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TRAUMATIC SURGERY

«
%

JOHN J. MOORHEAD, B.S., M.D., F.A.C.S.

Late Lt. -Colonel, Medical Corps, American Expeditionary Forces; Professor of Surgery and Directnc*

Department of Traumatic Surgery. New York Post-Graduate Medical School and Hospital;

Visiting Surgeon to Harlem Hospital; Attending Surgeon, Park Hospital; Consulting

Surgeon. All Souls' Hospiul (Morristown, N. J.); Lt.-Colonel, Medical Reserve

Corps, U. S. Army.

SECOND EDITION
ENTIRELY RESET

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1921

Copyrigbt, 1917, by W. B. Saunders Company. Reprinted April. 1917. August, 1917,

and Xovembcr, 1917. Rc\'iscd. entirely reset, reprinted, and

recopyrighted March, 1931

PRINTED IN AMERICA

PREM OF

W. B. SAUNDERS COMPANY

PHILADELPHIA

MY WIFE

PREFACE TO THE SECOND EDITION

Tms edition represents numerous changes and additions, much
of the texl being entirely recast. Many new drawings are included,
and another chapter has been added dealing with standardized
first aid methods as related to industrial surgery.

The first printing of this book antedated the entry of our country
into the war by only a few weeks, and verj' soon after that many of
us were practising a new kind of traumatic surgery in France. We
learned much from our early association with French, British and
Belgian surgeons, and later put into practice this knowledge in the
American Sector. Out of this large experience we found that certain
valuable methods are applicable to civil traumatic surgery, notably
as to wounds, compound fractures, joint injuries and methods of
functional re-education.

However, the author is not of the opinion that the management
of the injured has been radically changed by war experience, but
the militar}' surgerj' measures applicable to ciMl Ufe have been tried
out sufficiently to include many of them in the chapters that follow.

The almost universal use of the automobile has made motor
accidents one of the main sources of injurj-, and for this reason the
general practitioner, even in remote sections, is more than ever the
main factor in the treatment of the injured. Comr>ensation laws are
in force in most of our States and this also places an arlded responsi-
bDit)' upK>n the family doctor, often indeed making neccssarj' the
application of considerable surgical knowledge. The importance and
need of wider knowledge in accident surgery- i.s now so well recognized
that many medical colleges prowJe special p>ost-graduate courses in
this subject. Traumatic surgerj' has attained a fuller recognition
as an important branch of general surgery- and the time is at hand
when it will be looked upon as a definite specialty. The day has
gone by when the hospital care of the injured can be assigned U>
junior member of the \-i5iting or house ^tafi. and the profession and
the hdtv alike are keenlv aw2LTC that the maximum of care and atten-
tion means the minimum of disability.

\llth a real sense of appreciiition the author acknowleriges the
favorable reception accorded the earlier printings of thir; Yxxjk.

rn7.f-T

12 PREFACE TO THE SECOND EDITION

and it is hoped that the present volume may receive an equal welcome
and also that form of constructive criticism which has been so helpful.
War service brought us into intimate contact with a new type
of injured patient, a new tjT)e of fortitude and bravery in the field
and in the hospital, that tj'pe who by his spirit called up in us our
best efforts. In these post-war days let us not forget that we owe an
increasing duty to our patient in an effort to minimize the effects of
an injury that may disfigure or disable unless we amplify our knowl-
edge of these traumapathies.

John J. Moorhead.

115 East 64Tn Street,

New York City.

Marchf 192 1.

PREFACE

This book is written with the main idea of placing in one volume
the information necessary to diagnose and treat all the usual and
most of the unusual effects of accident and injury.

The profession at large has become reawakened to the problems of
accident surgery, and, incidentally, has come into a new relationsfiip
with the injured because of the operation of compensation and aUied
laws; likewise, the victims of accident, and civic, judicial, legal, and
other agencies are exacting from the physician a higher grade of care
and placing on him an added burden of responsibility.

The writer has long been of the opinion that cases of injury have
not received the same care and attention accorded other surgical
patients, and has often realized that a properly treated Pott's fracture
or infection of the hand is a far greater manifestation of the surgical
art than the successful removal of an "interval appendix."

What follows is purposely didactic, and much of it relating to frac-
tures has hitherto been the subject of clinical lectures to successive
groups of matriculants at the Post-Graduate Medical School.

The text also aims to state the measures which the writer has
found most practical in his own experience, and an effort has been
made to unify and standardize the treatment of such common injuries
as wounds, infections, bums, and the usual fractures. It will be
noted that stress is placed on the routine use of but few antiseptics,
the drainage of all wounds, the immediate and complete reduction of
fractures, and non-reliance upon complicated splints or those that hide
the part or are irremovable.

The writer believes that open air and sunshine is the best treat-
ment for any infected wound in any location from any source, because
purulent secretion is soon checked, there are no pus-soaked or wound
adhering dressings (literally pus poultices), and the comfort of the
patient is measurably increased and healthy granulations and mini-
mum scarring occur promptly. For many years now this plan has
been employed, and the writer is convinced that its efficacy is best

14 PREFACE

proved by the statement that skin-grafting has not been necessary
since this form of aerotherapy and heliotherapy has become routine in
his practice.

Many references are made to such recognized authorities as Stim-
son, Cotton, Gushing, Dana, and others; zealous effort has been
made to accredit properly these and other sources of information, and
if there is failure in this respect it is wholly imintentional.

The writer has had much encouragement and generous use of
material from many of his associates in the various hospitals with
which he is connected, and to these, and to successive members of
respective house-staffs, he expresses sincere thanks. He is especially
indebted to Drs. W. H. Stewart and I. S. Hirsch, radiologists respec-
tively to Harlem and the Post-Graduate Hospital.

The publishers and their artist, Mr. J. V. Alteneder, are deserving
of and are accorded acknowledgment for that co-operation without
which the writer could not have called this a completed book.

This is an age of preparedness, and the writer cherishes the hope
that this volume may, to some extent at least, better prepare his
confreres, as it has him, to care for the patient who has been hurt —
the many victims of these traumapathies.

John J. Moorhead.

