
page 411. If such a finger is in the middle of the palm its flexed 
phalanges should be amputated (Fig. 206). If a finger remains 
rigidly extended, it is almost as much in the way. 

The results of an old infection of the hand, which involved 
all the extensor tendons, is shown in Figure 207. The ulcer is 
recent. 

A virulent infection of a tendon sheath may lead to necrosis 
of bone, or even gangrene of the whole finger, but before it does 
so it usually extends to the synovial sheaths of the hand and 
wrist, or to the joints, and it may form an abscess in the forearm 
or axilla, or go on to general septicemia and death. 

If the infection extends above the wrist, it may form an ab- 



be flexed, 
flexor ten- 
gone, and 




FIG. 206. CICATRICIAL CONTRACTION OF FINGER FOL- 
LOWING SUPPURATION IN TENDON SHEATH TWENTY- 
FIVE YEARS PREVIOUS. Joint movable, but tendon 
gone. 



422 



INFLAMMATIONS OF THE ARM AND HAND 



scess in the forearm, beneath the bellies of the flexor sublimus 
muscle. Such an abscess should be opened along the ulnar border 




FIG. 207. Loss OK KXTKNSOU TENDONS FROM SUPPURATION, AND CONTRACTION 
OF SCAR OF MANY YEARS PREVIOUS. The ulcer is recent. 

of the forearm, between the flexor carpi ulnaris and the flexor 
sublimus digitorum muscle. In this way all risk of injuring the 

median nerve is 
avoided. The nl- 
nar nerve is pro- 
tected by the flexor 
carpi ulnaris mus- 
cle. Should the ul- 
nar artery be in- 
jured, it may be 
ligated and divided 
without harm to 
the patient. 

l^o matter how 
extensive the sup- 
puration, the same 
principles of treat- 
ment are applica- 
ble, viz., free in- 
cision, drainage fa- 
cilitated by a wet dressing or a constant bath, and absolute- rest 
to the part. These principles faithfully observed will often fully 




Fia. 208. SUPPURATION IN JOINT FOLLOWING PENE 

TRATION BY A SPLINTER SlX WEEKS PREVIOUSLY. 



S I I ' I ' URATI VK S YNOVITIS 



423 



restore the fund ion, even though suppuration has extended into 
the forearm. 

Suppurative Synovitis ; Suppurative Arthritis. In- 
feciion niiiv reach a joint and set up suppuration in the synovial 
sac which lines it, or in the ends of the bones themselves. This 
accident is usually due to the direct entrance of some sharp instru- 
ment into the joint itself. 
For example, a man with 
clenched fist strikes an- 
other a blow in the mouth. 
The edge of one of the 
incisor teeth may easily 
break through the skin 
and the capsule of the 
metacftrpophalangea 1 
joint as they are tightly 
stretched over the head of 
the bone. The wound it- 
self appears trivial, but 
in the course of a day or 
two the joint swells and 
becomes very painful, a 
little imicopurulent fluid 
finds its way out through 
the wound, and may be 
recognized by its tenac- 
ity if the finger which 
touches it is slowly drawn 
away. This is an absolute 
sign that fluid has come 
from the cavity of a joint 
or synovial sheath or a bur- 

sa ; in other words, that it contains muciii. Pressure on the end of 
the injured finger, tending to crowd the bones together, causes pain. 

The shape of the swollen finger also indicates that the in- 
flammation is located in a joint; for its maximum transverse 
diameter coincides with the plane of the affected joint, the whole 
finger being fusiform (Fig. 208). Compare the shape of the 
fingers shown in Figure 191, page 402, and Figure 204, page 420. 




Fiu. 20!).- -SrrrriiATivi; AHTJIIMTIS AND Los-; 
ov MKTACARPAL FOLLOWING WOUND OF 
JOINT MADE BY TEETH ONE YEAR PRE- 
VIOUS. 



424 INFLAMMATIONS OF THE ARM AND HAND 

Suppuration in a joint, if prolonged, leads to destruction of 
the cartilage, and later of a portion of one or both bones which 
make up the joint. If only one bone is destroyed, there may still 




FIG. 210. RADIOGRAPH OF A HAND IN WHICH THERE WAS EXTENSIVE Loss OF 
BONE FOLLOWING SUPPURATIVE ARTHRITIS. 

be considerable motion in the joint, so great is the power of the 
body to maintain its functions under adverse circumstances. In 



8UPPURATIVE SYNOVIT1S 425 

Figure i'0'J is shown an extreme case of this character, in which 

O . ' 

the whole metacarpal bone was lost from suppuration following 
a tooth-wound on the back of the metacarpophalangeal joint. 
'I' lie linger had a considerable range of motion. Figure 210 is a 
radiograph of a similar case in which a part of the metacarpal 
bone was preserved. In the usual case the destruction of carti- 
lage produces a rough grating w r hen the bones are slipped upon 
each other ; but if free drainage is instituted at this stage the case 
goes on to recovery without loss of bone. Convalescence is slow, 
however, and the function of the joint may never be fully regained. 
If treatment is commenced before erosion of the cartilaginous 
ends of the bones, two or three weeks' treatment should result 
in complete healing of the wound, and restoration of function 
should ultimately be complete. 

TREATMENT. The treatment of suppurative synovitis con- 
sists in an incision into the joint, irrigation of the joint cavity 
with peroxid of hydrogen and water, one part to six or eight, a 
moist gauze dressing, with or without a drain which reaches 
through the capsule of the joint, and a splint to keep the bones 
absolutely at rest. If the wound is a posterior one, the incision 
should also be made posteriorly. If the wound is an anterior 
one, the joint may perhaps be drained more satisfactorily from 
the posterior side ; or anterior and posterior drainage may be 
indicated. In a 'few days when the acute suppuration has sub- 
sided, the daily discharge will consist of a few drops of sero- 
mucopurulent fluid. If a drain has been kept in the joint cavity, 
it should now be removed. The gauze dressing should be light, 
not more than six or eight or twelve thicknesses, so that the splint 
may hold the finger firmly. A sheet of thin tin, cut from a 
cracker-box and molded accurately to the finger and hand, an- 
swers admirably for this purpose (Fig. 211). A pattern should 
first be cut out of paper. The base of the splint should reach 
nearly to the carpus, and should extend for an inch on either side 
of the metacarpal bone. The remainder of the splint should be 
broad enough to form a gutter half encircling the finger. The 
sharp edges of the splint should be slightly bent away from the 
hand to avoid pressure. 

Sometimes, on account of pain, the finger cannot at once be 
extended. The splint should then be bent to fit the position of 



426 INFLAMMATIONS OF THE ARM AND HAND 

the finger, and at each daily dressing a little more extension can 
thus be obtained. 

Treatment of this character to be successful must extend over 
several weeks. In the beginning the dressing should be changed 




FIG. 211. TIN SPLINT CUT FROM CRACKER-BOX WITH BANDAGE SCISSORS, FOR USE 
IN CASE OF SUPPURATION OF THE METACARPOPHALANGEAL JOINT OF THE SECOND 
DIGIT. At the left of the illustration are two paper patterns. The tin splint was 
cut from the pattern next to it. The other shows the shape of a splint for the 
third or fourth metacarpophalangeal joint. 

every day, and later on three times a week. The ultimate result 
in many instances will be a movable joint, .although one cannot 
promise such a favorable outcome. However, most patients prefer 
even a stiff joint to. resection of a joint or amputation of the 
finger, which are the alternatives of choice. 

When the sinus has quite healed, the patient should still wear 
his splint and keep the finger at rest for a couple of weeks, treat- 
ing the finger with a daily bath and rub, but not attempting to 
bend it until the swelling and soreness have disappeared. Undue 
eagerness on the part of the surgeon or patient to prevent stiffness 
of the finger by early motion will probably result in a renewed 
secretion of mucopurulent fluid into the joint cavity, which will in 
turn require another incision and a new period of treatment. 



SUPPURATIVE OLECRANON BURSITIS 



427 



If the ends of the bones are dead, so that they grate roughly 
11 IK ni one another, the casting off of the dead tissue may still 
sjil'dy be left to nature if free drainage is provided. This is a 
tedious process, and the financial condition of the patient may 
make necessary the resection of the ends of the bones or the am- 
putation of the finger. The latter operation usually gives a 
shorter period of recovery. 

The description of suppuration in one of the joints of the 
fingers and the treatment therewith outlined is applicable to sup- 
puration in the larger joints of the wrist and arm ; but the con- 
stitutional effects of these larger lesions are so great that the 
|);iticiit who suffers witli them has passed from the field of " minor 
surgery." 

Suppurative Olecranon Bursitis. A rather common form 
of abscess in the arm starts in the olecranon bursa. The wound 




FIG. 212. SUPPURATIVE OLECRANON BURSITIS. The characteristic swelling of the 
distended bursa is somewhat masked by the cellulitis around it. 

may be insignificant. The germs multiply rapidly in the bursa, as 
they do in all preformed serous cavities. If the bursa is intact, so 
that the seromucopurulent contents cannot escape, palpation will 
at once reveal a distinct rounded tense swelling. In most cases the 
fluid which accumulates in the bursa escapes through the wound, 



428 INFLAMMATIONS OF THE ARM AND HAND 

and this prevents distention of the bursa, while the edema of the 
adjacent soft parts obscures its outline. This renders a diagnosis 
more difficult. Sometimes suppuration starting in the bursa breaks 
into the tissues outside its wall, and then the usual signs of a 
subcutaneous abscess are added (Fig. 212). 

Treatment consists in exposure of the abscess cavity by a longi- 
tudinal incision. The bursa should be removed or allowed to 
granulate from the bottom, as otherwise relapse is likely to occur. 
If there is an extensive abscess, it is often of advantage to drain 
on both sides of the arm. Through and through drainage by mean* 
of gauze or rubber tubing may then be employed, but only for a 
few days. After that the drains should be inserted from both sides, 
but should not touch in the middle, so that repair of the deeper 
portion may be favored. It is easy to keep up a sinus by leaving 
a drain through a limb. 

Lymphangitis. It was stated on page 399 that inflamma- 
tory lesions may develop in related structures at a distance from 
the origin of an infection. These lesions are conveniently spoken 
of as " regional " in relation to the original lesion. They are 




FIG. 213. INFECTED WOUND OF FINGER WITH ABSCESS DEVELOPING IN THE COURSE 
OF THE LYMPHATIC VESSEL. The arrows are directed to these points. 

lymphangitis and lymphadenitis. Either may lead to the forma- 
tion of an abscess. 

Lymphangitis is produced by the extension of infection along 
the lymph vessels which drain the site of an infected wound. 
Usually the wound is insignificant; sometimes it is found' with 
difficulty. The inflammation of- the lymph vessels causes them 



LYMPHADENITIS 429 

to appear as slightly indurated red streaks. They are usually only 
slightly tender and painful. More than one vessel is involved 
in most cases. 

Treatment consists in the cleansing, and drainage, if necessary, 
of the original wound. When this has been accomplished the lym- 
phangitis quickly subsides, sometimes in a day or two. The portion 
of the arm which is inflamed is often enveloped in a wet dressing. 
This may be either cold or hot. The dressing makes the arm feel 
comfortable, and by maintaining an even temperature it probably 
facilitates recovery, but its curative action must be very slight. 

Only rarely does an abscess form in the course of the inflamed 
lymphatics (Fig. 213). 

Lymphadenitis. The regional lymph glands are very fre- 
quently involved in connection with infected wounds of the fingers 
and hand. In many instances it is evident that the bacteria pass 
through the lymphatic vessels without visibly affecting them, and 
produce a reaction in the lymphatic glands. The glands at the 
elbow are not often involved ; those in the axilla are usually the 
ones affected, whether the wound is on the front or the back of 
the hand. In many cases the glands are palpably enlarged and 
tender, but if the original wound is properly treated, suppuration 
in the glands does not take place ; but even in favorable cases they 
do not so quickly resume their normal condition as do the lym- 
phatic vessels. One or two weeks are often necessary before the 
tenderness and swelling disappear. In other cases the swelling 
of the glands continues or increases until abscesses are formed in 
them, which in the course of time may break through the capsules 
and form a single large abscess. Infection from the hand affects 
the deeper glands of the axilla, so that the latter may swell' to a 
considerable extent before the skin shows any change. 

If the infection starts in the hair-follicles of the axilla, and 
an abscess is formed in the subcutaneous fat or in the superficial 
glands, the parts present quite a different appearance (Fig. 214). 
This is a very common trouble, and one which is annoying rather 
than serious. The skin is invariably reddened, and shows one or 
more pustules, or perhaps also sinuses, if the abscess has already 
ruptured. The whole inflamed mass can be moved upon th6 deep 
axillary fascia. The process is correctly termed a superficial axil- 
lary abscess. 



430 INFLAMMATIONS OF THE ARM AND HAND 

TREATMENT. Local anesthesia is sufficient for the treatment 
of a superficial axillary abscess. The hair should be cropped with 
scissors, the skin washed and cocainized. The abscess should then 
be opened by a transverse incision near its lowest portion, an 




FIG. 214. SUPERFICIAL AXILLARY ABSCESS FROM INFECTION ABOUT HAIRS; TWELVE 
DAYS. Pus is seen dropping from a spontaneous rupture. Patient a man aged 
thirty-nine years. 

incision, in other words, parallel to the seam joining a sleeve to 
a coat. Fragments of glands should be curetted or cut away, and 
if more than one abscess cavity exists, they should all be made to 
drain freely into the wound. The edges of the wound should be 
kept apart by gauze for some days, until granulation is well estab- 
lished in the deeper parts of the wound. 

The treatment of suppurating deep glands of the axilla is a 
more serious undertaking, and is best carried out when a general 
anesthetic has been given. The skin of the axilla should be shaved 



ECZEMA 431 

and cleansed and a longitudinal incision made; an incision, in 
other words, parallel to the edge of the greater pectoral muscle. 
If the glands are freely movable in the surrounding areolar tissue 
their removal is easy; it may be very difficult if exudation has 
matted the various planes of tissiie together. Under such cir- 
cumstances the surgeon may think it best simply to open the various 
abscesses, drain them, and wait for the wounds to close by granu- 
lation. He usually has to wait some weeks, as the tissue of the 
gland is so spongelike that it affords a splendid opportunity for the 
continued propagation of bacteria, while the circulation in this 
spongy tissue is so good that the bacteria do not generally cause 
its necrosis after the pressure has been relieved by the incision of 
the gland capsule. Therefore, it is a good rule to remove a sup- 
purating gland wherever this can be done easily. The next best 
thing to the complete removal of the gland is to scoop it out of 
its capsule piecemeal by means of a curette. If the glands are 
removed entire, temporary drainage with rubber tissue will suffice 
and the greater part of the incision may be sutured. If the 
glands are merely incised, or incised and curetted, or if the ab- 
scess at the time of operation has already extended beyond the 
capsule of the gland, gauze drainage through an unsutured in- 
cision should be maintained for some days until granulation takes 
place. 

The treatment outlined for the deep suppurating glands is the 
same as that employed for tuberculosis of the axillary glands. In 
the latter case there is, of course, an additional reason for the 
complete removal of the glands in that the seeds of disease which 
they contain may spread to other glands or other organs. 

Eczema. The hand and forearm are favorite seats of eczema, 
which occurs in all its forms erythematous, papular, vesicular, 
and pustular. When of a chronic character, scales and crusts and 
fissures are well shown, particularly upon the palm. Besides what- 
ever form of " debility " may be the predisposing cause of the 
eczema, if the lesions are 'located upon the hand or arm, there is 
almost always a well marked local cause such as exposure to heat 
or cold, contact with strong chemicals, including laundry soaps and 
washing powders, irritating sand, etc. The history will generally 
indicate the diagnosis, which will be confirmed by the presence of 
the four cardinal symptoms erythema, serous exudation, infiltra- 



432 INFLAMMATIONS OF THE ARM AND HAND 

tion of the underlying skin, and itching. Eczema must be differ- 
entiated from the following diseases : 

Urticaria occurs in wheals scattered indiscriminately over vari- 
ous surfaces of the body. 

Erysipelas gives a continuous blush, which spreads constantly 
from the edge. This and its constitutional symptoms sufficiently 
distinguish it from eczema. 

Dermatitis from poison ivy closely resembles acute eczema. 
Its distinguishing characteristics are a history of exposure to the 
plant, the acute spread of the lesions, and their transference from 
one part of the body to another by contact, as from the hands to 
the face, neck, or genitals. 

TREATMENT. Applications useful in the treatment of eczema 
have been mentioned on page 58. If the best results are to be 
obtained, the irritating causes must, of course, be done away 
with. 

Sometimes a syphilitic eczema of the finger, especially of the 
forefinger or thumb, will persist long after all other signs of the 
disease have disappeared. The constitutional treatment should 
be continued under such circumstances, even though the patient 
may have taken medicine regularly for the usual period of two 
years or more. In addition, local applications, such as mercurial 
ointment, Lassar's paste, or strong preparations of salicylic acid 
should be applied during the night, in order to cause the old skin 
to scale off and give place to a newer, healthier growth. 

Ulcer from Vaccination. In normal vaccination the pus- 
tules dry up and the resulting scab remains in place until the 
repair of the skin is complete. If germs of various sorts are 
allowed to enter the lesion, at the time of vaccination, or afterward 
by a premature removal of the scab, the inflammation and loss of 
tissue may be extreme. It is no unusual thing to find an ulcer 
on the arm or leg of a child an inch in diameter and one-third of 
an inch deep. Such an ulcer is usually very slow in healing, and 
should be stimulated with nitrate of silver. The ulcer may be 
painted with a ten per cent solution of nitrate of silver, or gauze 
wet with a four per cent solution may be kept over the ulcer. 
This dressing should be moistened four times a day with x water 
and changed every day until granulation is well established. (Com- 
pare the treatment of ulcers of the leg, Chapter XVIII.) 



GONORRHEAL ARTHRITIS 433 

Articular Rheumatism. The less acute inflammations of 
the upper extremity are for the most part located in the joints. 
A complete study of joint affections is manifestly impossible in a 
work of this character, but it is worth while to consider the sur- 
gical aspects of articular rheumatism, gonorrheal arthritis, arthritis 
deform ans, gout, syphilis, and tuberculosis. 

The onset of articular rheumatism is sudden, with fever and its 
accompanying symptoms. One or more joints are diffusely swollen, 
and very tender and painful. Different joints may be involved at 
the same time, or one after the other. The affected joint contains 
little fluid. The administration of salicylates internally seems in 
some cases to hasten the restoration to normal of the affected 
joints. In other cases it seems to have no effect in this way. Pain, 
redness, and extreme tenderness usually disappear in a few days. 
Some swelling, and limitation of motion by tenderness and adhe- 
sions, persist for a longer time, possibly for weeks. 

LOCAL TREATMENT. Twenty or thirty drops of guaiacol 
should be sprinkled on a layer of cotton. This is wrapped around 
the joint, covered with oiled silk, and bandaged in place. The 
joint should be immobilized by a splint or sling. The initial 
pain is much relieved in this manner. In a few days hot fomen- 
tations or baking are indicated. When pain has disappeared and 
the swelling is Diminishing, massage and active and passive mo- 
tion of the joint is advisable. At a still later period it is some- 
times desirable to give an anesthetic in order to break up adhesions. 
This should never be done until all signs of acute inflammation 
have passed. 

During the painful stage of rheumatism of the wrist or fingers, 
the hand and fingers should be constantly extended. This position 
is favorable to subsequent treatment of any adhesions which form, 
for it is much easier to gradually flex a stiff, extended joint than to 
extend one which is adherent in the position of flexion. There- 
fore, if these joints are flexed or partly flexed, when the patient is 
seen for the first time, a splint should be applied, to prevent in- 
crease of flexion, and each day a slight extension of the part 
should be made and the splint reapplied in the better position. 

Gonorrheal Arthritis. In about ten per cent of the ca>os 
of gonorrhea some joint is involved. This occurs in the third or 
fourth week of the disease, or still later. This lesion is often 
30 



434 

spoken of as a monarticular one, and so it frequently is ; but the 
fact should not be lost sight of that in more than half of the cases 
of gonorrheal arthritis, more than one joint is involved. However, 
the inflammation does not skip from joint to joint, as in rheuma- 
tism, but pursues a tedious course of four weeks or more in each 
joint that is affected. Other distinguishing marks are the effu- 
sion into the joint cavity, edema of the soft parts, involvement of 
any bursse or tendon sheaths in the immediate vicinity of the 
joint, and the moderate character of the pain and tenderness. 