115 East 64TH Street,
New York City.

CONTENTS

CHAPTER I

PACK

Wounds and Their Complications 17

CHAPTER n
Contusions no

CHAPTER m
Shock 113

CHAPTER IV
Injuries of the Tendons and Joints ' '9

CHAPTER V
Dislocations 194

CHAPTER VI
Fractures 247

CHAPTER Vn
Special Fractures 280

CHAPTER Vm
Diseases of the Bones 49'

CHAPTER DC
Deformities of the Hands and Feet 50'

CHAPTER X
Foreign Bodies 5>7

CHAPTER XI
Injuries of the Head 528

CHAPTER XII
Injuries of the Spine 575

CHAPTER XIII
Injuries of the Chest 623

CHAPTER XIV
Injuries OF THE Abdomen 63S

l6 CONTENTS

CHAPTER XV

rAGK

Injitxies of the Nerves, Blood-vessels, and Lyiifh-vessels, Neusitis and
Perineuritis 660

CHAPTER XVI
Burns; Heat Stroke; Frost-bites 700

CHAPTER XVn

Injuries Due to Electricity; to Compressed Air or Caisson Disease; Injury
FROM Illuminating Gas 708

CHAPTER XVin
Injuries Due to Sxtbmersion; to Suffocation; to Smoee Inhalation 727

CHAPTER XrX
Injury in Relation to Abortions, Appendicitis, Visceral Prolapse 731

CHAPTER XX
The Traumatic Neuroses 757

CHAPTER XXI
Eye and Ear Tests and Standards 795

CHAPTER XXII
x-Rays; x-ray Burns S02

CHAPTER XXIII
Medicolegal Phases 806

CHAPTER XXIV
Standardized First Aid Methdds in Accidknts 827

Index 839

TRAUMATIC SU RGERY

CHAPTER I

WOUNDS AND THEIR COMPLICATIONS

WOUITOS

All such breaks in the continuity of the skin may be classified
as incised and lacerated.

Incised wounds are smooth and more or less regular, and are best
represented by cuts made by knives, glass, or sharp-edged materials.
Lacerated wounds are of many varieties, and they all are more or
less ragged and irregular, and are usually due to falls upon edged pro-
jections or blows from more or less blunt objects. If the area is
gouged or punched out, it is called a punctured wound. If it enters a
deep>er part or a viscus, it is known as a penetrating wound. If it
shows bruising of the edges or parts adjacent, then it is called a
contused wound. If only the superficial layer of the skin is scraped or
rubbed, it is called an abrasion; and if this has occurred in part from
friction, then it is called a brush burn, as from a rope sliding through
the handSji or from contact of the moving body with a stationary
object.

Sjrmptoms. — All wounds show some signs of bleeding, gaping,
pain, and sometimes swelling and discoloration.

Bleeding varies with the site, extent, and cause of the wound, and
it is likely to be most active when the source is arterial or from a
vascular territory. Incised wounds ordinarily bleed more than
lacerated wounds because the vessels are generally cut cleanly across
rather than more or less unevenly torn or bruised. Free bleeding
generally follows wounds of the scalp (especially below the crown),
face, fingers, palm, sole, scrotum, and tongue. Some large wounds
bleed surprisingly little because the vessels are twisted, stretched
or otherwise occluded, this notably occurs in some traumatic
amputations.

2 17

1 8 TRAUMATIC SURGERY

Gaping varies, and is most marked when the wound is deep enough
to sever underlying fascial or muscular fibers.

Pain is less marked in incised than lacerated wounds, and it is
most acute in sensitive areas and people. It may be entirely absent
even with quite extensive damage, as in some amputations.

Swelling and discoloration are variable, but are most likely to occur
in lacerated and contused wounds.

Treatment. — For practical purposes any wound not made with sur-
gical precautions should be regarded and treated as if already infectedy
irrespective of source, size, site, or symptoms.

The general indications are to (i) stop shock and bleeding;
(2) prevent infection; (3) provide coaptation, drainage, protection
and rest.

(i) Shock is ordinarily due to the bleeding, and after the wound
itself is cared for, the usual systemic treatment is given for any exist-
ing collapse. Gentle manipulation is essential, and only the abso-
lute necessities of the patient should be treated until shock is re-
covered from.

Bleeding is stopp>ed by pressure applied directly to the bleeding
spot by a clamp, the finger, or fabric; or indirectly, by cutting off the
blood-supply by a tourniquet. It is exceedingly unwise to stop bleed-
ing by styptics, as infection is almost certain to follow.

In emergency bleeding, finger pressure on the artery above the
bleeding place will usually answer until a sterile compress can be
packed into the wound or another form of tourniquet employed. An
ordinary rubber band around a finger, forearm, arm, leg, or scalp
makes an excellent tourniquet; and a garter, suspender, shoe-lace, or
necktie acts almost equally well as a first-aid expedient when no twine
or rope is at hand.

(2) Infection is prevented by allowing the wound to bleed a reason-
able amount so that any foreign matter may be washed out; then pure
tincture of iodin should be dropped into the cavity and allowed to
cover the area about it by overflowing. If sterile materials are at
hand, the bleeding should be checked before the iodin is used, so that
it may be better absorbed. No scrubbing or other irritating
measures should be employed. Oil and grease can be removed by
kerosene, benzine, or gasolene. Hair should be removed from the
margin of the wound. The iodin should be made to penetrate every
recess of the wound, especially if the parts are much crushed, muti-
lated, or stripped up. All bullet wounds, and those likely to be
contaminated by soil, are guarded against tetanus infection by the im-

WOtlNDS AMD THEIR COMPLICATIONS

Fio.^. — Continuous suture method. Fio.i. — Coapting the angle of a wound. -

Fig. 3. — Continuous suture method. Fig. 4. — Continuous suture reinforced.

Flo, S' — Continuous lock etitch. Fig. 6. — Adhesive plaster strapping for coapting

20 TRAUMATIC SURGERY

mediate use of tetanus antitoxin. This is notably needful in "Fourth
of July" injuries. Too much handling of these or other varieties is
inadvisable, and probing is almost certain to prove disastrous.

See also wound infection, p. 37.

(3) Coaptation is brought about by sutures of catgut (plain or
iodized), horsehair, silkworm-gut, silk, or linen. Of these, silk and
linen are most often used for emergency work. Ordinary sewing silk
or linen ("shoe-button thread") is just as good as the more expensive
varieties (Figs. 1-5). Sterile adhesive plaster may be used in some
cases (Fig. 6).

Small wounds of the scalp sometimes may not need stitches if a
few hairs on each side of the wound are intertwined and tied; this is
particularly useful in women and children (Fig. 530).