The treatment is similar to that for articular rheumatism :. rest 
on a splint, .with hot or cold applications to relieve pain during 
the first stage; then baking, followed by massage, and passive 
and active motions. Restoration of function is usually complete. 

Deforming Arthritis. This disease is also known by the 
names osteitis deformans, rheumatoid arthritis, and others. It is 
characterized by slight swelling, pain, and tenderness of the vari- 
ous joints of the body, and alterations of the articular ends of 
the bones due to deposits of lime salts. The range of motion in 
the joints is thereby greatly interfered with, and various deformi- 
ties are produced, such as flexion, overextension, or lateral dis- 
placements. 

When advanced, this disease is unmistakable ; in its beginning 
it may be mistaken for articular rheumatism or gout. It has not 
the fever nor pain of the former, nor the chalky skin deposits, 
and usually not the nephritic symptoms of the latter. 

Local treatment consists in maintaining and, if possible, in- 
creasing the range of motion of the joints during the periods of 
quiescence of the disease. The affected limbs should be baked to 
300 F., if the patient can stand it, and then vigorously massaged 
either manually or, still better, by mechanical vibration. Active 
motion should be encouraged for the sake of both joints and mus- 
cles. The use of splints is contraindicated, since immobilization in 
these cases reduces still further the range of motion. Sometimes 
increased motion may be obtained by manipulation under an anes- 
thetic, but such increased freedom is not generally permanent. In 
this, as in most joint adhesions, a slight, gentle motion, many 
times repeated, has a far greater permanent good effect in increas- 
ing the range of motion of the joint than an occasional violent 
motion. 



SYPHILIS 435 

Gout.- While early attacks of gout are often confined to the 
metatarsophalangeal joint of the great toe, they are common 
enough in some of the smaller joints of the upper extremity. The 
family history, and symptoms of gout manifested by the heart, 
kidneys, and gastrointestinal tract will usually indicate the true 
diagnosis. The affected joint (or joints) is swollen, hot, red, pain- 
ful, and tender, similar to the joint affected by articular rheuma- 
tism. Other joints should be examined for evidences of previous 
attacks, and uratic deposits looked for in the skin of the hands, 
feet, and ears. 

The extreme tenderness and pain usually last only a day or two. 
During this time pain may be lessened by guaiacol applied on cot- 
ton and covered with oiled silk, or ice cloths may be applied, or the 
patient may find very hot applications more comforting. The best 
and simplest way to apply moist heat is to wrap the joint with hot 
moist compresses, cover these with oiled silk, and then to increase 
and keep up the heat by laying hot bottles or bags on either side of 
the limb. These can be changed from time to time. In this way 
the temperature can readily be kept as high as the patient can bear 
it, and the inner dressing need not be touched. If it dries, the 
protective should be opened, and hot water poured upon the com- 
presses. Various counter-irritants are also employed. Tincture 
of iodine is the cleanest, and perhaps as good as any. When the 
attack has passed over, massage is beneficial, as these patients 
usually take too little exercise. 

If the gouty deposit of urates is large, or is so situated that it 
will interfere with the use of the member, or if it is very painful, 
it should be removed. This can easily be done under a local anes- 
thetic. The wound heals as promptly as any clean wound. An 
isolated nodule in an unusual situation has been mistaken for a 
tumor. 

Syphilis. Lesions of syphilis at every stage are found in the 
hand and arm. The primary sore or chancre has several times 
developed upon the forefinger of a physician after examination 
of a syphilitic patient. A chancre may also develop after contact 
of the hand with the teeth of a syphilitic patient. Such a case 
is illustrated in Figure 215. 

Late lesions of syphilis are often found in the upper extremity. 
Eczema of the fingers is mentioned on page 431. Gumma of the 



436 INFLAMMATIONS OF THE ARM AND HAND 

skin forming an ulcer (Figs. 216 and 2lT) has the usual char- 
acteristics of gunmia in other parts of the body, and demands the 
usual treatment. (See p. 61.) 




FIG. 215. PRIMARY LESION OF SYPHILIS DEVELOPING IN A WOUND OF THE FINGER 
MADE BY HUMAN TEETH. Photograph eleven weeks after injury. 

Syphilitic Dactylitis. When the soft tissues of the joints of 
the fingers become gummatous, or a gumma forms in one of the 
phalanges, the condition is called syphilitic dactylitis. The af- 
fected portion of the finger is spindle-shaped or spherical, the skin 




Fia. 216, SYPHILITIC ULGER OF THE HAND, OF FOUR MONTHS' DURATION. Patient 
a male aged thirty-seven years. 




FIG. 217. THE SAME HAND AS SHOWN IN FIG. 216, AFTER FOUR WEEKS OF TREAT- 
MENT BY lODID AND MERCURY. 




Fin. 218 CHRONIC INFLAMMATION OF HAND WITH SINUSES OF Two YEARS' 
DURATION; PROBABLY SYPHILITIC. Patient a man aged fifty-five years. 

437 



438 INFLAMMATIONS OF THE ARM AND HAND 

is dusky red and shiny, the underlying tissues are firm or, later, 
boggy, and flexion of the joint is interfered with by the swelling, 
although abnormal lateral motion is possible. The amount of pain 
varies in different cases, and may be wholly wanting. After some 




FIG. 219. SYPHILIS OF LEFT WRIST, LEFT FOREFINGER, AND RIGHT RING-FINGER, 
COMMENCING ONE YEAR AGO IN THE RING-FINGER, A PART OF WHICH WAS 
AMPUTATED BY A PHYSICIAN. Patient a woman aged thirty-six years. 

weeks or months the skin may break and allow the discharge of 
characteristic syrupy fluid. The discharge afterward becomes 
purulent (Fig. 218). The formation of sinuses may not take 
place for months, or recovery may. occur without any sinuses being 
formed. In other cases there is necrosis of bone which keeps open 
the sinuses. 

Differential diagnosis with tuberculous dactylitis, sarcoma, and 
chronic purulent synovitis may be extremely difficult. An exact 
history of the case, a radiograph, two weeks' treatment with iodid 
of potash, witk..a, splint and wet dressings to the finger if the joint 
has been opened' will almost always dispel the doubt. Amputation 
should never be resorted to in syphilitic cases, as recovery is almost 
always perfect if internal treatment is persisted in. Moreover, 



TUBERCULOSIS OF TENDON SHEATHS 



439 



amputation is no preventive of recurrence (Fig. 219), even in the 
stump of the amputated finger. 

Tuberculosis of Tendon Sheaths. There is also a chronic 
inflammation of the tendon sheaths, due to the tubercle bacillus, 
at least in most cases. Either the flexor or extensor tendon.sruiay 
be involved (Figs. 220 and 221). The sheaths of the. tendons "ace 
gradually distended with fluid which is at first serous, but which 
later contains rice bodies. These are fibrinous bodies about as 
large and about as slippery as wet melon seeds. They can often 
be detected by palpation, and can often be made to slip back and 
forth under the annular ligament from one relaxed portion of the 




FIG. 220. TUBERCULOSIS OF FLEXOR TENDON SHEATHS OF HAND. Especial dis- 
tention of sheath of middle finger; sinus in palm. Patient a boy aged six years. 



sheath to the other. The condition may remain about the same 
for months, causing little or no pain, and no swelling of the 
tissues outside of the sheaths; or the tubercular process may be 
more active, giving pain and edema, with a discharge of pus and 
detritus into the cavity of the sheath, or through the skin. 



INFLAMMATIONS OF THE ARM AND HAND 



TREATMENT. The only treatment to be advised is the com- 
plete removal of the affected tendon- sheaths by dissection under a 

general anesthetic. 
If this operation is 
performed at 
early stage, 




FIG. 221. TENOSYNOVITIS, PROBABLY TUBERCULAR, OF 
FIVE MONTHS' DURATION. Patient a man aged forty- 
nine years. 



an 
the 

wounds may be su- 
tured, and will usu- 
ally unite primar- 
ily. Slight active 
motions should be 
begun in a week to 
prevent permanent 
adhesions. There 
is in many cases 
full restoration of 
function. Opera- 
tions performed in 
the suppurative stage, or after the disease has extended beyond the 
synovial membrane, do not have so favorable a result. 

Tuberculosis of Joints. In tuberculous arthritis of the up- 
per extremity the disease .may begin in the synovial membrane, or, 
more commonly, in the extremity of one of the bones forming the 
joint. In the latter case it usually extends into the joint, but not 
necessarily so, as it may extend in the other direction, and when 
suppuration takes place the pus may break through the skin with- 
out having entered the joint. In the usual case, however, the 
joint is early involved, and the tuberculous arthritis which then 
exists must be differentiated from the various other chronic in- 
flammations of a joint. 

SYMPTOMS. The early symptoms of tuberculous arthritis are 
local heat, swelling, limitation of motion, partial loss of function, 
usually pain and tenderness, and muscular atrophy. This last is 
a symptom which occurs early in the disease, and is almost always 
demonstrable when the doctor first sees the patient. Muscular 
spasm, which is so prominent a symptom in tuberculosis of the 
joints of the lower extremity, is not so easily produced in the joints 
of the upper extremity. These various symptoms are worth further 
attention. 



TUBERCULOSIS <>K JOINTS 



111 



heat is readily determined by comparing the affected 
joint with other parts of the same limb, aiid with the correspond- 
ing joint of the opposite limb. 

Swelling should be measured circumferentially in inches or 
centimeters, not guessed at. It is a good plan to measure at the 
same time the circumferences of both limbs a certain distance 
above and below the plane of the affected joint, to determine the 
presence of atrophy. 

Limitation of motion, both active and passive, is ascertained 
by testing the various normal motions of the joint, one after the 
other, to the fullest possible extent. A goniometer is an iustru- 




FIG. 222. DIAGRAM TO AID THE EYE IN ESTIMATING THE RANGE OF MOTION IN A 

JOINT. 

ment to measure the range of motion, but this can be estimated 
with sufficient accuracy by the eye, if one bears in mind that two 
bones at right angles to each other make an angle of 90 degrees ; 
in the same line they make an angle of 180 degrees; while mid- 
way between a right angle and a straight line they make an angle 
of 135 degrees. If the quadrant in question is divided into thirds, 
the angles will be 120 degrees and 150 degrees (Fig. 22:i). 



442 INFLAMMATIONS OF THE ARM AND HAND 

Loss of function may be due to limitation of motion or to loss 
of muscular power, or to the pain which use of the joint elicits. 
It should be noted in the history in exact terms for future com- 
parison. 

Pain and tenderness vary much in different patients. Pre- 
sumably they are greater when there is an unruptured focus of 
disease in a bone than when such a focus has ruptured or when 
the disease is exclusively in the synovia or other soft tissues. 

A radiograph shows the tuberculous bone to be distended and 

decalcified. 

At a later stage there is often fluctuation, due to fluid within 
or outside of the joint; and there may be abscesses or sinuses. 




FIG. 223. TUBERCULOSIS OF THE WRIST, ONE YEAR, WITH SINUS. Patient a man 
aged twenty-nine years. 

Discharge of pus through a sinus, of course, reduces the swelling. 
The sinus often becomes blocked and the swelling and other acute 
symptoms reappear until relief is again obtained by discharge 
through the same or another sinus (Fig. 223). If a probe will 
follow such a sinus it will either enter the joint or touch diseased 
bone. 

Tuberculosis of the upper extremity is rare in both childhood 
and in adult life. The statistics of different observers vary, but it 
is probably safe to say that of all cases of tuberculosis of joints 
of the extremities, not more than two per cent fall to the shoulder- 



OSTEOMYELITIS 443 

joint, two or three per cent to the elbow-joint, and less than one 
per cent to the wrist-joint and bones of the hand, giving a total 
of about five per cent for all the joints of the upper extremity. 

Tuberculosis in the hand itself, or of the fingers, may be situ- 
ated iu the joints, or it may involve tin sluift of one of the longer 
hours. In the hitler ease a fusiform swelling is given to the 
a fleeted part, the center of the swelling being midway between the 
joints; whereas, in arthritis of whatever nature, the center of the 
swelling is opposite the plane of the joint. In syphilis there may 
he either type of swelling. 

TREATMENT. The tirst treatment of tuberculous arthritis is to 
keep the joint at rest by splints or plaster of Paris bandage. If 
fluid accumulates and causes pain or distends the skin, it should 
be evacuated through a small incision. 

Injections of iodoform (ten per cent in glycerin) and other 
substances into the tissues around the diseased foci have been favor- 
ably spoken of by some surgeons, but their use is often disap- 
pointing. 

If necrosis of a bone develops, the necrotic portion must, of 
course, be removed. Suitable splints should be worn until recovery 
is complete to limit the amount of the deformity as far as possible. 

The tendency of tuberculosis of a joint in infancy and child- 
hood is often toward recovery. Such a favorable outcome may be 
hoped for in adults, but it is far less frequent. If a reasonable time 
has been given to simpler measures and the condition of the patient 
does not improve, resection or amputation must be considered not 
only to terminate the local process, but to save the patient from 
extension of the disease to some other part of the body. These are 
operations fully discussed in books upon major surgery. The re- 
sults of resection are often not much worse than those which follow 
a spontaneous cure, since more or less disability often remains. 
Hence, in an adult one should not put off too long the question of 
operation. It is hardly necessary to add that whatever the local 
treatment, constitutional hygienic and dietetic treatment is even 
more important. Out-of-door life will cure nearly all cases of 
joint tuberculosis in children. 

Osteomyelitis. Inflammation of bone, without or with 
necrosis, may follow suppuration in the wound of a compound 
fracture (p. 386), or in a joint which has been wounded (p. 423). 



444 INFLAMMATIONS OF THE ARM AND HAND 

There is also a suppurative inflammation of bone, situated usually 
in the shaft or epiphysis, coming on without such evident trau- 
matic origin, and known as osteomyelitis. In a well marked case 
there is a high fever, a chill, and intense pain in the bone, followed 
by convulsions or delirium, for the disease is generally in childhood 
or adolescence. There are also milder cases, with less pain and 
slight fever. Pain is invariably increased when the affected bone 
is jarred. After the pus distends or breaks through the perios- 
teum, there are the usual signs of abscess in the soft parts. 

Osteomyelitis is about five times more common in the lower 
extremity than in the upper. Its early recognition is of the great- 
est importance. Free exit should be given to the pus by an in- 
cision through the periosteum, and if the pus is not then reached 
the bone should be opened with drill or chisel. Such prompt treat- 
ment will often save the life of the patient, and may even permit 
recovery without necrosis of the bone, though this is rare. 




TUMORS 

Ganglion. There is a cystic tumor often found in the upper 
extremity, and especially about the wrist, which is called a gan- 
glion. It consists of a fibrous capsule, intimately connected with 
the capsule of a joint, or with a tendon sheath, and a synovial 
lining, and it is filled with a thin, clear, sirupy fluid. Its cavity 
may or may not be continuous with the cavity of the joint or 
tendon sheath. The origin of a ganglion is a matter of dispute. 
Some observers believe that it is a true hernia of the joint capsule, 
and others assert that it is a fibrous tumor, growing from the 
fibrous capsule of the joint or tendon sheath, the center of which 
undergoes degeneration, and contains fluid ; and that this degen- 
eration may extend until the cavity of the joint is opened. 




FIG 224. GANGLION OF WRIST. Patient a man aged fifty-nine years. 

445 



446 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

The most common situation for a ganglion is the back of the 
wrist, in the space between the tendon of the long extensor of 
the thumb and the long extensor of the index-finger, where it is 
intimately connected with the capsule of the joint. It frequently 
follows some overexertion, and the patient will say that he felt 
something give in the wrist-joint. A few days later a little puffi- 
ness will appear, which will increase in size and hardness as time 
goes on. Such a tumor may remain for months without much 
alteration, or it may gradually increase in size while tending to 
weaken the joint and to make its use painful. There is usually 
very little pain in the tumor when the hand is kept at rest.. The 
overlying skin is freely movable and is not altered in appearance 
(Fig. 224). 

If left to itself a ganglion tends to increase slowly in size 
until it is an inch or more in diameter. 

TREATMENT. The old treatment for a ganglion was to 
make it tense by flexing the hand, and then to rupture it by a 
sharp blow with a heavy book. If the blow succeeds in breaking 
the sac the fluid contents escape into the surrounding tissue. 
Pressure made by means of a coin and a strap of adhesive plaster 
for a couple of weeks may cause the sac walls to grow together 
and so to obliterate the cavity. Usually the cavity refills and the 
patient is as bad off as ever. It often happens also that the wall 




Fia. 225. GANGLION OF THE WRIST. Lateral view to show the elevation of the 



tumor. 



of the sac is so firm that it will not rupture, or that the amount 
of fluid contained in the tumor is so slight that its size is not 
much diminished by its removal. A more rational treatment con- 
sists in the complete removal of the tumor through a longitudinal 
incision, the connection with the joint being closed, if it exists, 
by a ligature or a suture. This operation may be performed with a 



GANGLION 447 

local anesthetic, as the tissues are readily anesthetized. A longi- 
tudinal incision is then made in the skin, about half an inch 
longer than the diameter of the tumor (Fig. 225). The tissues 
are carefully divided until the fibrous capsule of the ganglion is 
reached. The top and sides of the ganglion are then fully ex- 
posed by blunt dissection (Fig. 22G). If the ganglion is a small 





FIG. 226. GANGLION OF THE WRIST. The skin has been 
incised and reflected back from the surface of the 
tumor. 



one, and has a slender pedicle, this blunt dissection may be con- 
tinued all around and beneath it until it is lifted from its bed, 
and the pedicle is ready for the ligature. In most cases, however, 
time is saved, and, the dissection is rendered easier and less pain- 
ful by opening the ganglion and evacuating its contents as soon 
as the sides of the capsule have been dissected free. It should 
then be split throughout its length so that the surgeon may obtain 
a clear view of its base and attachments. Nothing is to be gained, 
and needless injury may be inflicted by the attempt to remove it 
before it is opened, for the dissection of the base is the most diffi- 
cult part of the operation, and the only part which it is hard 
to make absolutely painless. The whole of the sac should be dis- 
sected away, and its attachment ligated and divided (Fig. 227). 
If the sac is closely attached to bone, ligaments, or tendons, the 
outer portion of the sac may be left as long as its lining is removed. 
A ganglion sometimes recurs after a careful excision. 

Another method of treatment which often yields a prompt and 
painless cure is the injection into the sac of the ganglion of twenty 
or thirty minims of a mixture of equal parts of crystals of chloral 
hydrate and carbolic acid. These two crystals when mixed imme- 
diately form a fluid sufficiently thin for injection through an ordi- 



448 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

nary hypodermic needle. Before making the injection it is desira- 
ble to withdraw the greater part of the contents of the ganglion. 
Sometimes the contents are fluid ; more often they are like jelly. 
Hence the aspiration should be made with a needle of large cali- 




FIG. 227. GANGLION OF WKIST, SHOWING THE LIGATION OF THE SAC. 

her, and the suction must be supplemented by strong pressure upon 
the sac. The injection of the carbolic mixture causes little if any 
pain. There may be some edema for a couple of days, but soon 
the sac shrinks, and. may entirely disappear after a single injec- 
tion. Unfortunately, the cure thus easily obtained is not always 
permanent. 

Another method of treatment is the insertion, of a needle by 
means of which numerous punctures are made through the sac, 
and its lining is scratched, and indeed the sac itself is torn to 
pieces as far as possible. This procedure should be followed by 
continuous pressure for several days to obliterate the space in 
which the fluid was contained. 

Aneurism. An arterial aneurism, the result of a punctured 
wound, is sometimes seen in the hand or wrist. When an aneu- 
rism due wholly to internal causes develops in the upper extrem- 
ity, it is likely to be found in the brachial artery. 

These tumors are small, smooth, elastic, compressible, and 
pulsating. They can be mistaken for some tumor overlying a 
normal vessel. Thus a ganglion of the wrist may lie on the radial 



VARIX 



449 



artery and transmit (lie pnlsal ion from llie vessel, just as a cold 
abscess may transmit pulsation from an underlying artery. A 
careful examination \\ill di H'erent iate tliis transmitted pulsation 
from a true expansile pulsation. 

The best treatment for aneurism of the upper extremity is dis- 
section and ligation of the vessel involved both above and below 
the aneurism with chromic catgut. The blood-supply is so free 
that gangrene need not be feared. The wound should be com- 
pletely sutured. 

Varix. One or more veins may be dilated, forming either a 
single smooth swelling (Fig. 228) or a more or less dilated and 




FIG. 228. NEVUS OF HAND, OF SEVEN YEARS' DURATION. Patient a girl aged 
ten years. The tumor disappeared completely when the hand was held up. 

tortuous one (Fig. 229). Such a dilation is called a venous 
aneurism or a varix. If such a tumor connects with an artery, 

it may pulsate faintly. A characteristic sign is its almost com- 
31 . 



450 TUMORS AND DEFORMITIES OF THE ARM AND HAND 



plete disappearance on steady compression, combined with eleva- 
tion of the arm, and its reappearance as soon as the pressure is 
removed, it is also softly fluctuating and gives . a bluish shade 
to the overlying skin. 

The treatment is the double ligation of the vessels with or 
without removal of the dilated portion. If a removal "of the ves- 
sels' is decided upon, 
it is well to place 
an Esmarch bandage 
around the arm be- 
fore operation, and to 
ligate all visible cut 
vessels before remov- 
ing the bandage, as 
bleeding from these 
dilated veins is very 
free. If an Esmarch 
bandage is not em- 
ployed, the dissection 
and ligation should 1x3 
carried on from below 
upward in order to 
avoid cutting and li- 
gating the same vessel 
several times. 

Inclusion Cyst. 
Sebaceous cysts do 
not occur in the hand, 
but similar cysts, lined 
with epithelium, are 
found in the skin of 
the, palm. They are thought to be due to inclusion of epithelial 
cells, either during the embryonic period or postnatally, as a 
result of traumatism (Fig. 230). A cyst of this character is 
smooth, tense, possibly fluctuating, and intimately attached to the 
skin, which cannot be moved over it. It most nearly resembles a 
fibroma in physical characteristics. It should be removed entirely. 
This can usually be performed in such a manner that the wound 
can be closed by sutures. If not, the resulting small granulating 




FIG. 229.- 



- EXTENSIVE TORTUOUS VARICES OF HAND 
AND ARM. 



LIPOMA 



451 



\\ouml will soon become covered by growth of epithelium t><>m 
its edg'-s. 




FIG. 230. INCLUSION CYST OF PALM. 



Lipoma. This is a common tumor in the upper extremity, 
where it occurs both singly ami in groups. A simple lipoma ( Fig. 
231), having the characteristics already described on page 137, 
when it occurs in the arm, can hardly be mistaken for anything 




FIG. 231. SIMPLE LIPOMA OF ARM. 



else; in the haml it may be confused with fibroma, or one of the 
other tumors mentioned below. The technique of its removal is 
given on page 137. 



Multiple Lipomata. Lipomata of the arm, occurring in group.-., 
appear to be hereditary. The tumors are situated in the subcu- 
taneous plane of fatty tissue, and can be easily removed ; but as 
they do no harm, and evince no tendency to malignancy, their re- 
moval is not indicated except upon esthetic grounds. 

Fibroma and Fibrolipoma. Fibroma occurs as a smooth, 
flabby, or firm tumor, either in or closely attached to the skin. 
It grows slowly, usually without pain. Jt is not compressible, 
as a -varix is ; it has a uniform consistence, and is covered by nor- 
mal skin (Figs. 232, 233, and 234). A tumor of this cliaraHrr 




FIG. 232. FIBROMA OF MIDDLE FINGER. Duration six years. Thought to have de- 
veloped from the sting of some insect. Patient a man aged forty-five years. 

often gives a distinct wave of fluctuation, which is very decep- 
tive. There is usually this difference, however: Fluid in a firm 
sac, if pressed upon, will give a much quicker fluctuation wave 
than when no outside pressure is applied. Outside pressure upon 
a solid tumor, such as" a soft fibroma, has little effect upon its 
fluctuation wave, since the pressure is not at once distributed 
equally in all directions. 

A fibroma may contain fat, and is then often spoken of as a 
fibrolipoma. This makes a softer tumor than a pure fibroma. 
The differentiation between fibroma and liponm is 'not very im- 
portant, since the prognosis -and treatment are similar. 

It is, however, very important to differentiate fibroma and 



1 |i',i;o.M.\ AND FIBROLIPOMA 



453 



snrroma. At :m enrlv slime of tlio hitter this m:iy !>< impossible 
exeepl bv miemseopie examination. Hoili nmv be sol'i or hurd. 



FIG. 233. SAMK SUBJKCT AS FIG. 232. Radiograph showing the bone not In In- 
affected. Compare Figs. 236 and 237 on pp. 455 and 456. 

The safe plan is to remove every growing tumor, and to subject 
it to microscopic examination. The wound should be closed by 




FIG. 234. FIBROMA OF HAND. 



454 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

suture, in order to await the report of the pathologist after his 
examination of numerous sections of the hardened tumor. In 
such a case it would be unwise to base the extent of operation upon 
an examination of frozen sections; for the similarity of fibroma 
to some forms of sarcoma is so great that a positive decision is 
difficult, even from the very best sections. 

If it is found that the tumor is a fibroma no further operation 
is necessary, and the patient has been spared the unnecessary loss 
of time. If it proves to be a sarcoma, a further extensive removal 
of adjacent tissue will be necessary. It has been my experience 
that patients will almost invariably submit to a second operation, 
should such be found necessary, if the exact plan of procedure is 
explained to them before the first operation. 

In some cases a fibroma may be mistaken for the lesions of 
tuberculosis or syphilis. Such a mistake is unlikely, and should 
soon be corrected by the progress of the inflammatory disease. 




FIG. 235. PAPILLOMA OF WRIST; FIBROLIPOMA. 

A ganglion should be differentiated by the fact that it is cov- 
ered by movable normal skin. The skin over a fibroma is closely 
attached to the tumor. 

An inclusion cyst is to be known by its development in the 
palm, by its fluid fluctuation wave, and by its different consistency 
near its margin and at its center.. 



NEUROFIBROMA 



455 



Finally, a fibroma may be so hard as to simulate an osteoma. 
The latter is of course immovable in the bone, while the fibroma 
is movable, at least to a short distance. Radiographs will clearly 
differentiate the two tumors (see Figs. 237, p. 456, and 239, 
p. 457). 

Papilloma. A fibrous and fatty tumor in other words, a 
fibrolipoma if pedicled, is called a papilloma. Such a tumor 




FIG. 236. OSTEOMA OF FINGER. 



is covered with normal or slightly hypertrophied skin, and it 'is 
attached to the body by a neck smaller than the mass of the tumor 
(Fig. 235). This type of tumor is commoner upon the trunk 
than upon the extremities (see p. 185). 

Neurofibroma. Contusion or wound of a nerve may lead 
to the development of a fibrous tumor in the nerve trunk. This 



456 TUMORS AND DEFORMITIES OF THE ARM AND HAND 



form of tumor reaches its maximum growth in the stumps of 
nerves after amputation, and especially in the lower extremity. It 
is also found in the palmar nerves of the hand, under the circum- 
stances mentioned, and sometimes causes the patient great pain. 




FH;. 237. SAME SUBJECT AS FIG. 236. Radiograph of osteoma. Note commencing 
t similar growths in the first phalanx of the same finger, and of the adjoining 
finger. 

The best treatment is dissection and removal of the visibly affected 
portion of the nerve, and a clean division of the trunk of the 
nerve, a little above the incision in the skin. This is to lessen 
the risk of pressure of its stump in the scar. Recurrence some- 
times hikes place. 

Osteoma. Osteoma of a small bone has the same character- 
istu-s as osteoma of a large bone, viz., it is a hard painless tumor 



457 



of slow growth, covered 1>\ normal movable skin, while it i- 
iirmlv attached to the hone from which it grows (Figs. 230 ;md 
_-'57). It niav be mistaken for a periosteal sarcoma, or a dense 
fibrolipoma. The former has nsnallv a more rapid growth, and 
the latter is less hard, and ahvavs somewhat movable on the under- 
lying hone. Iii such doiihli'ul cases a radiograph is a necessity 
(Figs. L'.'I.S jind :?'!!>). The radiograph of this ostcoma is in-.-t 
instructive on another account. Careful inspection will show 





FIG. 238. FiBHoi.iroMA OF FINCKK. 
Same subject as Fig. 239. 



FIG. 230. HADIOGKAIMI <>K I IHHOI.IPOMA 
OF FINGER SHOWING NORMAL, BONES. 



that two similar tumors were developing in the first phalanges 
of the second and third digits. Their presence was not suspected 
until the radiographs were made, hut one of them was palpahle 
when attention had been called to it. 



458 TUMORS AND DEFORMITIES OF THE ARM AND HAND 



An osteoma should be removed. The skin is incised longi- 
tudinally at a distance from the tendons, and the osteoma exposed 
by dissection and retraction of the soft parts. The tumor should 
then be chiseled away. It is not necessary to remove the bone 
from which an osteoma springs, unless there is a suspicion of 
sarcoma; and even in that case it is better to await the result of 
the microscopical examination when one can act intelligently and 
as radically as the facts warrant. 

Granuloma. Granulations may grow above the surface of 
a wound, and prevent the epidermis from growing over the wound. 
Such exuberant granulations are spoken of as proud flesh. They 
may be cut away with scissors and the free bleeding stopped with 
pressure for a minute, or they may be burned down by touching 

them with solid nitrate of sil- 
ver. If of long standing in a 
small wound, they become firm- 
er in texture and pedicled in 
shape, and present somewhat 
the appearance of a sarcoma. 
Such a mass is called a granu- 
loma (Fig. 240). 

A wart is a tumor of the 
epidermis, of papillary struc- 
ture and usually elevated above 




the level of the normal skin. 
Warts usually develop in the 
skin of the hands, and during 
childhood, but they are also 
found in other situations and in 
adult life. Their cause is not 
known. If a wart is so situated 
that it can develop freely it may 
attain a height of one-eighth of 
an inch, and a diameter of one- 
third of an inch or more. The 
top is flat and shows numerous 
clefts between more actively 

growing points. This gives the surface of an old wart something 
of a cauliflower appearance (Fig. 241). If situated where it is 



Fia. 240. GIIANUI.OMA OF FINGER. 



WART 



459 



irritated, for example, on the knuckle or along the nail, a wart 

is apt to crack and bleed and to give some pain. If situated under 

very tough epidermis, fur example <,n the palmar .>ide of .the 

lingers or hand, the wart is often confined in its growth, so that 

its papillary character 

is less evident, and it 

a p| tears more as a hard, 

tender tumor covered 

by thick epithelium 

and rising little above 

the skin surface. If 

the surface epithelium 

is shaved off, its true 

papillary structure will 

be evident. 

TREATMENT. The 
warts that appear in 
large numbers on the 
backs of the hands of 
children, usually disap- 
pear spontaneously, or 
after some local treat- 
ment. Single warts oc- 




curring in adult life 



FIG. 241. OLD WART OF L\DKX-KI.\.I:H. 



are not so easily dis- 
lodged. They may be removed by the knife (it is only necessary 
to remove the whole thickness of epidermis not the corium), or 
by caustics. Monochloracetic acid is the best for this purpose. A 
small crystal should be picked up with a moistened toothpick and 
placed on the wart. The moisture will fuse the crystal without 
diluting it unnecessarily. 

After three minutes, or sooner if the patient feels that it 
burns, it should be wiped away. In three days the burned tissue 
should be pared away and a drop of acid be applied to the living 
tissue beneath. This process should be repeated as often as is 
necessary until the wart, including its growing base, has been 
completely destroyed and removed. Too frequent applications of 
acid will make the part sore; too infrequent applications will allow 
the wart to grow in the intervals enough to make up for the par- 



460 

tial destruction. A weaker caustic, such as a saturated solution 
of bichromate of potash, may be painted on every day. This 
treatment is more suitable to place in the hands of the patient 
himself. Treatment by acid, if judiciously carried out, is pain- 
less, avoids the use of any dressing, and the permanent loss of 
any skin. Treatment by the knife is quicker, but it necessitates 
a dressing and usually' the loss of a bit of skin. If the wart is 
covered by thick epidermis (palm of hand, sole of foot), it can still 
be removed by acid, if the rules given are persistently carried out. 
Here, however, the two methods of treatment may be happily 
combined by injecting cocain and shelling out the wart with a 
curette, and cauterizing the base of the wound with acid before 
the anesthesia is over. 

Epithelioma in the upper extremity usually develops on the 
back of the hand in an individual more than sixty years old. It 




Fio. 242. METASTATIC CARCINOMA OF THE BONES OF THE HAND FROM CARCINOMA 

OF THE BREAST. 

may follow an injury, although usually there is no history of any 
traumatism other than the knocks and bruises to which the hand 
of a worker is frequently subjected. 

More often it develops in one of the scaly patches so common 



EPITHKLln.M \ 461 

mi the hands of the aged. It is generally of very slow growth, 
appearing for months as a shallow ulcer which bleeds easily and 
may heal in part but not wholly; later the growing margin is more 




FIG. 243. THE SITE OF THE ORIGINAL TUMOR OF WHICH THE TUMORS SHOWN IN 
FIG. 242 ARE METASTASES. 

evident. Metastases do not form early, and it takes a long- time 
for the growth to extend In-low ihe skin. Therefore, in m.i cases 
the removal of an elliptical piece of skin containing the ulcer will 
give a permanent cure. (For the details of such an operation see 
Chapter XX.) 

In giving a prognosis it is well to remember that any other 
scaly patch may undergo similar degeneration, so that this risk 
must be added to the slight risk of a recurrence after ex- 
cision. 

Carcinoma in the hand a rnctastatic tumor from carcinoma 
in some other part of the body is a rarer form of malignant 
growth. Such a ease is shown in Kigmv i'!^, ami the original 
tumor in Figure 243. There is, of course, no treatment for such 



462 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

metastatic tumors, unless pain or ulceration should make amputa- 
tion desirable. Usually these symptoms are obscured by the more 
serious symptoms of the primary growth or metastatic tumors in 
more vital parts of the body. 

Sarcoma. A sarcoma is a connective tissue tumor, and is 
therefore found in every part of the body. In the upper extrem- 
ity it usually originates, in the skin or in one of the bones. In the 
former situation (Fig. 244), it must be differentiated from fibroma 
and fibrolipoma, and also from the lesions of syphilis and tuber- 




Fio. 244. TUMOR OF HAND, SAID TO HAVE EXISTED TEN YEARS. The lesion was 
considered tuberculous, until the pathologist pronounced it spindle-celled sar- 
coma. The patient was a man aged thirty years. 

culosis. Sarcoma of a bone may be mistaken for osteoma or 
enchondroma, and also for the lesions of tuberculosis and syphilis. 
It is true that mistakes in diagnosis are most likely to be made 
at an early stage of the growth, but it is just at that time that a 
complete removal of the growth is possible; therefore, an early 
exact diagnosis is most important. If this cannot be made certain 
hi any other way, a section of the growth should be removed for 
microscopical examination. 

The only treatment for a patient with sarcoma of the upper 
extremity is thorough removal of the tumor and the tissue from 
which it springs, even though an amputation of hand or arm be 



CICATHK i \i. CONTB \< im.MS If,:; 

to accomplish this object. (For minor amputations see 
p. 390.) 

An operator is placed iii ;i Irving situation if lie cuts into a 
supposedly benign growth, and finds from its appearance that it 
is probably a sarcoma. If it can be freely removed without the 
sacrifice of important structures, this is evidently the course to 
pursue. Tsually the case will stand thus: The appearance of the 
tumor indicates malignancy, and yet a microscopical examination 
is necessary to determine this fact with certainty; the tumor i- 
so situated that to cut wide of its margin will destroy some im- 
portant structures. 1'nder >udi circumstances the >urn-oii -hoiild 
remove a section of the growth for examination and close the 
WOUnd, . stating the case frankly to the patient. After the mi- 
croscopic examination has been made the appropriate o]>erH- 
tiou can he performed. This plan is far better than an im- 
perfect removal of a sarcoma: for once the visible tumor is 
removed, the patient will almost certainly forbid a second 
operation in the hope that all of the tumor has been removed, 
and consent will not aa'aiu IK- obtained until the tumor is pal- 
pably re turning. In this way valuable time is ]<\, and the 

chance of radical removal lessened. The effect on the patient's 

.- . 

mind is quite different when the -uri:eon explains to him be- 
fore the first o | ie rat ion -the possibility of malignaiicv and a - 

1 

ond operation ( see p. t53). 

i i / 

ACQUIRED DEFORMITIES 

Cicatricial Contractions. The usefulness and beauty of 
the hand is greatly impaired by the cicatricial contractions follow- 
ing burns and severe inflammations (Fig. 245). (See also Y\^-. 
206 and 207, pp. 421 and 422.) If the damage is done in infancy, 
the deformity may actually increase with the growth of the parts. 
Hence the desirability of performing what restoration is possible 
before the fingers develop along abnormal lines. In many cases 
no treatment is indicated; in others plastic operations or skin- 
grafting may give a greater range of motion, or improve the 
position of the parts. In such cases there will always be a par- 
tial recurrence of the deformity, due to contraction of the new 
formed scar tissue. 



464 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

A certain amount of contraction also follows the successful 
application of a Thierscli graft. Therefore if the raw surface 




FlQ. 245. ClCATHICIAL CONTRACTIONS FROM BURNS IN INFANCY. 

which follows the dissection of the cicatrix cannot be covered by 
an attached flap of skin, a Wolfe graft should be employed. 
It will often be necessary to lengthen the tendons in order to 




Fro. 246. DIAGRAM TO SHOW A QUICK METHOD OF LENGTHENING A TENDON 
WITHOUT SUTURE WHEN THE TENDON is OF SUFFICIENT SIZE. 



DUPUYTREN'S CONTRACTION 



lor, 



>lt;iiii complete extension. This can be quickly accomplished 
without the use nf sutures I iv making l\v overlapping I. -haped 
iuri-iipiiv in each trillion (Fig. L' H>). Or the ten<|i.n may be 
divided obliquely and sutured. 

One should be careful not to sacrifice strength simply to gain 
a wider range of motion. A badly displaced u-eless finger is often 
justly amputated. 

Dupuytren's Contraction. This is a contract ion of the 
palmar fascia, which comes on gradually in per-oiis who work 
hard with the handle of ; m instrument 
in the palm. The fascia is thickened 
and drawn into distinct bands, which 
seem like cords extending to the various 
fingers, especially to the ring and little 
lingers. Complete extension of the fin- 
gers is then impossible (Fig. 247). The 
skin is puckered in places hy the traction 
upon it from the contracted I'a-cia. 

The only satisfactory treatment of 
this trouble is the removal of the thick- 
ened fascia after its dissection from the 
skin, and the underlying structures. 
When the fascia is removed, the fingers 
can be extended. There is some tend- 
ency to recurrence of the condition, but 
in a less marked form, so that operation 
is amply justified. It is performed as 
follows: After local or general anesthe- 
sia, a longitudinal incision is made 
through the skin of the palm at the site 
of the greatest contraction. It should 
usually be from two to three inches long. 
The skin is divided as deep as the fascia, 
and the two skin edges are dissected 
away from the contracted fascia for about an inch on either side. 
This is the essential part of the operation. ( 'are should be taken to 
keep these skin flaps thick so they will not slough. Xext the thick- 
ened and contracted fascia is divided, dissected from the deeper 

structures to which it is attached by numerous septa, and removed. 
32 




FIG. 247. DUPUYTREN'S CON- 
TRACTION OF Six MONTHS' 
DURATION. Maximum pos- 
sible extension of finders 
sliosvn. Xotc tin- pucker- 
ing of the skin, where it is 
ii'lhiTcnt to tin 1 tliirkt'iu-tl 
fascia. 



466 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

The fascia is sometimes thickened into cords like tendons, so that 
one who is performing this operation for the first time may hesi- 
tate to cut them. There are two unmistakable differences. The 
tendons are always the color of ivory; the fascia is pearly white. 
The tendons never lie immediately beneath the skin as the fascia 
does. After removal of the fascia the wound should be sutured 
and the hand kept on a splint fully extended for several weeks. 
Active and passive motions should be made as soon as the wound 
has healed, but to prevent return of the contraction, full extension 
on a splint should be kept up a part of each day or at night for 
several weeks. 

In slight cases multiple V-shaped incisions with forced ex- 
tension will accomplish something, but this treatment is gen- 
erally unsatisfactory on account of the intimate attachment 
of the skin and fascia. 