All stitches should be interrupted and so placed that the wound
edges just touch but do not overlap or jamb, otherwise necrosis will
occur. Usually stitches are inserted about }4 uich apart on the face
or actively mobile parts and i inch or more apart on other more
quiescent areas. In most cases they may be removed not later than
the fourth or fifth day, for, as a matter of practice, we know that
wound edges properly coapted become well sealed after a lapse of a
few hours. Metal clips of the Michel type are unpopular in this
country. Collodion makes an unsatisfactory and often dangerous
primary dressing, but may later be of service.

Drainage should be used in every wound not made ydth surgical
intent. Small wounds can be drained at one angle by a strand of the
suture material inserted the full depth, and when this is removed,
within a day or two, danger of infection will probably be past and
such a small drain will not interfere with primary union. A twisted
piece of rubber tissue or a small rubber band acts the same way.

Occlusion is best provided by sterile gauze, which may be dry in
incised wounds and moist in other varieties. Absorbent cotton is
objectionable next to the wound because it is not sufficiently absorp-
tive and becomes adherent. Moist dressings may be made by plac-
ing the gauze in salt, boric acid, alcohol (25 to 50 per cent.), or iodin
(i dram to a pint of water), solutions. Care should be taken not to
bind the dressing too tightly, especially in wounds of the forearm,
hands, and feet. In properly selected cases a gauze-covered wire
cage over the open wound offers the best treatment so that there may
be free access of air and sunshine ; this is especially true of infected or
secreting wounds. Collodion alone or in the form of the familiar
cotton-and-coUodion dressing should not be used until all secretion

WOUJJDS AND THEIfi COMPLICATIONS

lias ceased and infection is improbable. Moist dressings must not be
used too long as they macerate the parts, and usually a dry dressing
can be substituted after a few days. If there is much initial swelling,
pain or contusion, hot apphcations are often more effective than cold.
The prolonged use of bichlorid may cause sloughing or poisoning.
Carbolic solutions should never be used continuously.

Resl is provided by suitable bandaging that must not in any
manner act as a tourniquet. In many cases a splint is advisable, and
a suitable posture (usually elevation) will be an added factor of safety
and comfort.

SPECIAL WOUHDS
. Abrasions of the face, hands, and legs are very commonly due to
grazing contact producing scraping wounds of the superficial skin

Fig. 7- — Eitensive infected ab

jsh bum") of shoulder girdle region.

I layers, often quite extensive, but without muchbleeding. When much
* friction occurs, heat is generated and the edge of the abraded area
may also show signs of a first degree burn (the so-called "brush burn,"
Fig. 7). These are apt to be painful, and numbers of them are in-
fected by neglectful or self -treatment, especially "barks of the shin."
Treatment aims to prevent infection by the use of iodin liberally
applied, and then the part is covered by a moist sterile gauze dressing
of saline, boric, or alcohol solution. It is very unwise to use even a
moderately strong antiseptic protective dressing in such a case be-
cause local resistance b much lowered and a relatively large surface

33 TRAUMATIC SURGERY

is exposed for absorption. Carbolic applications are almost certain
to produce decided escharoUc effects even in weak solutions, and, in-
deed, this drug should not be used in acute surgical conditions
except as a cauterant. Likewise, dry dressings, particularly of the
collodion type, favor infection. A gauze-covered wire or other
caging is the best form of protective, so that air and sunlight may
have free access. If the area of denudation is very large, skin-
grafting may be needed. When the serous oozing (or "weeping")
has ceased, the use of balsam of Peru or scarlet red ointment will
aid granulations. "Barks of the shin" need to be treated with the
greatest care, so that periostitis and ulceration do not occur, especi-
ally in old people or when varicose veins or perhaps lues exist. In
cases of this sort, rest in bed with high elevation of the limb will be
beneficial, especially in the early stages.

The systemic conditions often need as much attention as the local
lesions.

CRUSHING WOUITDS

These are not infrequently associated with commniuted fractures,
and more or less shock is a common accompaniment. The majority

Fig. S. — Momburg constrictor applied above the level of the umbilicus to restrict
circulation through the abdominal aorta.

of these involve the hands, feet, or limbs, and are due to machinery,
railway, vehicle, mining, building, and other transportation and
industrial accidents.

Treatment is directed mainly to the bleeding and shock, and only
the most necessary manipulation is made at first so that the patient's
vitality may be conserved. In many cases, as in a crushed limb,
the patient is put to bed for shock treatment with a tourniquet in
place or artery clamps hanging to the vessels, the wound itself
covered by a sterile dressing {Figs. 8-13). Later, the appropriate
measures may be employed. In all instances the utmost gentleness

WOUNDS AND THEIS COMPLICATIONS

must be employed, and much good will follow "blocking the nerves"
by injecting the main or other visible trunks with i per cent, cocain,
^ per cent, novocain, or other analgesics. By such treatment pain-
ful stimuli are blunted or abolished and the dangers of secondary

.Fig. 9

-Bandaging the

the blood-supply in severe hemorrhage

shock greatly diminished. General anesthesia is of much aid, as in
many cases of even profound shock it has a stimulating effect,
ether being the anesthetic of choice, preferably used with nitrous
oxide or oxygen.

The free use of iodin is the best disinfectant and it should be
poured fearlessly into every crevice of the wound until the surgeon
feels certain that he is working in an iodmized field Gasolene,

Fig II — Hyperflemon of the
elbow acting as an mprovised
tourniquet for bleeding below the
—Tourniquet for the femoral vessels. joint.

benzine, kerosene, olive oil, or ilbolene may be used to remove
grease, but under no circumstances must vigorous scrubbing be
undertaken unless the surgeon is prepared to expose all parts of the
wound; this usually means that a general anesthetic will be required.

TRAUMATIC SURGERY

If there has been any possible infection from street dirt or the soil,
tetanus antitoxin should be given at once (500-1500 units).

Conservation next to sterilization is the main requisite, and no
tissue should be sacrificed unless absolutely necrotic or wholly de-
tached from blood-supply. This is especially true in extensive
woimds about the face^ hands and feet, or in other localities where
the blood-supply is known to be rich. Severed nerves and tendons
should be united when possible, otherwise they should be marked
for subsequent identification. Torn or pulpified muscle does not

FlO. 12.