FJQ 248. RADIOGRAPH or THE HAND OF AN INFANT, ALL THE BONES NORMAL, 
AND ALL THE FINGERS WEBBED The other hand was perfect. 



WEB-FINGER 



467 



CONGENITAL DEFORMITIES 



There are four types of 
congenital deformity seen 

ill the upper extremity, 
vi/., ircl)-/iii;/cr, .s-H/wr/m- 
)inTari/ /iix/cr. It ;/ fieri r<>- 
l)hy y ami deficiency of one 

or more liniMTs, m- some 
greater portion of the hand 
or arm. 

Web - Finger. Web- 
finger occurs in varying de- 
grees. In the simple cases 
there is merely an exten- 
sion of the normal web be- 
tween the fingers, all of the 




m 






Fid. 250. -I,\risioN AND Si ii in H.I; \\M:- 
FINGER. The incisions are not made in 1 In- 
best situations. < >ne should be more pal- 
mar and one more dorsal. Same subject 
as Fig. 249. 



Fir;. 249. THE HAND OF Cnii.n 
SHOWING CONGENITAL DEFORM- 
ITY. One finger is missing, and 
the other is represented by its 
distal portion only, the nail and 
terminal phalanx of which are 
closely joined to its fellow. 
Drawn from a photograph. 



bones of which are normal- 
ly formed (Fig. 248). In 
severer cases the bones lie 
much closer together, or 
may be fused, or some of 
the bones may be wanting 
i IM- -'-1!0. Web-fingers 
should be separated early 
by operation, so that as 
growth takes place the fin- 



gers may develop individually, but it is better to defer operation 
till the child is a year old, as a very young infant does not stand 
well the loss of blood. Operation consists in the division of the 
skin which forms the web, and the closure of the wounds on each 
finger by suture as far as possible. The incisions for this purpose 
should not be exactly opposite as they were in the case shown in 
Figure 250, for the web will then partly recur by granulation of 
the. wounds at the bottom of the fingers. A better plan is to 
make the incision on one finger ventral, and on the other finger 
dorsal. 

During recovery from the operation care should be taken to 
keep the fingers as widely separated as possible, and their active 
use should be encouraged as soon as the skin has united. 

Supernumerary Finger. The superfluous member may 
be attached to the normal portion by skin only, or by its bony 




FIG. 251. SUPERNUMERARY THUMB SPRINGING FROM THE FIRST PHALANX OF THE 
NORMAL THUMB, WITHOUT ARTICULATION. 

structure. In the latter case, there may be an articulation or the 
bone of the superfluous finger may spring direct from a normal 
shaft (Figs. 251 and 252). 

A supernumerary finger or thumb should be removed. Even 
if the extra member is articulated with the hand, its .possible use 
in no wise compensates to the individual for the unpleasantness 



TOO MANY ACCl'ISSonv TENDONS Hi!) 

of such an abnormality. If the attachment is of skin only, thi- 
should be divided. If there is an articulation, the line of -cpara- 
tion should pass through it. If the attachment is a hony one, 




Fia. 252. RADIOGRAPH OF SUPERNUMERARY THUMB. Note how the phalanx has 
developed abnormally. Operation in infancy would have prevented this. Same 
subject as Fig. 251. 

enough bone should be cut away to restore the normal contour 
of the bone from which the supernumerary finger springs. In 
all cases care should be taken to leave sufficient skin to cover the 
wound readily. These operations should be performed in infancy. 
The loss of blood is extremely slight so that they need not be 
deferred until the child is a year old. 

Congenital Hypertrophy and Congenital Deficiency 
of one or more fingers are conditions in which surgical interfer- 
ence is usually not indicated. Amputation of a part of a hyper- 
trophied finger, or of a useless undeveloped finger, needs no fur- 
ther explanation than that given for amputation of a finger on 
page 390. 

Too Many Accessory Tendons. The accessni-v tmdm* 
on the hack of the hand, the vinciihe which bind the extensor ten- 



470 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

dons together and add to the strength of the hand when used as 
a whole, greatly impede the action of the individual fingers. For 
some occupations and in some persons they may fairly be considered 
congenital deformities. The ring-finger (fourth digit) suffers the 
most, as its extensor tendon often has branches extending to those 
of the middle and little -fingers. Full extension of the fourth digit 
is then impossible unless the third and fifth arc at least partially 
extended. This is a distinct disadvantage for one who would 
play the piano or violin, and pupils often spend many weary hours 
trying to increase the range of motion of the affected finger. 
Some gain in motion may follow such practise, especially at an 
early age, but a far better plan is the removal through a short 
incision of the limiting accessory tendons. This slight operation 
will at once greatly increase the range of extension of the finger 
which is freed and will not materially weaken the hand. The 
operation is performed as follows: 

After preparation of the skin and injection of cocain, a longi- 
tudinal incision should be made through the skin directly over 
the accessory tendon to be removed. Its sheath should be exposed 
and opened, and at least an inch of the accessory tendon should be 
resected, so that it may be cut off flush with the sheath of the main 
tendon. The sheath of the accessory tendon should also be resected 
and the cut ends closed, each by a stitch or two of fine catgut. 
The skin wound should be closed by interrupted sutures or a sub- 
cuticular one (p. 573), and a dry gauze dressing applied. The 
stitches should be removed in five days. 

The resection of the accessory tendon sheath, and the closure 
of its cut ends, is to prevent the reformation of the accessory 
tendon. Even if this does take place it is several weeks before 
the new tendon becomes firm, and during this period the patient 
has an opportunity to extend the finger in question to a far greater 
extent than formerly. The gain thus made will be largely per- 
manent. Exercises should be begun a few days after the wound in 
the skin has united say in ten days. 



SECTION VII 
AFFECTIONS OF THE LEG AND FOOT 



CHAPTER XVII 
INJURIES OF THE LEG AND FOOT 

Contusions and Abrasions. Contusions and abrasions of 
the lower extremity are perhaps oftencst found upon the shin. 
The circulation of blood is less active in the leg and foot than in 
any other part of the body; hence, wounds do not heal as readily 
in these parts, and bruises or slight breaks in the skin, trivial in 
themselves, may become starting-points for serious inflammations. 
Therefore, every injury of the lower extremity should receive 
prompt and efficient treatment. If it is situated below the knee, 
the skin should be carefully cleansed, and a dry gauze dressing or 
a moist antiseptic dressing should be applied to it, and the limb 
bandaged from the toes to the knee, at least until repair is well 
started. As the heel never swells much, it should be left bare, 
unless it is wounded. Such a bandage will prevent edema and 
facilitate the circulation of the blood in the limb. Above the knee 
the circulation is better, and repair takes place more rapidly. 

Blister. Unaccustomed exercise and ill fitting shoes are re- 
sponsible for most of the blisters which develop on the foot, usually 
on the heel and toes. They may contain clear serum or bloody 
serum. Often they have been broken accidentally or intentionally 
before the doctor sees them. The fluid should be evacuated from 
the others by the passage of a sterile needle obliquely through the 
sound skin at the edge of the blister. Cleanliness should be ex- 
treme in order to avoid infection. Tender and abraded surfaces 
should be treated by cold cream, or by a moist antiseptic dressing, 
according to the severity of the lesion. Cold bathing and rubbing 
the sound skin with alcohol will toughen it and render less likely 

the formation of blisters. 

471 




FIG. 253. HEMATOMA OF FOOT PRODUCED BY A SLIGHT TURN OF THE ANKLE. Pho- 
tograph six hours after the accident. 




Fio. 254. HEMATOMA UNDER LEFT GREAT TOE,NAIL. Note the elevation of the nail 

beneath the skin as far as its matrix 
472 



HEMATOMA 



473 



Hematoina. For the diagnosis of a hematoma the reader is 
referred to page 2. If the amount of effused blood in a hema- 
toma is small (Fig. 253), it may safely remain undisturbed for 
resorption. If the quantity of blood is large, it should be removed 
through a longitudinal incision, and the wound sutured. If the 
patient is first seen some days after the injury, the blood clot may 
have softened sufficiently to permit its extraction through a large 
hollow needle. 

Hematoma under a toe-nail (Fig. 254) presents the same symp- 
toms and demands the same treatment as hematoma under a finger- 
nail (p. 325). 

Subperiosteal hematoma (Fig. 255) is less easy to diagnose, 
since it may exist without discoloration of the skin. It is usually 




FIG. 255. SuBPERiosTEAt, HEMATOMA OF THE HEAD OF THE TIBIA; THREE WEEKS 
OLD FROM TRAUMATISM. The joint was not involved and contained no fluid. 
Patient a man aged forty years. 

due to a direct blow. It gives a tense, rounded, fluctuating, ten- 
der swelling, immovable on the bone, and covered by movable skin. 
It must be differentiated from a contusion of periosteum (less 



474 INJURIES OF THE LEG AND FOOT 

swelling and no fluctuation) ; from a serous effusion under the 
periosteum (different fluid on aspiration) ; from a subperiosteal 
abscess (greater tenderness, edema of surrounding tissues, fever, 
etc.); from a fracture (usual signs, especially pain on pressure 
made on the two ends of the bone, radiograph) ; from syphilitic 
gumma ; from tuberculous osteitis, and from sarcoma. The three 
last mentioned lesions develop gradually, and often without trau- 
matism. Under certain circumstances fluctuation is present in all 
three, but the fluid, if aspirated, will be, in the case of gumma, a 
straw or orange colored thin sirup ; in tuberculous osteitis, a thin, 
flaky pus ; and in sarcoma, pure fresh blood ; while the fluid from 
a hematoma is dark, abnormal blood. The radiographs of the three 
lesions are also different, and a gumma will often diminish very 
much in size after a few days' treatment with potassium iodid. 
The treatment of hematoma is given above. After either aspira- 
tion or incision a firm bandage should be applied to prevent recur- 
rence. 

Rupture of a Vein. Rupture of a vein of the leg may 
be followed by a serious loss of blood. The vein which bursts 
is always varicose, and the overlying skin is much atrophied on 
account of this varicosity. A previous ulceration and cicatrization 
may also be present, though this is not necessary. The rupture 
of the vein usually follows some slight traumatism. The opening 
is small, and light pressure applied directly to it readily controls 
the bleeding. The wound should be cleansed (p. 13) and a 
sterile gauze compress bandaged over it and left in place for a 
few days. Ligation of the vessel is not often called for. To 
perform this operation, make a skin incision parallel to the vein, 
free the vessel for a half inch or more, pass a double catgut liga- 
ture about it, tie it above and below the rupture, and then cut 
the vein in two. Suture the incision in the skin and apply a dry 
dressing. 

Subcutaneous rupture of a vein also occurs, due either to direct 
violence or to indirect violence. When it is due to a sudden 
strain or to a fall, the presence of effused blood may lead to a 
false diagnosis of fracture. For the treatment of the resulting 
bematoma see page 3. If hemorrhage continues in spite of pres- 
sure, a free incision should be made and the bleeding vessel exposed 
. and ligated. The wound should be sutured. 



WOUNDS 475 

Rupture of Tendon. The slender tendon of the plantaris 

muscle sometimes snaps as the result of sudden tension. This acci- 
dent causes a sharp pain in the back of the leg, as if a smart blow 
were given with a stick. Soreness and lameness follow, lasting a 
few days. There may or may not be a slight ecchyraosis appear- 
ing on the surface after a few days. The only treatment required 
is warm bathing and rubbing, to overcome the soreness. The 
accident is not a common one. 

Wounds. While there is nothing peculiar in the diagnosis 
of wounds of the lower extremity, it is desirable to emphasize the 
importance of thorough treatment of even trivial wounds when 
they occur in the aged or others whose circulation is not the best. 
Many intractable ulcers of the leg and serious infections of the 
foot start in wounds which would have healed promptly had ra- 
tional treatment been given them. An old physician once said to 
the author : " No man ever performed an operation for cataract 
more carefully than I cut my corns." lie was a diabetic, and had 
good reason to be careful ; but infection and ulceration follows care- 
lessly treated wounds of the foot and leg in many persons whose 
resistance has been decreased by nephritis, heart disease, anemia, 
repeated childbirth, and other causes. 

Three common illustrations of the serious trouble which may 
develop from infected wounds are : Ulcer of the leg from a wound 
of the shin; suppuration in the first metatarsophalangeal joint 
from a wound of the overlying bursa ; perforating ulcer of the 
foot from a wound by the side of a callus of the sole of the foot. 

Punctured Wound of a Joint. There are a few special struc- 
tures which may be injured in wounds of the lower extremity. 
The knee-joint may be opened by a wound at either side of the 
patella, or either side of the quadriceps tendon; the ankle-joint 
may be opened by a wound behind, below, or in front of either 
malleolus; the first and fifth metatarsophalangeal joints may be 
opened by wounds at the side of the respective joints. ,If the 
wound of a joint is small and made by a clean instrument, the 
only symptom may be the escape of viscid fluid. In most cases 
there will be, however, some signs of irritation, such as swelling 
of the joint, increased fluid in it, tenderness on manipulation, and 
a limitation of motion on account of pain. If the infection is 
severe, there will be great edema and pain, high fever, chills, etc. 



476 INJURIES OF THE LEG AND FOOT 

In the usual case, if the wound is recent, it should be explored 
up to the joint capsule. If there is reason to believe that the joint 
has not been infected, a drain should be so placed as just to reach 
the capsule of the joint, and the superficial wound should be closed. 
If there is reason to suppose that foreign material has been car- 
ried into the joint, or if infection is already present, the joint 
should be irrigated and drained through a second incision, if 
necessary. (See p. 532.) 

Division of Tendons or Nerves. Every wound should be ex- 
plored for the sake of cleanliness and for the suture of tendons 
and nerves which may have been divided. This complication is 
most likely to follow wounds behind a malleolus or at the front of 
the ankle. The directions for suturing a divided tendon and nerve 
are given on pages 332 and 334. 

Bursitis. There are numerous bursa? in the lower extremity. 
More than twenty are described in the vicinity of the knee-joint, 
but most of them perform their function so perfectly that they 
never come to the notice of patient or surgeon. Of all the bursae 
of the lower extremity, the prepatellar bursa is most often affected, 
and on this account, and because its reactions are typical, its 
lesions will be first described. 

Acute Prepatellar Bursitis This affection is often seen in 
persons who work on their knees, scrubbing floors, laying carpets, 
etc., but is by no means confined to them. While it is true that 
a person kneels on the tubercle of the tibia rather than on the 
patella, yet the latter is constantly bruised and strained in reaching 
or crawling forward. The knee of a woman who scrubs for a 
living shows two calluses, one over the tibial tubercle and one at 
the lower margin of the patella, unless these two are fused in one 
large callus. 

If the prepatellar bursa is distended with fluid, serum, or pus 
or blood, it plainly fluctuates. Sometimes the bursa is situated 
directly in front of the patella, but usually it covers only the lower 
half of this bone, and may extend over a part of the patellar 
ligament. Such variations in situation have no surgical impor- 
tance. It is of the greatest importance to distinguish fluid in the 
prepatellar bursa from fluid in the pretibial bursa, situated behind 
the patellar ligament, and from fluid in the knee-joint itself. It is 
easy to do this if the patient, lying or sitting, is able to extend 



BURSITIS 



477 



the leg horizontally. Tho increased tension of the patellar liga- 
ment will obscure fluctuation within the area covered by the 
ligament, provided that the fluid lies behind it, although fluc- 
tuation at the sides may be made more distinct thereby. If the 
fluid lies in front of the ligament or patella, fluctuation will 
not be affected by extension of the leg. The fat behind the patel- 
lar ligament being 
mere or less con- 
lined, often fluctu- 
ates. If edema is 
present, the result 
of trauma, com- 
parison of the two 
knees may fail to 
clear the diagno- 
sis. A few days' 
rest will reduce a 
swelling due to a 
traumatic edema, 
but will not cause 
the disappearance 
f a bursitis. 

The physical 
signs of bursitis 
are these: A well 
localized fluctuat- 
ing swelling cov- 
ered by movable 
normal skin; nly 
slight tenderness 
and pain; little disturbance of the functions of the adjacent joint 
(Fig. 256). 

Suppurative Prepatellar Bursitis. If the bursa is infected, the 
contained fluid will be purulent ; there will then be edema and red- 
ness of the (issues outside of the bursa, and pain and tenderness 
and impairment of function will be proportionately greater. The 
lesion must then lie differentiated from an abscess in the subcuta- 
neous tissues outside the bursa. In this case the swelling will not 
be so sharply limited, and will probably not correspond so exactly 




FIG. 256. PHEPATELLAR BURSITIS. 



478 



INJURIES OF THE LEG AND FOOT 



to the situation of the bursa. For example, an abscess in the froiu 
of the knee will probably lie more to one side than the other, 
whereas swelling due to suppuration in the prepatellar bursa will 
extend equally toward both sides. It is of course possible for 
suppuration in a bursa to break through the sac and extend into the 

subcutaneous tis- 
sue. In the case 
of the prepatellar 
bursa, such rup- 
ture is usually 
through the skin 
(Fig. 257). 

Chronic Prepa- 
tellar Bursitis 
The acute bursitis 
may subside, the 
fluid being ab- 
sorbed. Usually 
the sac is slightly 
thicker than be- 
fore. With re- 
peated trauma- 
tisms, and reaccu- 
mulations of fluid, 
this organization 
of fibrous tissue 
inside the sac 
may go on until 
its cavity is near- 
ly or quite oblit- 
erated, and a 
slightly elastic 

fibrous tumor occupies the site of the bursa. Such a tumor 
is usually painless, but gives a permanent disfigurement. Fig- 
ure 258 shows a bursa in process of organization, removed by 
operation, and split open. Numerous buds of granulation are 
seen, one of which, lying across the blades of the forceps, is 
almost long enough to attach itself to the opposite wall. Two 
other processes, one slender and one thick, both of which are 




FIG. 257. SUPPURATION IN PREPATELLAR BURSA; RUP- 
TURE THROUGH SKIN FIVE WEEKS BEFORE PHOTO- 
GRAPH; REPAIR BY GRANULATION TAKING PLACE IN 
LOWER PORTION OF CAVITY. Patient a man aged 
seventy years. 



BURSITIS 



479 




also lying on tlio 1>1 ados of tlu- forceps, have already become so 
attached. 

TREAT MK, XT <>K I'KI.I'.VIKI.I ..\i; UIKSITIS. If there is uncom- 
plicated prepatellar bursitis, palliative treatment is permissible. 
Limitation of motion 
by a bandage or a pos- 
terior splint; pressure 
upon the bursa by a; 
bandage or adhesive 
strapping; moist ap-' 
plications or an ice- 
bag to relieve pain; 
and counter-irritants 
such as tincture of io- 
din or guaiacel, are 
suitable remedies. If 
the fluid does not di- 
minish in amount, it 
may be withdrawn by 
aspiration, and the 
part tightly strapped 
with adhesive plaster; 
or twenty minims of 
a mixture of equal parts of carbolic acid and camphor may l>e 
injected into the bin-sal sac. This will sometimes cause the 
disappearance of the fluid, even without aspiration. As it can 
be injected through a small hypodermic needle, it is a less for- 
midable procedure than aspiration, which to be thorough requires 
a good sized needle. Treatment by injection, if successful, leave< 
a thickened bursa. 

If the bursa is infected, it should be split longitudinally 
throughout its whole extent. This may be done under cocain or 
nitrous monoxid. The cavity should be lightly filled with gau/e, 
which should remain for several days to favor granulations from 
the whole of the lining of the bursal sac. When this has been 
accomplished, the gauze may be removed, and the skin edges gradu- 
ally brought together by strips of adhesive plaster, space being left 
between them for drainage. In certain cases a secondary suture 
of the skin is advisable. 



I'm. 258. PROLIFKUATIVR I'HKPATKI.I.AU Hi KSIIIS. 
Hursu removed by operation and split open. 
Note the granulating processes of various lengths, 
some of which have already heroine attached at 
both ends. Said by the pathologist to he tuber- 
cular. Same patient as Fig. 250. 



480 



INJURIES OF THE LEG AND FOOT 



The best treatment for chronic serous or fibrinous bursitis is 
dissection of the bursa (Fig. 259) and suture of the skin. This 
operation demands a general anesthetic in most cases. It is easy 
to free the anterior surface and sides of the prepatellar bursa with 
the help of a local anesthetic, but its base is very adherent to the 




FIG. 259. DISSECTION OF PREPATELLAR BURSA, INVOLVED IN CHRONIC INFLAMMA- 
TION, IN THIS CASE PRONOUNCED TUBERCULAR BY THE PATHOLOGIST. Same 
subject as shown in Fig. 256. Drawn from a photograph. 

patella or ligament, and the pain of this dissection is not easily 
stilled by eucain or cocain. Another reason for the removal of a 
chronically involved bursa is the possibility of tuberculosis. 

Subgluteal Bursitis. One of the bursse in the vicinity of the 
hip may become inflamed as the result of traumatism or tubercu- 
losis. The bursa most often so involved is situated beneath the 
gluteus maximus muscle. It gives a slight oval swelling with 
a little tenderness and limitation of the motions of the hip-joint. 
It may therefore be mistaken for hip-joint disease ; or, as stated 
above, it may be a complication of hip disease. In every case, 
therefore, of bursitis of this region, even if it follows a trauma- 
tism, it is well to bear this fact in mind. 



BURS1TIS 481 

The Bursa Gastrocnemio-Semimembranosa. Then- are other 

luirsie <!' tin- lower extremity which become enlarged with suffi- 
cient frequency I" make them iin]M)rl;iiit. ( >MC i~ the bnrsa under 
(lie tendon <d' (lie seniimembraiiosiis. When distended, a part 
f this hnrsa is palpable in the popliteal space, while the rest of 
it is hidden beneath the inner hamstring tendon-. A mistake in 
diagnosis ought not to occur. A popliteal anenri-m eeiipies the 
middle of the popliteal space and pulsates. An abscess is accom- 
panied by the acute signs of inflammation, which are lacking in 
detention of this bursa ; and even a cold abscess will be accom- 
panied by some local tenderness and loss of function, referable 
to the source of the pus. 

The only treatment worth considering is the removal of the 
bursa by dissection. This is not a serious operation, but it de- 
mands a general anesthetic and several days' rest in bed. In 
about one person in live this bursa communicates with the knee- 
joint, a fact which is no contra indication to operat ion. 

The Bursa Under the Tendo Achillis. The small bnrsa between 
the tendo Achillis and the os calcis sometimes becomes inllained 
as a result of excessive- exercise or a fall or blow; or the trouble 
may come on more gradually, as a complication of gout, rheuma- 
tism, etc. 

The chief symptom is pain at the back of the heel, so that the 
name achillodynia has sometimes been applied to this bursiiis. 
The pain may be continuous, or it ma\ be excited by contraction 
of the muscles of the calf when the patient bears his weight upon 
the ball of the foot. The easiest gait under the circumstances is 
to rotate the leg outward, and to avoid flexion and extension of 
the ankle. 

Treatment consists in the application of heat and counter-irri- 
tants; in the removal of pressure by splitting the heel of the shoe 
or wearing a slipper; in disuse of the foot and in fixation of the 
ankle joint by adhesive strapping or in more severe cases by the 
use of a plaster of Paris splint. In chronic cases complete ex- 
cision of the bnrsa is indicated through two short incisions, one 
on either side of the tendo Achillis. A plaster of Paris splint 
should l>e applied to insure recovery with the foot in a cor- 
rect position, i. e., flexed at least to a right angle and slightly 

inverted. 

33 



482 INJURIES OF THE LEG AND FOOT 

Metatarsophalangeal Bursitis; Bunion. A bursa lying between 
the skin and the head of the first metatarsal bone is exposed to 
pressure from a shoe, and often becomes inflamed. This bursitis 
is commonly called a bunion, although this term is used to indi- 
cate any painful swelling about this metatarsophalangeal joint. 
The corresponding bursa of the fifth metatarsal bone may be simi- 
larly affected (Fig. 260). 

The inflammation in the bursa may subside, leaving its walls 
slightly thickened, and subject to a recurrence of the attack. Or 




FIG. 260. INFLAMMATION OF THE METATARSOPHALANGEAL BURSA ON THE OUTER 

SIDE OF THE FOOT. 

if the inflammation is suppurative, the overlying skin may rup- 
ture and allow the escape of pus and mucus. The resulting sinus 
may heal, or it may persist, or it may close from time to time, 
only to break open as the fluid reaccumulates in the bursa. As 
the bursa often communicates with the metatarsophalangeal joint, 
the cavity of this joint frequently becomes involved in the inflam- 
mation, which may lead to necrosis of the metatarsal bone. This 
complication is most apt to occur in cases of hallux valgus. 
Indeed this bursa is rarely inflamed except in cases of hallux 
valgus. 



SEHol S SVNOVITIS 483 

TREATMENT. Mild cases of bursitis may be allowed to sub- 
side. The affected part should be protected from pressure by a 
bunion plaster, and pain should be controlled by counter-irritants, 
such as iodin, guaiacol, menthol, etc. Moist and dry heat both 
give the patient great relief. 

If the bursitis is suppurative the cavity of the bursa should 
be freely drained by a longitudinal incision to the plantar side 
of the bursa, or the whole bursa may be removed by dissection. 
In either case the wound should be drained, and the toe kept at 
rest by a plantar or lateral splint, so padded as not to press upon 
the inflamed part (Fig. 299, p. 553). If the joint is seriously 
involved, resection of the head of the melatarsal IM.MC will give 
the best drainage, and will at the same time enable the surgeon 
to correct the deformity of the hallux valgus (see p. .V.<M. 

Serous Synovitis. The majority of cases of serous syno- 
vitis are of traumatic origin, and are discussed under the heading 
"Sprain," pages 486-496, where methods of diagnosis and treat- 
ment are given. Serous synovitis not due to injury occurs in 
rheumatism and gonorrheal arthritis, though the process in these 
diseases is usually an arthritis, all of the tissues which surround the 
joint being involved. It also occurs in acute infections di-eases, and 
in gout, syphilis, and tuberculosis; and occasionally in tabes dor- 
salis (Charcot's joint), and under some circumstances in which no 
definite cause can be assigned. In many of tlioe ca.-es the collec- 
tion of serum in the cavity of the joint is only an early stage of an 
inflammation, which soon becomes purulent, or it is an accompani- 
ment of a deeper process, as in tuberculosis, tabes, etc. Hence 
every effort should be made in these non-traumatic cases to make 
a complete diagnosis, and not to rest satisfied with the diagnosis 
of serous synovitis. The location of the tin id, whether in the 
joint, in some bursa, or diffuse in the soft tissues; and the pres- 
ence of accompanying cellulitis should be determined. The 
amount of pain on manipulation, and especially the presence of 
pain produced by crowding together the cartilaginous ends of the 
bones, without flexing or extending them, is of importance as 
showing the extent to which inflammation has involved the bones. 
The circumference of the joint and of the limb above and U-lnw 
it should be compared with the sound limb and recorded for future 
reference. Similar note should be made of the limitation of flex- 



484 INJURIES OF THE LEG AND FOOT 



ion 



and extension, and whatever other motion the joint has nor- 
mally. The patient's temperature should be taken several times, 
for a day or so at least, and if circumstances permit, the blood 
should be examined, and fluid aspirated from the joint should 
be tested for bacteria. Our knowledge of joint diseases is so 
imperfect that no opportunity should be lost by which clinical 
data may be added. Finally, there is the test of treatment, and 
especially the effect of rest, and of the salicylates and of iodid of 
potash. 

The treatment of traumatic synovitis is outlined on page 41)3. 
The measures there indicated are, rest, obtained by strapping with 
adhesive plaster or by the use of splints or by remaining in bed ; 
elastic pressure to favor the resorption of the fluid ; ice to control 
pain ; massage or counter-irritation to stimulate circulation. These 
measures are equally beneficial in non-traumatic serous synovitis. 
Massage and passive or active motion should not be employed as 
long as an active inflammatory focus exists. Aspiration of fluid 
has a curative as well as a diagnostic value. In sluggish cases it 
may be followed by the injection of a three per cent solution of 
carbolic acid. If clots or fibrin prevent the escape of the joint 
contents, saline should be injected and withdrawn, and this re- 
peated until the joint is clean. The importance of absolute asep- 
sis in aspiration or irrigation cannot be too strongly emphasized. 
Immediately after the aspiration pressure should be applied to 
the joint. 

Chronic Serous Synovitis. If the knee or ankle is subjected 
to repeated traumatisms, the condition of the joint may become 
chronic. It is then desirable to use counter-irritants in addi- 
tion to the measures spoken of above. The actual cautery is 
one of the cleanest and best. Tincture of iodin, iodin ointment, 
and cantharidal collodion are other efficacious remedies. The 
counter-irritation should be repeated in three days or one week, 
according to depth of irritation produced. 

Floating Cartilage. Patients sometimes complain that the 
knee catches in walking, or in going up or down stairs, giving 
more or less pain, and requiring some manipulation before it will 
work again. Sometimes a clear history of injury is given ; more 
often this is not the case. Such mechanical difficulty may be due 
to a loose cartilage (Fig. 261), a body found only in the knee- 



II. MATING CARTILAGE 



485 



joint, and whose origin is not satisfactorily accounted for; while 

sometimes ;i loosened meniscus plainly slips from iis normal situ- 
ation ;ilnl ^els caught lietween the hones; ;IIK| soinel imes one Can 

only speculate ;is to the cause of the trouble. 

A joint which suffers from such repeated small injuries natu- 
rally becomes weakened, and usually contains a little lhiid. If 
there is a loose cartilage, 
freely movable in the joint 
cavity, one cannot hope to 
improve the condition of 
the joint until it is re- 
moved. If it can be 
brought well to one side, 
and fixed by a hat-pin, it 
can be removed through an 
incision made under the 
influence of a local anes- 
thetic. This should not be 
attempted unless it is rea- 
sonably certain that only 
one such loose cartilage ex- 
ists ; and the asepsis slnntld 
be absolute. The wound 
in the capsule should be 
sutured with fine plain cat- 
gut and the skin wound sutured with fine silk and a dry dressing 
and posterior splint applied. If any drain is employed, it should 
reach only to the incision in the capsule, and should be removed 
in two days. 

While in removing a floating cartilage it is necessary to cut ' 
directly down upon it, there is often a choice of location, since it 
can be moved about. The most favorable line of incision is that 
shown in Figure 2G2, or just anterior to the internal lateral lU.-i 
ment. At this point the capsule of the joint is covered only by 
the skin with its fat and a thin fascia. When the leg is extended 
this incision is parallel to its long axis. 

These are the simplest cases. If more than one loose cartilage 
exists, or if displacement of one of the semilunar cartilages causes 
the symptoms, exploration of the knee-joint may be neces-sary, and 




FIG. 261. FLOATING CAHTII.ACK KIJU.M 1111 
KNEE-JOINT: THE " JOINT MOUSK " <>i mi: 
GERMANS. Removed through an incision 
made under cocain after the cartilage was 
speared with a hatpin. The illustration 
shows the cartilage enlarged 1J diameters. 



486 



INJURIES OF THE LEG AND FOOT 



a general anesthetic should be given. The exact site for the inci- 
sion in case of semilunar displacement may sometimes be deter- 
mined by palpation. A depression can sometimes be felt where 
the base of the semilunar has become loosened, and pressure at 

this point causes pain. 
Usually it is the ante- 
rior part of the inner 
semilunar which is af- 
fected. If it is not 
deformed or broken, it 
should be stitched in 
correct position by fine 
chromic gut. If this is 
not feasible, so much of 
the cartilage as is a hin- 
drance to free motion of 
the joint should be re- 
moved. 

The incision for the 
removal of several float- 
ing cartilages from the 
knee-joint is a longitu- 
dinal one slightly longer 
than the one shown in 
Figure 262. A second 
incision, opening the 
outer side of the joint, 
is rarely necessary. The 
capsule of the joint 
should be sutured, not 




FIG. 262. INCISION FOR REMOVAL, OF FLOATING 
CARTILAGE FROM THE KNEE UNDER LOCAL AN- 
ESTHESIA. In the case shown the cartilage had 
been chipped from the tibia by traumatism, 
and although loose, was not in the knee-joint. 
Its approximate shape and location is shown 
by the wad of adhesive plaster, the upper edge 
of which is exactly in the horizontal plane of 
the knee-joint. 



too tightly, with fine 

plain catgut, so that fluid can escape if it accumulates. A drain 
should lead to the wound in the capsule, but not through it, and 
the skin should be sutured with silk or horsehair. A splint should 
be employed; either a removable posterior one or a circular gyp- 
sum splint with a fenestrum to permit the removal of the drain 
in two days. 

Sprains. In injuries of this sort it is well to distinguish as 
far as possible, between overstretching, or even rupture of the liga- 



SPRAIN OF THE HIP 487 

ments, and contusions of the soft parts, or even of the bones them- 
selves (see p. 338). 

Sprain of the Hip- joint. The hi p- joint is so well surrounded 
with strong muscles that it is rarely sprained. Contusions of the 
hip from falls on the side are common. In children a differential 
diagnosis must be made between sprain or contusion and tul>ercu- 
losis of the joint; in adults beyond middle age, the usual differ- 
ential diagnosis is between contusion and fracture (possibly 
impacted) of the neck of the femur. Age is not an absolute 
classifier of these three, so that all should be considered at 
any age. 

METHODS OF EXAMINATION. The patient should be stripped 
from the waist down and placed on a firm level surface. A folded 
towel laid between the thighs and brought up over the pubes to the 
umbilicus in no way interferes with a complete examination, and 
by lessening very much the feeling of exposure, aids the patient 
in relaxation. The hip should bo inspected and palpated, and 
compared with the opposite side. Any change in color or outline, 
any thickening of the bones about the trochanter, any points of 
tenderness, and an abnormal position of either limb (abduction 
or rotation), should be carefully noted. 

The two limbs should be measured from the anterior superior 
iliac spines to the internal or external malleoli. Before making 
these measurements, one should see that the two ilia are on a 
level, and that the feet and legs are equally distant from the 
median line of the body. A difference in length of less than 
one-half an inch has little diagnostic value. Fracture of the neck 
of the femur gives a shortening of an inch or an inch and one- 
half. In only a few cases is it more or less than these amounts. 
In sprain and the early stage of tuberculosis there is no short- 
ening if the lirnb can be fully extended. If measurements reveal 
the existence of shortening, further measurements should be made 
to determine its exact location. This can be done in three ways: 
(1) The tibiae can be measured; or (2) the distance from the 
tip of the great trochanter to the external malleolus ; or (3) 
Bryant's perpendicular laid out. To do this accurately one 
should mark the upper limit of the great trochanter on. the skin 
with ink; mark the anterior superior spine in the same way; 
and then draw a line on the skin directly backward (a vertical 



488 



INJURIES OF THE LEG AND FOOT 



Hue as the patient is lying horizontally), and let fall a perpen- 
dicular from the trochanter to this line (Fig. 263). A difference 
in these two perpendiculars on the two sides will indicate a dis- 
location of the femur, a fracture of the neck, or an error of meas- 
urement. This method is far more accurate than Nekton's, by 




FIG. 263. RELATIONS OF THE GREAT TROCHANTER TO THE ILIUM. 
PENDICULAR IS THE BROKEN LlNE. 



BRYANT'S PER- 



which one estimates the possible displacement of the trochanter 
by drawing a line on the surface from the anterior superior spine 
to the ischium. Such a line is a curve, more markedly so in stout 
persons, and it is difficult to be sure that it follows the same course 
on the two sides of the body, even though its ends are accurately 
placed. By means of these various measurements one can in most 
cases say positively that shortening does or does not exist, and if 
present, estimate its amount and locate it exactly. 

Occasionally a person is found whose legs differ in length by 
as much as an inch. If such a one sprains his hip on the short 
side, the diagnosis will be obscure for a few days until the prompt 
recovery rules out any serious injury. The author met one such 
case in a boy aged fourteen. 

Finally, functions of the joint are to be tested. The various 
motions of which the joint is capable, adduction, abduction, flex- 
ion, extension, and external and internal rotation, are to be per- 
formed both passively and actively, and limitation of motion, pain, 
and muscular spasm are to be noted. Muscular spasm is most 



SI'KAIN OF TH10 KM-iK 489 

marked in tuberculosis, especially <u overextension or external 
rotation. Jn fracture there is loss of active motion to a great 
degree, and the limb is usually fixed in external rotation, a de- 
formity which cannot be overcome either actively or passively. 
Tuberculosis, also gives a daily fever, at least of one or two de- 
grees. Impacted fracture should always be recognized when pres- 
ent, by the abnormal rotation of the limb, its shortening, the 
marked loss of function, and the palpable thickening about the 
trochanter. A single examination may not serve in all cases 
to differentiate sprain and tuberculosis. The former will be 
cured by a few days' treatment of rest, secured by a light spica 
bandage of plaster of Paris; while the symptoms of the latter 
will only be somewhat improved by the bandage, even when com- 
bined with rest in bed, and will promptly return and grow worse 
as soon as the patient goes about again. 

An unimpacted fracture of the neck of the femur, having the 
unmistakable symptoms of shortening, crepitns, and abnormal 
motion at the hip, can scarcely be confounded with the other 
lesions mentioned. In both impacted and unimpacted fractures 
of the neck of the femur there should be found displacement of 
the trochanter upward. 

TREATMENT. The treatment of sprain or contusion of the 
hi]) consists of rest in bed, with external heat or counter-irritants 
to control pain. The patient should be early encouraged to make 
the motions of flexion and rotation at the hip-joint while still 
in a recumbent position. As soon as tenderness subsides the nor- 
mal use of the limb should be resumed. Such an injury is most 
apt to occur in the aged, and the early use of their joints is to 
be encouraged, in order to avoid stiffness. But first there should 
be a careful examination to exclude fracture, and second, the 
patient should be assisted in the early attempts to walk, lest a 
second fall add to the existing injury. 

Sprain of the knee produces some or all of the following symp- 
toms: Pain; tenderness, especially if extreme flexion or exten- 
sion is attempted; partial loss of function; swelling of the soft 
tissues, and effusion of fluid into the joint, cavity. If one of the 
lateral ligaments is lorn there will also IK- an abnormal lateral 
motion in the joint when manipulated. Tin- last named sign com- 
ing on suddenly after an injury is pathoguomonic ; but continued 



490 



INJURIES OF THE LEG AND FOOT 



distention of the joint cavity will also stretch the ligaments of the 
joint, so that abnormal lateral motion is obtainable. 

DEMONSTRATION OF FLUID IN THE JOINT. Fluid in the knee- 
joint is best demonstrated by compressing the cul-de-sac beneath 
the quadriceps tendon with the palm of the hand, while one finger 
of the other hand pushes the patella lightly but quickly backward 
to the femur (Fig. 264). The leg should be extended on the 
thigh and the muscles relaxed during this test. If the joint con- 




FIG. 264. DEMONSTRATION OF FLOATING PATELLA. 

tains no fluid, the patella is in contact with the femur, and noth- 
ing happens when it is thrust backward. If the joint contains 
even a little fluid, the position of the limb and the compression 
of the upper hand (left in the figure) forces the fluid into the 
lower and anterior part of the joint and the patella is separated 
from the femur. The sudden thrust of the finger pushes the 
patella backward through the fluid, and it strikes the femur with 
an appreciable click. 

The fluid in the knee-joint after a sprain is usually serous, 
though it may be bloody if the injury is more severe. Fluid is 
not pathognomonic of sprain, since it may be caused by internal 



SPRAIN OF THE KM I 491 

sources of irritation, as is mentioned below, and in some cases 
no fluid r;m !>< demonstrated in the joint, even though a sprain is 
known to have occurred. 

DIFFER K ATI A i, I >i \<..\<>sis. In differential diagnosis with 
sprain of the knee- joint one must consider prepatellar bursitis, 
rupture of a lateral ligament, reduced dislocation of the knee, 
dislocation of a meniscus, loose or floating cartilage, and the vari- 
ous acute and chronic inflammatory disorders of joints to which 
the knee is especially subject, and sarcoma. For a full list of 
the symptoms of these various diseases the reader should look 
under the appropriate heads, as only the most striking differences 
are here given. 

In prepatellar bursitis the fluid is confined in a compara- 
tively small sac, which lies in front of the patella and not behind 
it, as in sprain, and the functions of the joint are not affected 
by it. 

Rupture of a lateral ligament gives abnormal lateral mobil- 
ity; reduced dislocation may be recogni/ed by this same sign, or 
possibly only by the history. 