, Rubber tubing tourniquet on femoral vessels.

on axillary vessels.

by Rubber tubing tourniquet

unite well and must be loosely coapted. Broken bones are provision-
ally wired or held by strands of kangaroo tendon or otherwise
placed in as good position as possible for subsequent treatment.
No bony spicule is removed unless wholly detached from perios-
teum or obviously acting as a foreign body. Wiring, plating, or
other metallic devices for permanent bony junction are usually
contra-indicated until the danger of infection has passed.

The soft parts are loosely sutured with horsehair, silkworm-gut,
linen, or silk. Plentiful drainage is provided by strands of rubber
tissue or rubber bands. A large loosely applied gauze dressing is
moistened by saline, boric, alcohol, or other mild solution, and then

WOUNDS AND THEDt COMPLICATIONS 25

the part is placed at rest on a well-padded splint. When the patient
is abed the member is kept elevated and the dressing remotstened
every twelve hours by poking a glass syringe or irrigating tip into
the meshes of the dressing and allowing the solution to flow from an
irrigator, fountain or hand syringe. If Carrel tubes are used, the
appropriate technic is followed (see p. 52). Shock is suitably treated.
If possible the patient is kept out of doors, and many of the cases do
best with the wounded area exposed to the
air and sunlight except for the gauze
covered wire screen previously mentioned.

Alcoholics need whisky and bromids
until they sleep, begin to eat, and cease
to show tremor of the tongue or fingers.
The dressings need not be changed for
twenty-four hours unless local pain, dis-
charge, or '.constitutional developments
indicate trouble. If now some of the
parts are gangrenous or dead, they may
be removed, but unless inflammatory re-
action is very active it is advisable to
wait as long as possible before excising
supposedly dead soft parts, in the con- Fig. 13,— Rubber tubing on
fideat hope that at least some vitality ^ SuX"' «"." L"l
will return. Drainage is gradually re- tourniquet.
moved, and when the granulation stage

is under way, balsam of Peru or balsam of tar may be used as a
dressing.

The general health of the patient is suitably cared for after the
maimer indicated under Infected Wounds.

AVULSIONS

In these cases the part is forcibly torn away, as the scalp from the
skull or the arm from the shoulder (disarticulation avulsion). These
accidents generally occur to persons working about revolving belts,
gears, conveyors, buskers, or similar appliances (Fig. 14).

Scalping is commonest among women, and the entire scalp
may be avulsed with the ears and eyebrows, or any portion of the
hairy part may be removed, with or without a portion of the outer
table of the skull. Bleeding is usually slight, but shock is often
profound.

TRAUMATIC SURGERY

Treatment is primarily for the shock, and later autogenous skin-
grafting will be necessary. Very occasionally an avulsed scalp has
been replaced and some portions of it have successfully healed, but

Flo. 14. — Partial avulsion of scalp.

such cases are obviously only those in which the entire scaip is not
denuded.

In the case shown (Fig. 15) the patient had been scalped by a

moving belt, and one ear and both eyebrows were removed and two
portions of the outer layer of iJie skull were also torn away. Skin-
grafts from friends and relatives proved unsatisfactory, but after

WOUNDS AND THEIR COMPLICATIONS 2^

many operations, extending over a year, autogenous grafts finally
covered the entire area. In all, over two hundred segments were
removed from her thighs and arms (Thiersch method) before healing
occurred. In this instance an effort was made about every six weeks
to cover an area approximately 4 inches square on opposite sides
of the scalp, and when she recovered from the anesthetic, protection
was afforded by a wire cage, so that the grafts were exposed to the
air. . For a long time the grafted area cracked and ulcerated from slight
pressure, but eventually a movable thin scalp resulted, and the defect
is very well covered by a wig with a very low "bang" to cover the
eyebrow region. Four unsuccessful later efforts were made to graft an
eyebrow, hairy parts being taken from Jier adjacent scalp and pubes,
and on the other occasions from the scalp of donors.

Avulsions of a limb from the socket {disarticulations) are com-
monest at the shoulder and knee, and often the separation is done
with almost surgical precision. The vessels are usually so twisted or
stretched that little bleeding occurs. In one case the patient had
his right elbow caught in a belt-conveyor, and was brought to the
hospital with the intact humerus entirely denuded from a point just
below the axilla, and an immediate operative disarticulation of the
shoulder was done. There was practically no bleeding despite the
tearing away of the limb at the elbow and the stripping of soft parts
from the armpit down. The remaining muscle and skin was sufficient
to form a good flap, and healing was almost as prompt as if the disar-
ticulation had been performed deliberately.

Treatment of this class of cases designs to control shock and bleed-
ing and to disinfect by iodin, later making such closure as the condi-
tions warrant. Extensive manipulation should be postponed in the
presence of shock.

BULLET WOUNDS

These are exceedingly common in civil practice, and they gener-
ally occur from revolvers (.32, .38, and .44 caliber), shot-guns, and
rifles.

Symptoms. — The wound of entrance is ordinarily round, with
dark edges, and if the contact is close, powder stains are generally
in evidence. Occasionally clothing has been iginited, and then
burns of various degrees are added factors. In some instances the
wadding of the missile or pieces of clothing and debris are carried
subcutaneously. If the head or thorax has been struck, it is not
uncommon for the bullet to glance and travel a long distance sub-

28 TRAUMATIC SURGERY

cutaneously after striking the bone just beneath the place of en-
trance. Many such cases soon show a ridge of swelling and
ecchymosis outlining the course of the bullet. Bleeding is usually
slight unless a main vessel has been cut, and then the blood is more
likely to collect subcutaneously than to appear at the wound of
entrance or exit. If the wound is over a reasonably large vessel,
such a hematoma may within a short time develop the hum or
thrill characteristic of an arteriovenous aneurysm. I recall in
civil practice such an occurrence in the femoral vessels following the
wound of a .38 caliber bullet that entered the upper part of the thigh,
traversed the limb, and appeared in the buttock subcutaneously.
In this patient a large hematoma obscured the actual conditions for
a few days.

Treatment.— The wound is sterilized by flooding it with iodin
and then applying a sterile moist dressing after a small rubber drain
has been inserted.