A patient with displacement of a meniscus usually gives a 
history of repeated attacks of painful locking of the joint, fol- 
lowed by fluid in the joint and limitation of motion fojr a few 
days. Sometimes palpation will reveal an alteration in the joint 
about the base of the loosened meniscus. 

A loose or floating cartilage will often have been detected by 
the patient, who may be able to demonstrate its presence by bring- 
ing it to one side of the joint. It keeps up the effusion in the 
joint to an extent not warranted by the history of injury, and 
indeed may exist without any pain or loss of function. 

Acute suppuration in the knee-joint, following a punctured 
wound for example, on account of the great surface of the joint 
cavity produces much pain, swelling, fever, etc. It is a serious 
condition which cannot be confounded with slight injuries. A 
puncture of the knee-joint without suppuration does not prevent 
a patient from walking about. It should be recognized by the 
tenacious character of the escaping fluid, not by ilic probe. Such 
a wound should be cleansed and dressed at once, a posterior splint 
applied, and the patient put to bed, lest lie suffer the much greater 
ills of a suppurating joint. 



492 INJURIES OF THE LEG AND FOOT 

Acute rheumatism comes on without injury, gives a fever, and 
usually involves more than one joint. 

Gonorrheal, gouty, tuberculous, and syphilitic arthritis are 
also slowly progressing affections with local and general symptoms 
of inflammation. If the inflammation is not marked and the dis- 
ability of the knee is first noticed after some traumatism, a mis- 
take in diagnosis is possible, but a careful history and examina- 
tion will clearly separate these lesions from a sprain. 

Arthritis deformans is a progressive affection which alters the 
ends of the bones, gives little or no fluid in the joints, and limits 
motions very greatly. It usually occurs independent of injury. 

Sarcoma of the lower end of the femur is more likely to be 
mistaken for tuberculosis than for a traumatism of the joint. 
It always enlarges the bone, a point which can be demonstrated 
by the X-ray if not by the fingers. 

TREATMENT. The essentials of treatment of a sprain of the 
knee are rest to the joint and compression. These ends can be 
secured by a posterior splint and bandage. An excellent splint 
is made by wetting a plaster of Paris bandage and drawing it 
back and forth on a board fifteen or twenty times, a distance of 
two feet or more, according to the length of the patient's limb. 
It should reach from the ankle to the great trochanter. The 
layers of the bandage should be well rubbed together as they are 
applied to each other, so that the splint when completed shall 
be one solid piece. Three bandages, each three inches wide, are 
needed. The splint should be bandaged in position immediately, 
so that it may take the shape of the bare limb before it sets. 
If the limb is hairy, it should be smeared with vaseline or shaved. 
When the splint is hard it may be removed and covered with 
canton flannel, reapplied, and held in position by a soft bandage. 
A pure flannel bandage may be used for this purpose. If an 
inelastic bandage is used, the knee should be covered anteriorly 
with a broad pad of cotton, so that elastic pressure may be 
obtained. The splint should be broad enough to enclose fully 
one-third of the circumference of the limb, and the leg should 
not be absolutely extended on the thigh when the splint is applied, 
but should make with it an angle of about one hundred and sixty- 
five degrees. This gives the knee the greatest comfort when the 
patient is walking, sitting, or lying. Such is the initial treat- 



SIM!. YIN OF Till; ANKLE 



I'.*:; 



nient for a sprain of modem to degree. If the sprain is more 
severe, or if one of the lateral ligaments is ruptured, the patient, 
should not be allowed to put any weight on the limb, and should 
lie in bed or go about 
on crutches. 

A pleasanter meth- 
od of treatment, appli- 
cable to slight sprains 
or more severe ones 
after the first or second 
week, is the strapping 
of the joint, laterally 
and anteriorly, with 
strips of adhesive plas- 
ter laid on diagonally 
(Fig. 265). 

Still another meth- 
od is daily massage and 
the application of an 
elastic bandage of flan- 
nel or rubber, without 
any splint. 

Sprain of the Ankle. 

The ankle is more 

often sprained than any 

other joint of the lower extremity. For convenience, it is well 
to consider these sprains in three classes, according to the degree 
of the injury, whether slight, medium, or severe. In almost all 
cases the foot is turned inward, so that any tearing of the liga- 
ments which occurs is usually on the outer aspect. 

SPRAIN OF SLIGHT DEGREE. In a slight sprain of the ankle 
there is a little pain and tenderness and a little swelling, espe- 
cially below the external malleolus. The patient walks without 
difficulty, and there is no abnormal motion of the foot. 

Treatment. For the first, and second day following the in 
jury the limb should be kept in a bori/onla! position and treated 
by hot fomentations, light massage, and passive motions two or 
three times a day. On the third day and thereafter it should 
have a hot douche for thirty minutes, followed by a cold douche 




FIG. 265. STRAPPING WITH ADHESIVE PLASTER 
FOR SPRAIN OF THE KNEE. 



494 INJURIES OF THE LEG AND FOOT 

for a minute, and this followed by massage. This treatment 
should be repeated twice a day and active motion begun, the 
patient being allowed to walk. 

Another plan is to apply adhesive strapping at once, as de- 
scribed below. 

SPKAIN OF MEDIUM- SEVEKITY. If the sprain is of medium 
degree, the pain and tenderness are more marked, the swelling 
is greater and involves the whole circumference of the ankle, and 
there is more difficulty in walking. Some of the ligaments are 
ruptured, and in addition there is probably contusion of the articu- 
lar surfaces of the bones. 

The treatment described above for slight sprain may be car- 
ried out for forty-eight hours ; or a flannel bandage ,may be firmly 
applied from the toes to the knee and the limb soaked in water 
at 110 to 115 degrees for three or four hours to prevent swelling. 

After this preliminary treatment with hot water, or hot 
fomentations and massage, adhesive straps should be applied -to 
the foot, ankle, and leg. They serve a threefold purpose, keep- 
ing the foot in a correct position, preventing extreme motion in 
any direction, and exerting automatic massage by varying the 
pressure in different parts every time the foot is moved. 

The leg should be shaved, washed with soap and hot water, 
alcohol, and ether. Strips of adhesive plaster should be applied 
in such a manner that they will fit accurately and each will overlap 
the next by a third of an inch. The exact pattern makes little dif- 
ference, since the individual strips are soon welded into a single 
casing. A good plan is to apply a broad strip like a stirrup, ex- 
tending from below the knee on the inner side of the leg, cover- 
ing the inner malleolus, the plantar surface of the heel, the outer 
malleolus, and finishing on the outer surface of the leg near the 
head of the fibula. In applying this, the foot should be held at 
a right angle to the leg, and in a correct position laterally, or 
possibly slightly abducted, in order to relax the strain on the 
injured ligaments. Additional strips not more than an inch 
wide should circle the heel horizontally, and reach to the base of 
the toes (Fig. 206). These should be carried well above the 
ankle. If there is fear that the swelling will increase, these hori- 
zontal strips may be stopped before they meet in front, although 
the support in that case will be less firm. A light gauze bandage 



SPRAIN OF THE ANKLE 



495 



completes the dressing. On the third day the patient can walk 
about with a cane, but the massage and passive motion should be 
continued. 

If the adhesive plaster becomes loose, it should be removed and 
renewed. After two weeks it may be removed, but douches and 




FIG. 266. A GOOD METHOD OF STRAPPING A SPRAINED ANKLE WITH ADHESIVE 

PLASTER. 

massage should then be resumed and continued as long as the 
joint is weak. 

Some surgeons prefer cold to heat in the early treatment of 
these sprains, and keep an ice-bag in contact with the ankle for 
a part of each day after the adhesive plaster has been applied. 
This plan works well in some cases, but must be used with cau- 
tion if the patient is old or feeble. 

SPRAIN OF EXTREME SEVERITY. In sprains of extreme de- 
grees of severity there is marked pain and swelling, and a great 
deal of abnormal motion, amounting to a partial dislocation. One 
often suspects a fracture of one malleolus, although it may be 
impossible to prove this without a radiographic examination. 

The plan of treatment is as follows: One should elevate the 
limb and apply hot fomentations to relieve the pain, and keep 
them hot with hot water bags, which can be changed from time 
to time without disturbing the wet cloths. The limb should be 
fixed by sandbags, not too tightly filled. Two or three times a 
day the dressing should be removed, and gentle massage given 



496 INJURIES OF THE LEG AND FOOT 

without disturbing the joint. A bed rest should keep the clothes 
from touching the foot. On the third, fourth, or fifth day, when 
the swelling has somewhat subsided, the leg 'should be shaved, 
covered with sheet wadding, and encased in a plaster of Paris 
bandage from the toes to the knee, the foot being held at a right 
angle. The patient may go about on crutches. 

After two weeks the cast should be removed, a hot douche 
and massage should be given twice a day, and passive and active 
motion begun. The patient should bear his full weight on the 
injured foot in three or four weeks, according to the degree of 
injury. 

Molded gypsum splints may also be used. (See Figs. 270 and 
271, p. 506.) They are easily removed for massage and can be 
reapplied by the patient 

Recurrent Sprain of Ankle. The ankle is especially liable to 
a resprain, and hence it is desirable in many instances to advise 
the patient to protect the joint long after the external evidences 
of injury have disappeared. Many persons prefer a woven rub- 
ber anklet, or one made of leather, which laces up, to the daily 
application of a bandage. Such apparatus is more serviceable 
at the ankle than at the knee, as the more limited range of motion 
at the ankle and the different shape of the parts make it easy to 
keep it in place. 

Rupture of a Lateral Ligament of the Knee. This in- 
jury is usually produced by direct violence. A heavy body, for 
instance, a falling sack of grain, strikes against the leg or knee, 
when the foot and body are fixed. The result is an undue stretch- 
ing of the ligaments on the opposite side of the knee,' with rupture. 
If this rupture is not too extensive, the patient can walk about, 
but he is careful to use the limb in such a manner as to prevent 
strain being brought on the ruptured ligament. Pain after this 
injury is slight if the limb is kept at rest. There is often very 
litllo oochvmosis, and the swelling may not be excessive. The 
pathognomonic symptom is an abnormal lateral motion, best shown 
as follows: Let the patient lie on his back, or lean back in a 
chair, with both legs at rest in a horizontal position. Test the 
lateral mobility of the sound knee by grasping the leg firmly 
above the ankle, and using the other hand as a fulcrum placed 
against the patient's knee. Test first the internal and then the ex- 



FRACTURE <>| HI I- l-'KMUR 497 

let-mil ligament, Repeat the tests on the injured side. If one of 
tin- liniments is ruptured moderate force will swing the leg away 
from its normal line to an appreciable angle, perhaps twenty or 
thirty decrees. \\'lien (lie leg is, relaxed it swings hack into line 
with a peculiar snap, which is easily remembered if it has once 
been felt. Jt is something like the snap with which the lid of a 
match-box closes, if there is a spring in its hinge. Treatment 
is similar to that for severe sprain, plus a longer protection of 
the ligament by a posterior splint. The patient should remain in 
bed a few days, sit about or walk with crutches for ten days more, 
and wear a splint for another two weeks at least. Massage and 
passive motions are indicated after the first week or so. 

Dislocations. Dislocations of the larger joints of the lower 
extremity are rare and serious lesions, which are not seen in ambu- 
lant practise. 

Dislocation of one of the toes sometimes occurs. In diagno- 
sis and treatment it closely resembles dislocation of a finger, which 
see (p. 357). 

Fracture of the Femur. Most of the fractures of the 
femur are too serious to tind a place in a text-book on minor 
surgery except in so far as they have to be considered in the 
differential diagnosis of sprains and contusions. It is, however, 
possible for a patient to fracture the femur and yet walk about. 
This is sometimes the case after impacted fracture, and walking 
is possible after fracture of the great trochanter. 

Fracture of the Great Trochanter. This rare injury 
is caused by a fall or blow directed against the great trochanter, 
a part of which may then be separated from the femur, remain- 
ing attached to the gluteal tendon. 

The diagnosis is not difficult. There is a local pain, swelling, 
and ecchymosis. The patient walks guardedly, and gets up and 
sits down with pain and diflicnliy. Palpation reveals the loosened 
fragment, which may also be shown in a good radiograph (Fig. 
207). 

All the treatment that is necessary is to press the trochanter 
firmly against the shaft of the femur by a strip of adhesive plas- 
ter and to keep the patient in bed two or three weeks. The 
bone united firmly in the case of the patient referred to in 

Fijjuro L'<;7. 
34 



498 



INJURIES OF THE LEG AND FOOT 



Fracture of Patella. The patella may be broken by direct 
violence, as by a fall on the knee; or by indirect violence, when a 
sudden strain is brought upon the tendon of the quadriceps ex- 
tensor. In the first case the fracture may be single or multiple, 
and the separation of the fragments slight or extreme, and there 




FIG. 267. RADIOGRAPH OF A MALE PATIENT WHO FRACTURED His RIGHT GREAT 
TROCHANTER BY A FALL. The uninjured trochanter is shown for comparison. 

may or may not be rupture of the strong aponeuroses at the sides 
of the patella. These aponeuroses form so important a part of 
the extension apparatus that if they are not ruptured the patient 
may be able to extend his leg. 

If the fracture is due to indirect violence, it is almost always 
single and transverse, the lateral aponeuroses are apt to be torn, 
and the gap between the fragments is proportionately wide. Diag- 
nosis is usually easily made by the history of the accident, by 
direct palpation of the fragments, by the presence of a gap which 
is lessened by pressure together of the fragments and increased 
when the leg is flexed, and by the inability of the patient to extend 
the flexed leg, although this can be readily performed by passive 
motion. Accompanying signs are swelling, ecchymosis (often 



FRACTURE OF PATELLA 



absent), and fluid in the joint (cither serum or blood). If the 
swelling is not great, crepitus may be obtained by crowding the 
fragments together, and moving one on the other. 

TREATMENT. The limb should be extended on a molded pos- 
terior splint for four weeks, more or less, during which time the 
fragments should be held in apposition in one of four ways: (a) 
by strips of adhesive plaster, or (b) by a suitably dimpled plaster 
of Paris eiivular bandage, or (Y) by suture of the aponeuroses at 
the sides of and in front of the patella, >r (d).by suture of the 
fragments themselves. If the fragments cannot be approximated 
digitally, neither (a) nor (6) is a suitable mode of treatment. 

The posterior splint necessary, if plan (a), (c), or (d) is 
followed, is best made of plaster of Paris, according to direc- 
tions on page 707. The 
leg should be fully ex- 
tended when the splint 
is applied. When the 
splint has set, it should 
be removed, fully dried, 
and covered with can- 
ton flannel. It may be 
bandaged to the limb, 
or held in place with 
several pieces of broad 
tape or light webbing, 
brought together in 
front with buckles. 

If plan (a) is fol- 
lowed, the limb is 
shaved about the knee, 
the fragments are digi- 
tally approximated, and 
fixed by two strips of 
adhesive plaster, one 
passing below the pa- 
tella and anchored on 
the sides of the thigh, 

the other passing above the patella and anchored mi the side- t 
the leg (Fig. 268). If these tilt the fragments a third strip may 




FIG. 268. A DEMONSTRATION OF THE METHOD OF 
APPLYING STRIPS OF ADHESIVE PLASTER TO 
APPROXIMATE TIIK FRAGMENTS AFTER FRAC- 
TURE OF THE PATELLA. 



500 INJURIES OF THE LEG AND FOOT 

be applied directly across the patella. The posterior splint should 
then be applied. 

If plan (&) is followed, the fragments are approximated digi- 
tally by the surgeon, while the assistant applies a circular plaster 
of Paris bandage from above the ankle to the upper part of the 
thigh. The limb is kept in full extension by lifting it and placing 
the foot on a box some twelve inches above the level of the bed 
or table on which the patient is lying. Sheet wadding or some 
similar material is evenly spread over the whole limb. As the as- 
sistant carries the bandage across the knee, the surgeon carefully 
removes his fingers, one at a time, and quickly replaces them, thus 
keeping up pressure at the points at which he has found that he 
can best overcome displacement of the fragments. This procedure 
is repeated as often as the circular turns of the plaster bandage 
pass the knee. When the splint is completed there will be in it four 
or more depressions made by the finger-tips, and so disposed that 
they prevent the fragments of patella from becoming separated. 

The accumulation of much fluid in the knee-joint will inter- 
fere with the successful employment of plans (a) and (&). The 
pressure of a rubber or other elastic bandage may cause its resorp- 
tion in a few days. If not, it may be evacuated with a medium 
sized trocar and cannula, or better, through a quarter-inch incision. 
The risk of infection is extremely slight if the skin is washed with 
soap and water, turpentine, and alcohol, and the instrument is 
boiled and its point not handled. Local anesthesia suffices. The 
opening should be made at the side of the knee, and far enough 
back to be out of the way of the adhesive strips. 

Treatment by Operation: Plans (c) and (d}. If digital 
approximation of the fragments is impossible on account of the 
presence of fascia between the fragments or for any other reason, 
ligamentous or bony suture should be advised : plans (c) and (d). 
Both of these entail the risk of sepsis, which in the knee may be 
serious; but in favorable cases the period of recovery is lessened 
and the union of the fragments is stronger than in many of the 
cases treated without operation. Therefore, operation is advisable 
even in many cases in which digital approximation can be achieved. 
A transverse incision of the skin, removal of blood clots from the 
joint cavity, and suture of the lateral aponeurotic tears and of the 
gap in the strong fascia anterior to the patella itself, with twenty 



FRACTURE OF THE TIBIA 501 

day chromic catgut, is the simplest operation. But good results 
have IK-CM <>!>ta in< -.1 |>\- suture of the bony t'ra^Mieuts, or by IU-MMI: 
a -trim: around the patella, or by other methods of approximation. 
The materials used have been wire and silk, as well as absorbable 
materials. The skin wound is to be sutured without drainage, 
and a posterior splint applied. 

In the after treatment, massage is a valuable aid. It may be 
begun as early as the fourth day, care being exercised not to pull 
upon the fniirments. Passive Miotioiis may be employed in two 
weeks, but they should be slight in extent until there is plainly 
union between the fragments. By these methods stiffness of the 
knee may be avoided. They cannot be employed if plan (6) is 
adopted, and hence the circular splint should be cut away in two 
weeks, and a new one applied, or a change in treatment may then 
be made to plan (a) the use of adhesive strips. 

A patient should walk with a shortened posterior splint in four 
weeks, but he should not attempt to bring strain upon the fractured 
patella, and such motions as kneeling or using that limb for stair 
climbing should be forbidden for three months. 

Fracture of the Tibia. Delayed Union. Fracture of the 
tibia and fibula coexisting, and fracture of the tibia alone above 
the malleolus, are excluded from ambulant practise. Patients with 
such lesions may come for treatment some weeks after the in- 
jury, the bones not yet having united properly. It is therefore well 
to consider the treatment of non-union of the tibia. Palpation 
will reveal the plane of the fracture. The leg should be grasped 
firmly above the fracture w r ith one hand, and below the fracture 
with the other. By a firm, quick motion, the broken bone should 
be tested for abnormal mobility. This test should be applied both 
laterally and anteroposteriorly. The position of the fragments, 
when at rest and when the patient bears weight on the injured limb, 
should also be noted. All of these facts should be recorded for 
future comparison. Radiographs should also be made in two 
planes. 

TREATMENT. The treatment will depend upon the conditions 
present. If the deformity is not extreme, or can be manually 
corrected, and if the fractured ends of the bone are in contact or 
can be brought into contact without producing too great deformity, 
union may be obtained by the following plan of treatment: Make 



502 INJURIES OF THE LEG AND FOOT 

two lateral molded plaster of Paris splints to reach from the 
ankle nearly to the knee. Each should be broad enough to cover 
about one-third of the circumference of the limb. This gives them 
a firmer grasp, and the curve adds greatly to their strength. When 
they have set they should be removed, dried, covered with canton 
flannel, and affixed to the leg with cloth straps and buckles. Every 
day, or every second day, the fractured ends of the bone should 
be ground together by the surgeon for two or three minutes or more, 
according to the temperament of the patient. This is not so painful 
a procedure as it sovinds, and no anesthetic is required. The 
splints should be firmly strapped in place, and the patient en- 
couraged to walk about with crutches, yet bearing much of his 
weight on the injured leg. This treatment should be repeated 
until there is tenderness and swelling at the site of fracture. The 
grinding of the bones together may then be performed less often, 
allowing time between treatments for the tenderness to subside 
somewhat, but not enough for all signs of irritation to disappear. 
In two or three weeks increased callus interferes with the grind- 
ing of the bones on each other, and this part of the treatment may 
then be omitted; but the patient should increase his exercise, and 
bear more weight on the limb. In many cases a complete bony 
union will result in one or two months. 