Probing is exceedingly dangerous and should never be done. Tetanus
antitoxin is to be given in every instance. If the bullet is doing
harm, it will manifest itself by adequate and appropriate signs of
pressure, and it can be removed when the chances of infection have
subsided. In many instances it is suitably encysted and may be
left undisturbed indefinitely. If the missile is hidden, careful radio-
graphic examination is the best guide to the location, but in such
cases the ic-ray plates must be made in at least two axes, and prefer-
ably are stereoscopic. If doubt exists as to the presence of wadding,
clothing, or other foreign substances, the wound is 'to be enlarged
and inspected; this is especially needed in Fourth-of-July wounds from
** blank cartridges." Through and through wounds as a rule heal
kindly and require only iodine sterilization at the wound of entrance
and exit; this was the procedure in war wounds in the absence of
hematoma, injury to vessels (vascular or neural) or gross splintering of
bone.

Bullets penetrating the thoracic cavity are never searched for at
once unless evidences of heart injury exist.

If the abdominal cavity, however, has been penetrated, immediate
op>eration is necessary to determine the presence or absence of intra-
abdominal mischief, as in such cases it is unwise to await definite evi-
dences of hemorrhage or peritonitis.

Skull penetration requires operation, as a rule, because of the
possibility of hemorrhage or infection from the bullet, other foreign
bodies, or spicule of bone; however, it is usually safe to wait some

WOUNDS AND THEIR COMPLICATIONS 29

days in such cases, and in all instances x-ray localization is
essential. War experience showed that these cases stood transport
better before than after operation.

Joint penetration by a bullet demands expectant treatment with
suitable drainage, extension, and immobilization, on the theory that
infection will be quite likely to subside or localize unless stimulated
by manipulation that often is like a search in the dark. Joints are
less likely to become infected if a 2 per cent, formalin solution in
glycerin is injected at once, the part being kept in forced extension.
K the facilities are adequate, it is safer to immediately remove the
missile bearing in mind that the entire tract is to be exposed when
possible. If the wound is ragged or bruised, the edges of the tract are
to be trimmed off (debridement). When the joint is exposed,
the missile and all other foreign material is removed. The cavity
is then flooded with ether several times. All bleeding is stopped.
The joint capsule is then closed by interrupted catgut stitches.
The muscles and fascia are likewise closed, and finally the skin is
closed by interrupted non-absorbable stitches (silk, linen or silk-
worm). Drainage leads to infection and is not used. For a few
hours the parts are kept quiet on a splint and then are purposely
moved daily. If re-effusion occurs, it is aspirated under strictly
aseptic precautions. When the wound tract does not lend itself to
the best exposure of the joint, the most direct route to the latter
may be chosen.

As a matter of civil surgery practice, it may be stated that an
intra-abdominal bullet wound is the only variety requiring immedi-
aU exploration; all the others can usually await the development of
symptoms and proper localization.

The surgeon in every case must be certain that the bullet has
actually entered the suspected cavity and not ricocheted into a
more or less subcutaneous locality.

Hematoma formation may eventuate in abscess, and in such an
event the bullet, or some foreign substances entering with it, will be
usually found in the cavity thereof.

Bullets affecting bones practically cause symptoms of compound
fracture, and they are treated accordingly. If the bone is bored
through with little or no comminution, the treatment resolves itself
into sterilization and drainage. Bullets embedded in bone usually
do no harm and are left alone.

Shot-guns cause more or less "peppering" of the parts with buck-
shot, and often many powder grains are embedded. Penetration is

30 TRAUMATIC SURGERY

usually relatively superficial, otherwise the parts present symptoms
not unlike extensive lacerating or crushing injuries. Shot is picked
out after the area is iodinized; powder grains are likewise treated, and
their removal is facilitated often by brisk scrubbing of the part. It
is stated that a dressing of hydrogen peroxid favors the removal of
powder grains, but personally I believe that repeated poultices of
sterile oil or vaselin better softens the tissues; at best the extraction
is a tedious and painful process. Zinc oxid adhesive sometimes
sweats out powder flakes.

STAB WOUNDS

Generally these are from knives, stilettos, and other pointed ob-
jects like spikes, splinters, umbrellas, canes, and tongs.

The signs are those of lacerated wounds, and the treatment is
based on control of shock, hemorrhage, and infection. Sterilization
and drainage are tiie two essentials, but meddlesome interference is
likely to prove harmful, especially if pursued with the idea of "open-
ing up" the zone penetrated. Intra-abdominal stabs demand imme-
diate exploration, even though the wound seems to have involved
only the omentum or mesentery that so often is found extruding. So
far as possible, operative access to the abdomen is gained close to the
median line, and the incision is planned so that it may be extended if
required. The retrorectus line of approach is ordinarily the best, and
the original stab may be used for drainage purposes.

Stabs of the chest may injure the intercostal vessels and cause
alarming bleeding that often is hard to control. Packing ordinarily
suffices, but if this fails, it may be necessary to clamp the lower edge
of the rib or to encircle it with catgut passed on a wide semicircular
needle or sharp ligature passer.

Mucous membrane wounds, as a rule, heal kindly, notably those of
the mouth and nose. Bleeding is generally promptly controlled by
pressure, failing this, an encircling ligature is often needed.

Epistaxis that is not controlled by packing the anterior naris can
be checked by plugging the posterior naris with cotton passed on a
Bellocq's canula; a soft-rubber catheter answers the same purpose.
A very effective method is to insert a condom or rubber glove finger
or cot far into the nostril and then distend it by air or water (Fig.
270). If a cotton or gauze plug is used, it may be previously moist-
ened in cocain or adrenalin. Such a plug rapidly becomes foul, and
should not be allowed to remain more than twenty-four hours, and
the removal of it may be facilitated by injection of peroxid of hydro-
gen, albolene, or oil.

WOUNDS AND THEIR COMPLICATIONS 31

Urethral wounds often bleed excessively, and if injections of adre-
nalin are inadequate, a large steel sound may be passed and allowed to
remain in place several hours, thus acting as an effective plug.

WOUNDS IN DETAIL

From a practical standpoint, wounds may be divided into three
degrees irrespective of their cause or their effect on soft parts, vessels,
viscera, bones or joints.

First Degree Wounds. — These are of minor severity and are
produced usually by relatively sharp edged materials that cause
superficial wounds of the incised, smoothly lacerated or punctured
variety. The amount of bleeding depends more on their location
than their depth. The tissues adjacent to the wound are little if
any damaged, and if the muscular layers are reached, the cutting
of the fibres is inconsiderable. Superficial bones or joints are ex-
posed, if any.

Typical Examples, — ^A scalp wound due to a fall; an incised
wound of the leg due to a knife cut, a punctured wound of the thigh
from a splinter of wood.

TreaimenL — Assuming that the surgeon sees within a few hours
(not more than 12 hours) one of the "typical examples" named
above, the procedure is:

1. Brush away with sterile gauze any gross debris and cover the
wound and the parts near it with a piece of gauze soaked in a 7 per
cent, alcoholic solution of Tr. lodin. If there is paint, oil or grease
m or about the wound, remove these with gasoline, benzine, kerosene
or ether. Hair is to be dry-shaved for a radius of at least two inches
about the wound. All dirt or foreign material is now removed
by wiping with dry gauze ; if this does not effectively cleanse the
area, use gauze wet in gasoline, benzine, kerosene or ether.

2. Remove the piece of iodin soaked gauze temporarily pro-
tecting the wound and clean the. wound margins with the iodin.
The entire "field" is now relatively clean and no foreign matter has
been rubbed toward the wound.

3- A 3M per cent, solution of alcoholic iodin is now placed in,
on and about the wound, the edges of the latter being spread for this
purpose.

4. Cut a + in a piece of sterile gauze or paper and place this over
and around the wound to have a protected field.

5. With sterile instruments or the sterile fingers examine the
interior of the wound for foreign bodies. If in the scalp, exclude

32 TRAUMATIC SURGERY

fracture of the skull by inspection and palpation, extending the
original wound by incision if necessary.

6. Suture with interrupted stitches, using silkworm, silk, linen,
horsehair or some non-absorbable material. Place these stitches
deeply and about one-half inch apart where there is tension, else-
where the spacing can be greater. Bring the edges snugly together
but do not squeeze or jamb them.

7. At the lower margin of the woimd, introduce a thin drain
to pass half the length of the wound. This drain must not act as
a plug or cork. A few twisted strands of the suture material will
answer. A thin strip from an old rubber glove or an ordinary rubber
band act efficiently. Gauze drainage is apt to plug.

8. Dry sterile gauze compress and a bandage or adhesive are now
to be applied.

9. Change this dressing in 24-48 hours, removing the drain
unless infection is present.

10. Stitches to be removed 4-6 days. Straps of adhesive plaster
(sterilized by heating over a flame) will sometimes answer instead of
sutures.

Precautions. — ^Any bleeding vessel not likely to be included in
the sutures is to be separately ligated.

Any damaged nerve or tendon is to be suitably cared for at the
same time by separate suture; if this cannot be done because of
emergency equipment, do not suture the wound but merely cover
it with sterile gauze after it has been suitably sterilized in the manner
described.

Second degree wounds are of moderate severity and are
produced by sharp or blunt materials that cause moderately
deep wounds of the incised, lacerated or punctured variety with
irregularity of the edges and bruising of the parts adjacent. Bleed-
ing is not excessive unless main vessels are involved. The fascial
and muscular layers are cut and may be stripped or undermined.
Main joints or fairly well protected bones may be involved. Com-
pound fractures with wound orifices of moderate extent are in this
group.

Typical Examples. — ^A ragged incision of the foot from an axe;
a laceration of the forearm from a falling piece of timber; a puncture
from the jab of an umbrella.

Treatment. — (Jeneral anesthesia may be needed.

I. Brush away with sterile gauze gross debris, or better, remove
same with sterile forceps and then cover the wound and the parts

WOUNDS AND THEIR COMPLICATIONS 33

near it with a piece of gauze soaked in 7 per cent. tr. iodin. Cleanse
the surrounding field of oil, grease or paint with gasoline, benzine,
kerosene or ether. Dry shave the hair for a distance of two inches
from the wound. Further cleanse this field if necessary by using
gauze soaked in gasoline, benzine, kerosene or ether.

2. Remove the gauze from the wound itself and cleanse this
remaining zone as just indicated, thus obtaining a relatively clean
area in and about the wound.

3 . Pour into and about the wound a 3 percent, solution of iodin, tak-
ing great care that the wound is flooded by holding its edges apart.

4. Cut a + in a piece of sterile gauze or paper and place this
over the wound and field, or otherwise protect the latter.

5. Examine the interior of the wound for foreign bodies, for
frayed edges or crevices. If there are any pockets into which
the iodin has not penetrated, inject the iodin solution into these
with a pressure syringe.

6. Clip away any frayed skin, fascia or muscle, removing only
the thinnest slice; this conservation should be greatest about the
face, scalp, fingers and toes as in these areas the blood supply is
ample enough to care for tissues much more devitalized than else-
where. Enough has been removed when the parts resume normal
color, bleed or contract. This paring or cutting away ("dfibride-
ment " and **6pluchage" as the French call it) should free the edges of
all frayed or semi-detached portions. Ligate any vessels that will not
be included in the subsequent suturing. Hemostasis should be
absolute.

7. Now pass deep non-absorbable sutures (silkworm, silk, linen
or horsehair) about one inch apart and bring the wound edges snugly
but not too firmly together.

8. Place a soft small calibered rubber tube, or strip of rubber
(such as a piece of a rubber glove or a rubber band) at the lower
angle and make it pass half way along the length of the wound for
drainage.

9. Dry sterile gauze compresses and a bandage complete the
dressing. Gauze wet in iodin lotion (tr. iodin one dram to
water i pint) is to be used if much contusion accompanies the
wound.

10. Change the dressing in 24-48 hours and remove the drain
if there is no infection or excessive secretion.

11. Stitched to be removed in 4—6 days.

Precautions. — If there is any question as to the sterility ob-

34 TRAUMATIC SURGERY

tained by the use of iodin or d6bridement, place the sutures but do
not tie them so that the wound may be left wide open, covered only
by dry gauze. Within the following 24-72 hours, the stitches may
be tied if infection has not developed. This in effect is carrying
out the principle called in war surgery "intermediate suture,"
"delayed primary suture," or ''primo-secondary suture," or by
the French, "suture primitif retard^." At the first dressing a
smear taken from the channel along which the drain was placed,
from the drain itself, or from any part of the wound will give bacter-
iologic evidence to support clinical evidences as to the future pro-
gress. If streptococci are found, the stitches should be removed at
once irrespective of the clinical signs for infection evidences are sure
to follow. The presence of other bacteria may require merely the
removal of a few sutures and the reintroduction of the drain and
the application of a wet dressing of iodin lotion. If suture is
attempted after the sixth day, the method is called "late suture,"
"Secondary Suture," or by the French, "suture secondaire."