If there is bad angular deformity which cannot be corrected 
manually, or if the ends of the tibia are plainly separated, and 
cannot be brought into contact except by producing an angular 
deformity, as is often the case after compound fracture with loss 
of bone (non-union after operation), the treatment above outlined 
is not indicated and operation must be considered. 

It is also well to remember that a united fibula may keep 
apart the ends of a fractured tibia, especially if there is loss of 
the tibial substance. The author has seen two cases of failure 
after operation for non-union of the tibia, which were clearly due 
to this cause, as in both cases the condition was the same. There 
had been no resection of the fibula, and the cut ends of the tibia 
could not be approximated except by producing a bad angular 
deformity. 

Fracture of the Fibula. Fracture of the shaft of the 
fibula is usually the result of direct violence, but the bone may be 
broken near its upper extremity by a sudden pull of the biceps 



FRACTURE OF THE FIBULA 503 

muscle. As the greater portion of the fibula is covered by thick 
muscles, fracture of its shaft may exist without the usual signs of 
swelling, ecchymosis, and crepitus. Palpation is unsatisfactory, 
and the patient may be able to walk. Hence it is no uncommon 
tiling for a fracture of this character to be overlooked. Positive 
signs are shortening of the fibula, measured from end to end, pain 
on direct pressure, pain on pressure upon the bone at a distance 
from the point of fracture, and absolute inability of the patient to 
lift the heel from the floor while bearing weight on the injured 
limb. The reason of this is obvious. The heel is raised in part by 
the action of the flexor longus pollicis, and longus and brevis pero- 
nei muscles. These muscles arise from almost the whole length of 
the fibula, and their contraction disturbs the fragments of the 
broken bone. If the break is in the lower part of the shaft of the 
fibula, displacement of fragments, crepitus, and false motion can 
usually be made out in addition to' the signs given above. 

TREATMENT. If the patient chooses to remain in bed, no 
apparatus is necessary other than small ' pillows or sandbags to 
steady the leg, and a cradle to keep the clothes from resting on 
the limb; but in 'most cases it is desirable to apply a light plaster 
of Paris bandage from the toes to the knee, with the foot at a right 
angle to the leg. The following day the patient may go about on 
crutches. During the first week, when sitting or lying, the foot 
should be kept at least as high as the hips in order to counteract 
the tendency to swell. 

The immediate application of a circular bandage of plaster of 
Paris is often advised against on account of the risk of swelling in 
a constricted space. When the injury is a slight one, as in frac- 
ture of the fibula without severe contusion, this risk is slight. In 
all cases, however, the toes should be left uncovered for inspection. 
They should remain warm, and the circulation should remain 
active. The blood should return quickly to the surface when pres- 
sure made with the finger is removed. Such inspection should 
be repeated every few hours for a day or so, especially if the 
patient complains of a tight feeling or pain. In cases of doubt, it 
is better to cut the splint down the front. It need not be removed. 

After the second day the patient may go about with crutches, 
and may begin to bear a litlle weight on the foot after the third 
week, increasing the pressure gradually, but not bearing full weight 



504 INJURIES OF THE LEG AND FOOT 

on the foot for at least four weeks. The splint may be discarded 
in two or three weeks after the fracture, according to the cir- 
cumstances. 

Fractures of the Tibia and Fibula (Either or Both), 
Involving the Ankle-joint. These fractures are almost in- 
variably due to indirect violence. They often follow slips and 
falls" on the street. Many of them would be sprains except for 
the close mortising of the astragalus between the two malleoli. 
Many of these fractures are serious injuries, but others permit the 
patient to walk. It is necessary therefore to consider the whole 
class. The chief end of treatment after a fracture is to restore 
function by Obtaining (1) bony union of the fragments in good 
position, and (2) mobility of the adjacent joints. In the treat- 
ment of fracture involving the ankle-joint, the second object has 
often been overlooked ; and that is the more unfortunate, since 
non-union of a malleolus is very rare. 

DIAGNOSIS. Diagnosis in these cases should include not .only 
the determination of a 'fracture and its approximate position, but 
also the change, if such exists, in the relation of the three bones 
forming the joint, namely the two malleoli and the astragalus. 
Upon the recognition and the correction of such displacement de- 
pends the restoration of the function of the limb. In most cases 
it is well to examine the patient under an anesthetic, and when 
possible to make radiographs of the ankle in both anteroposterior 
and lateral directions. 

Displacement, if it exists, is usually lateral and backward. 
There is often great swelling in these cases, a part of which is due 
to the accumulation of fluid, blood, or serum in the ankle-joint. 
This masks the bony deformity, and often makes it impossible 
to reduce the bones properly if the patient is first seen a day or 
two after the injury. 

TKEATMENT.- The old plan, and one that is still advocated 
by many, was to tie the leg up in a pillow, or with side splints, 
for a few days until the acute swelling subsides. While good 
results have many times been obtained in this way, the treatment 
is irrational. It is far better to put the broken bones at once 
into as nearly normal relations as possible. At a later day, if it is 
seen on examination that the replacement can be made even more 
perfect, the surgeon should not hesitate to reapply the splints, 



FRACTURES INVOLVING T11K A.NKI.I. 



differently padded, <r to make iu-\v splints. 11' one has at com- 
mand a good X-ray machine, the swelling of the soft parts will 
not prevent a correct diagnosis ; but even without this help one can 
usually judge of the character of the displacement, and manipu- 
late the parts accordingly. The best plan of treatment is then 
as follows: 

Having determined the site of fracture and the degree of dis- 
placement, the surgeon should manipulate the foot until con- 
vinced that it is brought into a correct position. Sometimes it is 
only necessary to support the weight of the leg by a firm grasp 
of the toes, in order to prevent a recurrence of the deformity. 
A better plan in most cases is to grasp the heel between the thumb 




FIG. 269. CORRECT METHOD OF HOLDING FOOT AND LK<;, IMUIN-, mi. AITI.K -ATIHN 
OF A PLASTER OF PARIS SPLINT IN CASES OF FRACTURE OF ONE OH BOTH 
MALLEOLI. 

and two fingers, and while making traction with this hand in the 
long axis of the leg, to flex the ankle to a right angle by a firm 
grasp of the toes (Fig. 269) ; or one may correct lateral or poste- 
rior displacement by grasping the leg with one hand and the heel 
with the other. In both of these ways the foot can be Hexed to 
a right angle with the leg, and slightly inverted. According to 
circumstances, the surgeon will hold the leg or entrust it to an 
assistant. If his assistant knows how to make and apply a plaster 



506 INJURIES OF THE LEG AND FOOT 

of Paris splint, and can bandage it to the leg, the surgeon should 
hold the limb in a correct position, as this is the more important 




FIG. 270. STRAP SPLINTS FOR FRACTURE OF THE MALLEOLI IN POSITION. 

task. The making of strap splints is described on page 707. In 
this case two are required, each about twenty-four inches long, and 
three or four inches wide. Three roller bandages will make the 




FIG. 271. STRAP SPLINTS FOR FRACTURE OF THE MALLEOLI REMOVED. 

two. The posterior is first applied, and K - uld reach from the up- 
per part of the calf to the tips of the4oes. . Next a lateral splint, 



FRAOTUHK OF THE ASTRAGALUS 507 

cither internal or external, starting at the same level, is carried 
down the leg, across the middle of tin- sole, and (hen across the 
dorsiim of the foot, until it reaches itself, after having encircled 
the foot, (Fig. -!70). These are bandaged in place with a gauze 
bandage. The person who is holding the foot in a correct position 
should not let go until the plaster has set ten or fifteen minutes, 
if it is fresh. When dry the splints may lie removed ( Fig. 271), 
lined with canton flannel, and reapplied ; but a safer plan is to 
leave them undisturbed for at least a week, as the lateral splint 
never gets quite such a firm grip again after it has been removed. 

If one prefers a circular plaster of Paris splint for this class 
of injuries, its application is described on page 703. The correct 
holding of the foot and leg is equally important. 

The object of flexing the foot to a right angle with the leg is 
twofold. This brings the wide portion of the astragalus between 
the malleoli, and thus insures a slot wide enough for free motion 
of the astragalus in walking. Secondly, if the ankle-joint should 
be stiff, the patient can stand with his heel on the floor, and there- 
fore walk, not gracefully, but without pain. If the ankle is stiff 
in an extended position, equally good walking is impossible except 
by building up the heel of the shoe on the affected side, and the 
heel and sole of the other shoe. 

The slight inversion of the foot is to prevent the formation of 
a traumatic flatfoot, which may result if the foot is everted. This 
inversion should not be excessive. 

The patient may go about on crutches from the start in cases 
without displacement, and after a few days in the graver injuries. 
The injured foot should be kept elevated when the patient is sit- 
ting. After the first week the lateral splint at least should be 
removed for daily bathing and massage. This will add greatly to 
the comfort of the patient and hasten the recovery. The patient 
should bear some weight on the injured limit in four or six 
weeks, and the full weight in from six to eight weeks. There are 
numerous instances of recovery delayed beyond these periods, in 
which the functions were ultimately completely restored. 

Fracture of the Astragalus. The astragalus is broken by 
falls upon the feet, especially if the foot is sharply flexed against 
the anterior surface of ,..' tibia. In such a case the fracture will 
probably extend through the neck of the astragalus, separating the 



508 INJURIES OF THE LEG AND FOOT 

head from the body. One-half the bone may then be dislocated 
from its normal position. 

The symptoms complained of are pain when an attempt is 
made to move the foot or to bear any weight upon the heel. If 
there is no dislocation' of a fragment, the diagnosis may be ex- 
tremely difficult. It is desirable, therefore, to make radiographs 
of both feet for a careful comparison. 

Treatment consists in reduction of the fragments. If thoro 
is marked displacement, reduction can seldom be effected with- 
out an operation. If the deformity is slight, the limb should 
be immobilized, with the foot at right angle to the leg and slightly 
inverted. A light plaster of Paris circular bandage from the 
base of the toes nearly to the knee accomplishes the objects of 
treatment admirably. In a few days this should be split down 
the front, removed for daily massage and passive motion, and 
reapplied. 

Prognosis depends chiefly upon the amount of displacement. 
If this is slight, a normal gait may be regained in two or three 
months. If the displacement is considerable, the function of the 
ankle-joint is likely to be permanently impaired. If reduction 
cannot be accomplished by manipulation, the displaced fragment 
should be removed. It is worth remembering that good function 
has been obtained after the removal of even the whole astragalus. 

Fracture of the Os Calcis. The os calcis is broken by 
falls or jumps from high places, the patient striking squarely upon 
his heels. One or both bones may be broken. The plane of frac- 
ture may be either vertical or horizontal, or oblique, or irregular. 

The chief symptoms complained of are pain and an inability 
to bear the weight on the heel. Examination will show a distinct 
increased bony thickness beneath the malleoli, as compared with 
the uninjured side. There is tenderness on pressure, and crepitus 
can often be obtained by grasping the malleoli with one hand and 
manipulating the base of the os calcis ; or the anterior portion 
of the bone may be grasped with one hand and the posterior por- 
tion manipulated with the other. In some cases, when the acute 
swelling has subsided, the plantar surface of the heel is dis- 
tinctly nearer the tips of the malleoli than on the uninjured side. 

TREATMENT. The foot should be placed in a correct position 
that is, flexed to ninety degrees or less, -and slightly inverted 



AMPUTATIONS 509 

and held in this position by a light plaster of Paris bandage 
extending nearly to the knee. The patient should go about on 
crutches, without touching the affected limb to the floor. No other 
treatment is necessary. In two or three weeks the splint should 
1)0 removed, niid passive and active motion encouraged. 

The pain after fracture of the os calcis varies greatly. Some 
patients suffer little, while others have some pain upon using the 
foot months after the injury. 

If fragments of the os calcis are badly displaced, they should 
be removed, the prognosis after operation being favorable. The 
incision may be made on cither side, low enough down to avoid 
injury to the vessels and nerves and tendons which pass under the 
malleoli. 

Fracture of the Met atarsals. Fracture of one or more 
of the metatarsal bones is almost always due to direct violence, such 
as the passage of a wheel over the foot or the fall of a weight upon 
it. The accompanying swelling, and possibly wounds of the soft 
parts, mask the fracture of the bone, but such a fracture can usually 
be made out by careful examination. The symptoms are swelling, 
ecchymosis, and pain. The pain is increased by pressure against 
the head of the affected metatarsal as well as by pressure directly 
upon the site of fracture. If the head of the bone is grasped and 
manipulated, pain is also increased, and often crepitus is produced. 
The patient can usually walk by bearing his weight upon his heel. 
A constricting bandage, either of adhesive strips or, better, of 
plaster of Paris, extending above the ankle, will give the patient 
considerable relief. Recovery is usually complete in one or two 
months. 

Fracture of the Phalanges. The bones of the toes are 
broken as the result of direct violence, and the fracture is often 
a compound one. The usual signs are present and are easily 
elicited. 

Fracture of the great toe can be treated by splints. If one 
of the other toes is broken, it may be immobilized and deformity 
in it reduced by weaving rubber adhesive strips over and under 
the toes (Fig. 300, p. 555). 

Amputations. Most of the amputations of the lower extrem- 
ity are major operations, and are followed by rest in bed, at least 
until the flaps have united ; but as compound fractures of the toes 



510 INJURIES OF THE LEG AND FOOT 

are common in ambulant practise, a few words as to minor amputa- 
tions will not be out of place. What has been said on amputation 
of the fingers (p. 390) is true for amputations of the toes. They 
should not be sacrificed for the sake of immediate appearance, al- 
though it is often well to lose a phalanx to gain primary union. 
However, a part of a toe has nothing like the value of a part of 
a finger. It is of the highest importance, however, to preserve the 
whole of the first and fifth inetatarsal bones, because of their func- 
tion in completing the arch of the foot and because of the muscular 
attachments to them. If the great toe is amputated, the tendon 
of the long flexor should be firmly sutured in the attachments of 
the short flexors to the inetatarsal. If there is plenty of skin for 
the flaps the suture line should be kept away from the plantar 
surface of the toe by making a large plantar flap. In amputation 
through the metatarsophalangeal joint an oval incision may be 
chosen, or a long plantar flap may be sutured to a short dorsal flap. 



CHAPTER XVTTT 
INFLAMMATIONS OF THE LEG AND FOOT 

EFFECTS OF HEAT AND COLD 

Frost-bite. Slight exposures of the liniLs of healthy persons 
to cold produce only temporary discomfort. Anemic and ill nour- 
ished individuals suffer from subsequent pain and burning of the 
exposed parts called chilblains. Prophylactic treatment consists 
in the administration of iron and other tonics, in the wearing of 
warm loose clothing, in the improvement of local circulation by 
cold bathing, etc. 







FIG. 272. FROST-BITE OF BOTH FEET, THREE WEEKS AFTER INJURY, SHOWING A 
ZONE OF SLIGHT INJURY WITH Loss OF EPITHELIUM (Now RESTORED), A ZONE 
OF DEEPER INJURY WITH Loss OF THE WHOLE SKIN (Now A GRANULATING 
AREA), AND A ZONE OF TOTAL GANGRENE. Patient a woman aged fifty-six yeara. 

511 



512 INFLAMMATIONS OF THE LEG AND FOOT 

When any part of the body has been chilled or frozen its 
temperature should be very gradually raised to normal. The 
more severe the frost, the greater the importance of this rule. 
Hence it is generally understood that a limb which is frozen 
Folid should be thawed out by rubbing with ice or snow, or 
by immersion in ice-water. Even in less severe cases the per- 
son should keep away from the fire on entering the house, and 
should bathe the affected part with cold water. Painful spots may 
be painted with tincture of iodine. 

The importance of conservative treatment in the severer de- 
grees of frost-bite has been emphasized on page 39 7. The accom- 
panying illustrations (Fig. 272 and Fig. 273) show most graph- 
ically how much may be gained by delay. The new growth of 
epithelium and granulations made it possible to amputate less 
tissue and still gain union of the flaps. All of the tarsal bones 
were preserved in the right foot, while in the left foot it was 




FIG. 273. FROST-BITE OF BOTH FEET SHOWING THE RESULTS AFTER DELAYED AM- 
PUTATION. The patient (same subject as Fig. 272) walks easily without a cane. 

necessary to remove the cuneiforms. The patient notices a dis- 
tinct difference in the stability of the two feet on this account. 
At the time of the amputation even these flaps were not entirely 



GANGRENE 



513 



covered with epithelium. The deeper tissues united promptly, 
but the granulating areas required many weeks to become covered 
by epithelium, in part derived 
from skin-grafts, and in part 
from lateral growth from the 
existing epithelium. This is, 
however, time well spent, since 
the useful feet obtained are far 
superior to the stumps remain- 
ing after a Syme's or even a 
Chopart's amputation. Com- 
pare what is said below, in the 
paragraphs on gangrene. 

Burns. The dorsum of the 
foot is often burned by hot wa- 
ter, etc., spilled upon it. More 
serious burns of the lower ex- 
tremity are due to the skirts 
catching fire. The burns in 
such cases are most severe on 
the posterior surface from the 
knee to the hip (Fig. 274). 

Directions for the treatment 
of burns are given on page 26. 

Gangrene. For clinical 
purposes cases of gangrene of 
the toes or foot should be di- 
vided into two classes: In one 
class the cause is external a 
crush, a burn, carbolic acid, 

frost-bite, etc., and is usually not repeated. In the other class 
the" cause is internal endarteritis, diabetes, Raynaud's disease, 
etc. In this class the cause is more or less continuous. In the 
first class palliative treatment should be carried out until the line 
of demarcation is well established. The superficial gangrene in 
these cases is almost always more extensive than the deeper gan- 
grene, so that by delay good flaps may be obtained for a lesser 
amputation than at first appeared possible (Fig. 275). 

The reverse is often true in gangrene due to a constitutional 
35 




i. 274. BURNS OF THE BACK OF TIIK 
LEG AND THIGH OF A CHILD CAUSED 
BY CLOTHING CATCHING FIRE. Pho- 
tograph four weeks after injury. 
Note that a few deep groups of epi- 
tlirliul cells have escaped injury, and 
have grown up so as to form islands 
in the granulating area. 



514 



INFLAMMATIONS OF THE LEG AND FOOT 



disorder. Then one has to do with a condition which tends to 
progress. Hence amputation should not be too long delayed, and 
when performed, it should be at a sufficiently high level not only 

to insure union of the 
flaps, but to render im- 
probable a recurrence 
of the gangrene within 
a short time. 

The early manifes- 
tation of gangrene from 
an internal cause is a 
venous congestion, 
sometimes accompanied 
with blisters extending 
part way from the toes 
to the ankle, and usu- 
ally a little higher on 
the inner than the out- 
er side of the foot. In 
this early stage of the 
trouble hot and cold 
bathing, rubbing, ele- 
vation of the foot from 
time to time during the 
day, and most impor- 
tant of all, a dry dress- 
ing of cotton to prevent loss of heat, will generally postpone the 
gangrene for a considerable time, perhaps for months or even 
years, if the general state of health can be improved. The 
skin under such circumstances is easily destroyed. One should 
avoid the use of counter-irritants, as intractable ulcers may 
easily be produced by them. 




IG. 275. GANGUENE OF TOE, POSSIBLY FROM 
FROST-BITE ; NO DIABETES. Duration one 
month. Patient a man aged fifty-two years. 



ACUTE INFLAMMATIONS 

While in the upper extremity the hand is especially exposed 
to injury, the foot is protected by the shoe, so that contusions and 
wounds of the lower extremity are oftenest met with in the shin, 
and, owing to poor circulation, lesions at first slight may become 



PHLEBITIS AND THROMBOSIS 515 

serious. Thus a small cut or scratch may develop into an annoy 
ing ulcer in individuals whose general health is good, while in 
those in whom there coexists chronic systemic trouble or eczema, 
edema, or varicose veins, destructive inflammations are even more 
common. These differences result chiefly from the poorer circula- 
tion in the dependent extremity; partly from the fact that the 
parts injured in the two extremities do not usually correspond. 
Thus it is the hand which is most, often injured in the upper 
extremity, and the leg in the lower. Infected wounds of 'the 
forearm behave more nearly as do those of the leg in forming 
local cellulitis and abscess. These remarks apply only to acute 
infections. Syphilis and tuberculosis have their own methods of 
tissue destruction, so that the lesions of such diseases vary little 
whether in the arm or leg. 