If the wound is in an extremity, or where muscle tension or con-
traction occur, a splint should be used from the first as rest and
elevation are adjuncts in healing.

Involved tendons or nerves should be sutured by fine chromic
gut or silk stitches.

Third degree wounds are of maximum severity as to length,
depth and involvement of soft and hard tissues. This variety is
practically always an uneven laceration and accompanied by much
loss of substance in the skin, fascia and muscle; often the bone is
comminuted.

Typical Examples, — ^A fall from a height impaling on a spike
or picket. Machinery accidents in which the skin is stripped, the
soft parts are mashed and the bones are fragmented. Run-over
accidents in which soft parts are much severed or in which partial
or complete amputation occurs.

TreatmenL — (i) If the patient is in shock, make sure that the
primary dressing is adequately controlling bleeding. Then care of
the shock itself by:

(a) Recumbency with the foot of bed elevated.

(6) External heat (hot water bags, electric pads, hot bricks).
Sections of a discarded inner tube from an automobile tire make an
excellent hot water bag.

{c) Hot saline solution by rectum, either drop by drop; or saline
6 oz. and whisky, brandy or coffee, 2 oz. of either.

WOUNDS AND THEIR COMPLICATIONS 35

(d) Saline solution under the chest wall or intravenously.

(e) Transfusion of blood (whole or citrated) when needed.

(/) Camphorated oil (i c.c), adrenalin (HI x)'or strychnine gr.
J^o hypodermatically.

2. Anesthesia (general) will usually be needed; nitrous oxide
or ethyl chloride will answer if the operation is not to last more
than 20 minutes. Ether (drop method) is the inhalant of choice;
chloroform is the most dangerous.

3. Cover the wound with sterile gauze soaked in 7 per cent. Tr.
lodin and then cleanse the margins about this to remove debris,
grease, dirt and all foreign matter. Gasolene, benzine, kerosene,
alcohol or ether will aid in this. Shave all hairy parts for a distance
of several inches from the wound.

4. Remove the iodin gauze from the wound and cleanse the wound
itself so that all the zone is dirt-free. Now flood the wound and
the parts about it with 7 per cent. Tr. Iodin and then drape the field
with sterile towels or gauze held in place by clips.

5. Remove by a sharp knife or curved scissors any frayed, bruised
or otherwise devitalized parts so that the entire wound tract is laid
wide open. In this "debridement," pare away only the actually
destroyed parts and enough has been removed when normal color has
been restored, when the parts bleed and when the muscles contract;
this act of treatment should be conservative and not mutilative.
Do not remove any bony splinters unless they are wholly detached;
place all these in warm sterile saline and at the end of the operation
some or all of them may be replaced and janmied into position or
suitably held by kangaroo sutures, wire, screws or plates. See that
every such fragment is free of dirt and clotted blood before it is rein-
serted. Carefully curette bone marrow if soiled. Suture tendons
and nerves when possible; if the loss is too great for accurate apposi-
tion, bridge the gap by silk strands or a piece of fascia. Make
hemostasis as absolute as possible.

6. Suture with catgut (iodinized catgut is best) the deeper
layers; interrupted sutures are to be used and they must not be placed
tight enough to prevent escape of the blood and serum sure to collect.
One layer of stitches to take in fascia and muscle is usually enough.
Insert a "cigarette'' drain (gauze wrapped in rubber tissue) so that
it reaches the depth of the woiind along half its length and bring
this out at the lowest angle of the wound. Suture the skin with
interrupted stitches of silk, linen, silkworm or horsehair. Do not
have any tension in the sutured parts as this will lead to strangu-

36 TRAUMATIC SURGERY

lation and infection. Underminng, sliding or scarifying the parts
may overcome this tension and j>ennit closure otherwise impossible.

7. The dressing is to be of gauze (preferably moistened in boric
solution or iodin water (one dram iodin to a pint of sterile water)
covered by cotton and a bandage. A splint is then to be applied,
with or without fracture, and the part is to be elevated and kept in
such a position that contracture will not be caused or aided.

8. Repeat the dressing in 24 hours and shorten the drain by
half. The next day the drain can be removed if there is no infection
or secretion, especially if examination of the latter shows no
streptococci.

9. The stitches can be removed in 5-8 days.

Precautions. — If there is doubt as to the sterility secured by
this mechanical cleansing (debridement) place but do not tie the
sutures (non-absorbable) in the superficial parts, insert at least
two drains, dress with dry gauze and wait twenty-four hours. If
now infection is not apparent, remove all but one drain and tie the
sutures.

If there is much loss of tissue and it is impracticable to coapt the
deep or superficial parts, suture where it is possible, then place in the
wound cavity several strips of gauze soaked in Dakin's solution or in
"soap solution" (for formula see p. 703) and dress the rest of the
wound as above.

If there is much oozing and this cannot be otherwise controlled,
insert strips of gauze as in the preceding paragraph, do not in any
way tightly pack the wound for this will stagnate circulation, produce
ischemia and defeat what has been attempted. This gauze is to be
removed wholly or in part twenty-four hours later and subsequent
drainage is afforded by rubber tubing or rubber tissue strips or
rubber bands. Experience has shown that the prolonged retention
of gauze or any form of drainage favors infection.

If after the removal of all drainage, the wound is clinically
healthy, and especially if bacteriologic tests show that streptococci are
absent, suture of the wound may be attempted. If however, infec-
tion is present, chemical sterilization must be attained before closure
can be attempted. Likewise when there has been loss of tissue it is
unwise to attempt closure until the wound is germ free.

Wounds with Loss of Tissue. — The gap may be due to absence of
skin, fascia, fat or muscle and some sort of substitute must often be
provided either by implant, sliding or grafting.

Skin loss may be made up by grafting, preferably by autogenous

WOUNDS AND THEIR COMPLICATIONS 37

Thiersch grafts taken from some broad surface,, such as the thigh.
In some cases, flaps of skin from the margin of the wound can be slid
over the gap so that such a ''sliding flap" will cover the defect.
Reverdin grafts (small piece of skin) are rarely useful in covering
anything but small areas. Occasionally heterogenous grafts can be
made to "take" and for this purpose prepucial grafts obtained at
circumcision may be tried. On a few occasions I have successfully
used a hernial sac placing the internal surface next to the wound.
Sometimes the skin from the amputated limb of another patient
has been satisfactory.