Cellulitis. Cellulitis in the lower extremity is apt to l>e ac- 
companied by an unusual amount of edema on account of the 
poorer circulation in this part of the body. The same may have 
existed before the injury or it may be wholly due to the infection, 
a point which can be settled by comparing the two limbs. To over- 
come the edema the patient should lie down most of the time, or 
sit with the affected limb in a horizontal position. A wet dr 
ing is cooling and assists in overcoming the infection. It is !! 
ter not to prevent evaporation by rubber tissue, but to keep the 
gauze wet by pouring water on it every hour or so. For the 
further treatment of cellulitis see page 35. Abscess should be 
watched for, and opened early. A large hypodermic needle is a 
most satisfactory means of making an early diagnosis of ahsce . 

Lymphangitis. A superficial lymphangitis with reddened 
vessels traceable as far as the glands in the groin, and correspond- 
ing to that which so often occurs in the upper extremity, is seldom 
seen. A deeper lymphangitis, following the veins, and often asso- 
ciated with phlebitis and thrombosis, is of more frequent occur- 
rence. It is a serious malady, and by extension upward into the 
vena cava, or by embolism, or simply by the intensity of the septic 
process it may cost the patient his life. In view of this fact every 
patient who has a deep lymphangitis of the leg should be treated 
in bed from .the time the diagnosis is made. 

Phlebitis and Thrombosis. Phlebitis or inflammation of 
a vein may develop in a varicose vein (p. 538), and run the course 



516 INFLAMMATIONS OF THE LEG AND FOOT 

of an acute inflammation without suppuration, or it may be accom- 
panied by suppuration, though no visible source of infection be 
present. The first symptoms of phlebitis are pain, heat, redness, 
and swelling over an area an inch broad and which is more or 
less long, according to. the extent of the inflamed vein. The vein 
itself can usually be felt as a tender indurated cord in the center 
of this area. If thrombosis takes place in the vein, the hardness 
of the vessel is more marked, and persists after the tenderness 
and surrounding swelling have subsided. 

The phlebitis may gradually subside without extending fur- 
ther, but it usually extends upward either in continuity or skip- 
ping a few inches of the vein the process will repeat itself further 
up. Thus a patch of phlebitis in the calf of the leg may be fol- 
lowed by another in the thigh, the intervening veins remaining 
normal. Usually, however, it spreads by continuity. 

TREATMENT. In the first days phlebitis should be treated by 
rest in bed and an ice-bag. When the acute pain has subsided, 
unguentum ichthyol and a firm bandage make a good dressing. 
The limb should be bathed and moved with caution, even after 
the, acute symptoms have passed over. Massage is contraindi- 
cated. One does not wish to break up a thrombus and send its 
fragments into the blood -current. 

. If the patch of phlebitis is small, a patient may absolutely 
refuse to go to bed. His leg should then be treated with unguen- 
tum ichthyol and a firm bandage, and he should keep as quiet 
as possible. The danger in such a case is that the thrombus may 
extend upward, or that a portion being detached may form a fatal 
embolus. Still embolism is a very rare accident in thrombosis of 
the -veins of the leg or thigh. 

Suppuration may occur at any time in the history of a throm- 
bus, even without any visible break in the skin. If an abscess 
forms, it should be opened. If it is of a sluggish character a short 
incision will suffice. 

Resection of the affected vein has been advocated recently as 
a means of quicker recovery (ten days to two weeks) in non-sup- 
purative cases. This is a heroic remedy for a disease which is 
often very mild ; but it is especially suited to cases in which the 
varicose veins require removal irrespective of the acute inflam- 
mation. 



517 



Lymphadenitis. The femoral or inguinal glands may be- 
come inflamed from an infected wound of the leg or foot. Scan-li 
will usually reveal the entrance of the infection. If the wound 
is treated properly, the swelling of the lymph-glands usually sub- 
sides. If the glands suppurate, the pus must be evacuated. Re- 
moval of the affected gland should be performed when possible, as 
the healing afterward is more prompt than when the gland is 
merely incised. (Compare p. 431.) The incision for either oper- 
ation should be strictly longitudinal to avoid injury of the nerves 
and vessels of the groin. The removal of a lymph-gland is always 
a more difficult procedure than the previous examination of the 
parts would indicate. 
The gland is so readily 
palpable that one is 
apt to forget that the 
very fact that it ele- 
vates the skin also in- 
dicates that the under 
surface of the gland is 
deeply embedded in the 
tissues. Hence the pa- 
tient should be given 
a general anesthetic 
before any attempt is 
made to remove the 
gland, especially if it 
is inflamed. 

Abscess. Super- 
ficial abscess in the 
thigh or leg may fol- 
low a contused or lac- 
erated wound, or it 
may develop from a 
small scratch or from 
the bite of an insect 
(Fig. 276). It is usu- 
ally associated with 
much edema and cellulitis, so that the presence of pus is not 
always easy to make out. In doubtful cases, if there is considerable 




FIG. 276. ABSCESS IN FRONT OF THE KNEE FROM 
AN INFECTION ON THE SHIN. Patient a girl, one 
year old. 



518 



pain, and particularly if the process is extending in spite of a wet 
dressing and rest to the limb, an incision should be made. A quan- 
tity of serum will escape and relieve the tension, even if no pus is 
found. If phlebitis can be ruled out cellulitis in the leg will gen- 
erally be found to have a purulent center. (See p. 515.) 

Suppuration about the knee in the form of small boils may 
keep up for a long time, reinfection taking place in a most pro- 
voking manner. 

Abscess in the foot may arise from a punctured wound made 
by a wire nail or sliver and from injudicious paring of a corn or 
callus. If the vicinity of such a wound is swollen and tender it 
should be incised and drained. (Compare punctured wound of 
finger, p. 331.) If the punctured wound is in the ball of the 

foot, the pus often col- 
lects dorsally and should 
then be evacuated by a 
dorsal incision, either 
with or without a plan- 
tar incision through the 
original wound. It is not 
necessary to connect these 
two incisions; each can 
be treated from its own 
surface of the foot. 

Infected Insect- 
bites Vagabond's 
Disease. The bites of 
the body louse, insignifi- 
cant in themselves, cause 
an intense itching, to re- 
lieve which the patient 
scratches the skin violent- 
ly, making deep abra- 
sions. In a healthy per- 
son with a clean skin in- 
fection would not be like- 
ly to result; but the per- 
sons infested with body lice are usually impoverished individuals, 
often weakened by sickness or alcoholism, or lack of food, and 




FIG. 277. 



THE LEG, Two WEEKS, 
Pa- 



FHOM PEDICULOSIS AND SCRATCHING. 
tient a boy aged sixteen years. 



CHHONIC ULCIOI: OK Tin; u-;<j 



519 



unable to kitlic i'n-t|iiciillv. llnn-c the smitrhrs ol'ini nli-crate 
especially those made upon the back and legs (Fig. 277). The 
;i|i]H>;irances are so uniform that the condition is often spoken of 
as ^ ^ agabond's Disease. 

TREATMENT consists in the removal and disinfection of the 
clothing by boiling or otherwise, bathing the patient, and the use 
of some antipruritic lotion or salve to control the itching, which 
often lasts long after the insects have ceased to bite. Shallow ulcers 
generally heal promptly ; the deeper ones should be treated accord- 
ing to principles laid down in the following pages. 

Eczema. Eczema of the leg is of interest to the surgeon be- 
cause it so frequently precedes and accompanies chronic ulcer. It 
is usually of the dry papular form, but a weeping eczema is occa- 
sionally seen in connection with ulcer of the leg, forming a com- 
bination of lesions which tries the skill of the doctor severely. 
The eczema causes itch- 
ing, the itching causes 
scratching, the scratch- 
ing causes ulceration, 
the ulceration ' causes 
discharge which irri- 
tates the skin and in- 
creases the eczema. 
Such conditions, if 
neglected in ill nour- 
ished individuals, may 
easily lead to chronic 
ulceration. 

The treatment of 
eczema is given on pa ire 
57. Its treatment, 
when combined with ul- 
cer of the leg, is given 
on page r> _' 1 . 

Chronic Ulcer of 
the Leg. Both on ac- FlG - 278 '~Ii LCER A OF E LE t CCURRI '* A 

MAN AGED FORTY YEARS. 
count of its frequent 

occurrence among working people, and still more because of its 
duration, chronic ulcer is by far the commonest lesion seen in a 




520 INFLAMMATIONS OF THE LEG AND FOOT 

surgical dispensary (Fig- 278). Some ulcers can be cured in a 
few weeks, in other cases months of the most faithful treatment 
must elapse before the epithelium can be coaxed over the granu- 
lating area. In these difficult cases a single ill chosen dressing, 
or a failure of the patient to come for treatment for a few days, 
or an alcoholic debauch, may wipe out the gain of weeks. In 
dealing with a problem of this character it is evident that a change 
of doctors, or carelessness on the part of the patient, must mate- 




FIG. 279. CHRONIC ULCER ALMOST SURROUNDING LEG. 

rially interfere with the success of treatment. Hence there are 
instances of patients who have come to be treated for an ulcer of 
the leg, more or less continuously for many years. Probably most 
of these patients could be cured if they could be regularly treated 
by the same surgeon for a period of six or eight months (Fig. 
279), 

It is at least the opinion of the writer after dressing hundreds 
of these ulcers for weeks together that they can all be healed by 
local ambulant treatment if they are due solely to local causes. 
There are a few ulcers due to constitutional causes in which local 
treatment has no effect, but .these are rare exceptions. 

PREDISPOSING CAUSES. The constitutional disorders predis- 
posing to chronic ulcer of the leg are alcoholism, anemia, diabetes, 
syphilis, and any trouble such as cardiac or nephritic disease, 



CHRONIC ULCER OF THE LEG 521 

which causes chronic edema, and any disease of the nervous sys- 
tem which affects the nutrition of the skin. Endarteritis, dia- 
betes, and some nervous affections produce degenerative processes 
in the toes and feet rather than ulcers of the leg. 

The local conditions which favor chronic ulcer of the leg are 
eczema, edema, dermatitis, and varicose veins. 

Eczema is a prominent factor in many cases, and of secondary 
importance in others. It causes the patient to rub and scratch 
the leg and thus form new ulcers. 

Edema may be soft and easily compressible, disappearing at 
night when the patient lies down, and reappearing after he has 
been for some hours on his feet. It may also be of a chronic 
type, almost as hard as a board, seriously interfering with the 
local circulation. 

Dermatitis is usually seen only in the early stages of an ulcer, 
or after neglect, or very bad treatment 

Varicose veins are often spoken of as though they were the 
sole cause of a chronic ulcer. Hence the name " varicose ulcer." 
This is an erroneous idea, as varicose veins are only one factor in 
chronic ulcer; and a chronic ulcer which depends chiefly on vari- 
cose veins for its existence is one of the easiest kind to heal, be- 
cause the dilatation of the veins can be so readily counteracted 
by a well fitting bandage. The term " varicose ulcer," as applied 
indiscriminately to chronic ulcer of the leg is therefore mislead- 
ing and should be given up. 

ETIOLOGY. The immediate cause of an ulcer of the leg is usu- 
ally a traumatism, such as a blow on the shin or a scratch of the 
finger-nails. Occasionally the traumatism may be so slight that 
the patient cannot explain the beginning of the ulceration ; or the 
start may be in the spontaneous rupture of a dilated vein. Wrong 
applications or infection of the scratch spread the necrosis of 
the skin and an ulcer is started, which in a few days may destroy 
skin that can be restored only by careful treatment of several 
weeks' duration (Fig. 280). It may fairly be called a chronic 
ulcer therefore, even from the beginning. 

TREATMENT. It is obvious that an ulcer which is largely due 
to unfavorable circulatory conditions is more easily handled if 
the patient can lie up in bed. This should be the first advice to 
those who can afford to follow it. Unfortunately most patients 



522 



cannot afford the time for this; so that the problem before the 
surgeon is, in most cases, how to repair the leg while the patient 
is walking about all day, or worse yet, is standing at a wash- 
tub or bench. Let him console himself with the thought that an 

ulcer healed under 
these conditions will 
be likely to remain 
healed with reason- 
able care, while one 
healed in bed may 
easily break down 
when the patient goes 
about, unless the 
patient is especially 
careful to guard 
against the change 
in circulation when 
he leaves the bed. 
This is one reason 
why ulcers closed by 
skin grafts are so apt 
to break down again. 
Since so many 
factors may contrib- 
ute to keep a chronic 
ulcer of the leg from 
healing, it is plain 
that the treatment 
must be different not 
only for different patients, but also for any given patient, ac- 
cording to the appearance of the ulcer. When a single remedy 
is advocated as a sure cure for all ulcers, it is evident that the 
experience of its advocate is limited, or else his observation is 
careless. The measures here given are intended to combat one 
or more of the conditions which retard recovery. They should 
be combined in a way to meet the symptoms which exist. When 
one measure has been used for a week or so with good effect, and 
then its influence wanes, continued improvement may follow a 
change to another agent of the same class. 




FIG. 280. ULCER OF LEG TWO WEEKS FROM SCRATCH; 
SPREAD BY VASELINE DRESSING. Patient a man 
aged thirty-three years. 



CHRONIC ULCER OF THE LEG 523 

1. Measures to Overcome Anemia and Chronic Edema. A 
daily hot batli of the foot and leg for twenty minutes will stimulate 
circulation, and in a few days soften and reduce an old hard 
edema. Besides it cleanses the surrounding skin, lessens the 
itching, and thus reduces the tendency of the patient to scratch 
the leg. Rubbing the leg with a cotton swab saturated with crude 
petroleum will remove discharges and crusts, will soften the skin 
and reduce edema, will alleviate itching, and will not increase 
any existing eczema. 

2. Measures to Cleanse the Ulcer. The ulcerating surface 
may be wiped with a cotton swab soaked with any mild antiseptic 
solution. If hydrogen peroxid is used, it should be dilutee! with 
four or eight parts of water. Many ulcers are extremely tender 
when treatment is first, begun, and strong jiero.xid causes sharp 
burning pain. If there is a tendency to ec/ema one should be 
extremely careful to avoid the application of irritating solutions 
even for cleansing. A swab soaked in crude ]M-tn>leum is a g>od 
thing to cleanse such skin. 

3. Measures to Allay Acute Inflammation. If the skin and 
subcutaneous tissues about the ulcer are inflamed, it is a good 
plan to soak the foot and leg daily for twenty minutes or more 
in a pail of hot carbolic solution (1 : 120), and to apply compresses 
wet with carbolic acid in 1 : 100 solution, or creolin in 1 : 200 
solution, or corrosive sublimate 1:2,000 solution, or aluminum 
acetate in 1:25 solution. The limb should be bandaged with a 
gauze bandage, and the dressing kept constantly moist by cold 
water poured on the outside of the bandage every hour or two. 
No gutta-percha or other impervious material should be wrapped 
about the leg. An outside piece of flannel may be used to keep 
up the warmth if the leg feels cold. This dressing is more suit- 
able for warm weather than for cold, unless the patient is con- 
fined to his bed. 

4. Measures to Stimulate Granulations. Eight or twelve 
thicknesses of gauze, cut so as to overlap the ulcer on all sides by 
a half-inch, and saturated with red wash, may be kept moist by 
additions of water, or by the application over it of a large com- 
press thickly spread with Lassar's paste or any thick salve non- 
irritating to the surrounding skin. This will keep the astringent 
gauze moist for two days, and does not sweat the underlying skin, 



524 INFLAMMATIONS OF THE LEO AND FOOT 

as does rubber tissue. Other solutions, such as creolin, 1 : 200, 
or nitrate of silver, 1 : 100 or 1 : 200, may be used to saturate the 
inner gauze. 

Another plan is to apply to the ulcer gauze saturated with 
balsam of Peru, pure or mixed with oil. This balsam gauze 
requires no protective covering, as it does not quickly dry out. 

The granulations are even more powerfully stimulated by 
dusting the nicer thickly with granular naphthalin before apply- 
ing the wet gauze. This powder is antiseptic and does not cake. 

5. Measures to Promote the Growth of Epithelium. Epi- 
thelium will grow rapidly in moisture and warmth, provided there 
is freedom from irritating discharges, a good circulation, and 
granulations which are as nearly as possible on a level with the 
skin. The measures already described in paragraphs 1, 2, 3, and 4 
are calculated to assist therefore in promoting the growth of epi- 
thelium. Exuberant granulations are rarely seen in chronic 
ulcers of the leg. If they occur they should be burned lightly by 
touching them in spots with a pencil of silver nitrate, which 
should in no case be applied within one-fourth of an inch of the 
skin margin, since the caustic action spreads somewhat beyond 
the area touched. Under the most favorable conditions epithelium 
can hardly be made to grow in the leg at a faster rate than one- 
eighth of an inch a week. This would give a month as the shortest 
possible time for the healing of an ulcer of the leg one inch across, 
provided the ulcer involves the whole thickness of the skin, so that 
no islands of epithelium may grow up in the center of the ulcer. 

Occasionally it happens that granulations grow up in little 
tufts and become covered with epithelium (Fig. 281). This gives 
a pebbly appearance to the scar which can still be seen even after 
the epithelium has become of normal thickness. Such an ulcer is 
usually very painful until entirely healed. 

6. Measures to Overcome Itching and Eczema. Mild dry 
eczema is sufficiently treated by the measures mentioned under 
paragraphs 3 and 4. For excessive itching nothing is better than 
sponging with a solution of carbolic acid, 1 : 20.. If the eczema is 
the chief feature, it may be treated by cleansing with crude petro- 
leum, dusting freely with lycopodium, and covering with com- 
presses soaked in crude petroleum; or compresses soaked with 
aluminum acetate solution, 1 : 25, may be applied and kept con- 



CHRONIC ULCER OF THE LEG 525 

stantly wet with water ; or other measures suitable to the treatment 
of eczema elsewhere in the body may be employed. 

Eczema occuring at the junction of the skin of the sole and 
that of the dorsum of the foot leads to ulceration that is very slow 




Fia. 281. CHRONIC ULCEU OK Lix; WITH PROLIFERATION, GIVING IT A PEBBLY AP- 
PEARANCE EVEN WHEN HEALED. Patient a woman aged sixty-three years. 

to heal. Therefore one should be very exact with the early treat- 
ment. Compare perforating ulcer, page 529. 

7. Measures to Reduce Venous Engorgement and Edema. In 
all cases in which edema or venous engorgement is present, 
whether or not large varicose veins are prominent, elastic bandag- 
ing is of great importance. While the ulcer is still open, a rub- 
ber bandage or stocking is not permissible. Elastic compression 



526 INFLAMMATIONS OF THE LEG AND FOOT 

may be applied outside of the dressing selected, by means of an 
even layer of non-absorbent cotton and a cotton bandage or by a 
flannel bandage or a stockinet bandage. In any case the bandage 
should begin at the base of the toes and extend above the calf, omit- 
ting, the heel unless the ulcer is situated below a malleolus. The 
successful application of a bandage of this sort requires consid- 
erable practise. The test of a good bandage is not in the pattern 
made by its turns, but in the smoothness with which they lie one 
over the other, felt by passing the hand down the back of the 
leg after the bandage is complete. If all the turns press evenly 
the bandage will remain in place, even though the patient is con- 
stantly walking about, and when removed there will be no ridges 
in the edematous leg to indicate where one edge of the bandage was 
drawn tighter than the other. The best-type of bandage to apply 
is shown in Figure 396, page 67-i. 

8. General Measures to be Observed During the Healing of 
an Ulcer. Any habit of the patient or constitutional condition 
that exerts an unfavorable influence on nutrition and repair 
should be corrected if possible. The patient is better without 
much alcohol, tobacco, or tea. Constipation often needs to be 
corrected. Circular garters have been severely criticized, but 
probably have little effect in producing varicose veins. If possi- 
ble, the patient should rest for an hour or two a day in a hori- 
zontal position. At least he can make a practise of putting the 
affected leg upon another chair whenever he sits down. If there 
is good reason to believe that an ulcer- is syphilitic (Fig. 282), 
mercury and iodid of potash should be administered. It is a mis- 
take, however, to infer that every chronic ulcer occurring in a pa- 
tient who has had syphilis at some period of his life is syphilitic. 

9. Measures to Preven