Fascia-loss can be remedied by the implanting of fascia lata from
the patient.

Muscle-loss can be compensated for by the splitting and suture of
adjacent muscles, but the transplantation of wholly detached muscle
is uniformly unsuccessful. A considerable gap can be closed by
grafting a thick layer of fat or fascia, preferably taken from the thigh
or abdomen.

WOUND COMPUCATIONS

These may be said to consist of infections, aneurysms, keloids, and
contracPures.

WOUND INFECTION

An infected wound is one that harbors and nurtures pyogenic or-
ganisms. The ordinary pus-producing germs are the Staphylococci
{aureus, citreus, and albus) and the Streptococci acting alone or in com-
bination. Infection may also be caused by numerous other organ-
isms, but for practical purposes the two foregoing are most important.
For example, wound infection may be due to the colon, the pneumo-
cocci, the diphtheritic, the anerobic and other groups of organisms.
If more than one variety of bacteria is present, a mixed infection is
said to exist, and wounds thus invaded are often serious and
protracted.

This general subject is also discussed in the chapter headed In-
fections of the Hands, p. 85.

Causes and Varieties. — Germs are more or less constantly pres-
ent, and they gain entrance at the time the wound is produced {pri-
mary infection) or are subsequently introduced during the course of
treatment {secondary infection) ; in another class the original infected
focus is the source of involvement of distant or adjacent tissues {rein-
fection). The vitality of the part wounded {local resistance) is also a
factor, as is the constitutional physique {general resistance).

38 TRAUMATIC SURGERY

Germs vary in their virulence and in their manifestations, and an
essential prognostic element is the amount of the introduced infection
and the vital resistance of the subject; in other words, the outcome is
directly proportionate to the amount of the dose and the capacity to
react from it.

Prophylaxis is a most important feature, and if sterilization can
be promptly and thoroughly accomplished, the extent of infection will
be minimized.

Staphylococcus infection is the least dangerous and the most com-
mon. It is characterized by a tendency toward limitation, abscess
formation, and the presence of large quantities of thick yellow or
whitish pus (the so-called "laudable pus" of the older surgeons).
Occasionally the pus becomes greenish, indicating pyocyaneiis infec-
tion, often of low grade and usually of good import.

Streptococcus infection is the most dangerous but, fortunately, less
common. It is characterized by a tendency to invade adjacent
tissue, little if any abscess formation or pus, and is prone to involve the
lymph-channels and thus gain entrance into the general circulation.

Cellulitis is inflammation of the subcutaneous cellular tissue, and
if widespread usually means a streptococcic infection. Erysipelas
is essentially the same process.

Lymphangitis is inflammation of the lymph- vessels.

Lymphadenitis is inflammation of the lymph-glands.

Septicemia is systemic pyogenic infection, ordinarily of strepto-
coccic origin.

Pyemia is that form of infection due to metastatic deposits from
an original pus focus.

Phlebitis is inflammation of a vein, and it often occurs as a septic
thrombophlebitis.

Symptoms. — Local signs in the wound are the swelling redness,
pain, and heat, characteristic of all inflammatory reaction. Wounds
that bleed freely are less likely to become infected than those of the
punctured or non-bleeding variety.

The local onset of infection is ordinarily manifested by throbbing
or stinging pain, very promptly followed by redness, swelling, and
heat. If seen early, the wound discharge will be thin and watery,
not unlike brownish serum; if seen later, pus will be present in varying
quantities. If the process is sharply localized the infection is prob-
ably solely staphylococcic; but if there is little or no pus, and if the part
is red, swollen, edematous, hot, and painful, then the infection is
probably streptococcic. If there are tender red streaks running from

WOUNDS AND THEIR COMPLICATIONS 39

the focus, lymphangitis is present and the neighboring glands will
be swollen and painful, constituting lymphadenitis. If the area is
quite red and brawny and more or less circumscribed, then cellulitis
is present.

General signs are malaise, loss of appetite, fever, chilliness, and, in
advanced cases, chills, high fever, and sweats. These constitutional
signs depend upon the type and extent of the infection and the vital
resistance to it. If these signs persist, septicemia is present, and we
sp>eak of the condition also as "sepsis,'^ "bacteremia," or **septic state."

If pus foci have been carried from the original zone or from a
broken-down thrombus to more or less distant parts that show evi-
dences of abscess formation, then pyemia exists. Between the chills
and high fever of pyemia, the temperature may be normal or sub-
normal and each chill is said to represent the formation of a metasta-
tic abscess. Such abscesses may give more or less appropriate
evidences if they form externally, but if they are deep seated their
location may be most difficult to determine. Involvement of the
lung, liver, spleen, and kidney is very common in this condition.

In all these "septic states" the examination of the blood is of
much diagnostic, therapeutic, and prognostic value.

Differential diagnosis as between various forms of wound infec-
tion is not particularly important except in so far that the surgeon
must be reasonably sure whether or not a pus focus is within reach
of surgical attack; in other words, the type of treatment depends
in large degree upon the possibility of incising and draining pus-con-
taining foci.

In joint infections, rheumatism (simple or gonorrheal) is sometimes
diagnosticated when the history or local signs of injury are imperfect
or indistinct; such an error is usually avoidable by careful repeated
observations, especially if a blood examination is made. The newer
teaching of some would have us believe that "rheumatism" is an in-
fective process probably of streptococcus origin, but even with this in
mind the error should not be made of overlooking a contiguous or dis-
tant abscess.

Typhoid, pulmonary tuberculosis, and malaria sometimes cause
confusion because the temperature-curve in each may for a time re-
semble that of a wound infection. Here, again, careful examination
plus blood tests provide the earliest and safest differentiation. Ery-
sipelas is easily confused with cellulitis; the newer views regard them
as practically identical, and hence their separation is more academic
than necessary.

TRAUMATIC SURGERY

Treatment — Prophylaxis is the main dement^ andy as stated hitherto^
every wound not made with surgical intent under aseptic conditions
should be regarded and treated as if already infected.

This means that the primary treatment by sterilization, suture,
and drainage should anticipate infection and thus be appropriate to
the end in view. lodin disinfection is the best single means at
hand, for the average case, and this antiseptic should be used liberally
and fearlessly, as it may be applied to any broken surface or member

with impunity, the eye and other deli-
cate parts being included (Fig. i6).
Suturing should not be too tight.
Drainage must be adequate, and not
so placed that it will act as a cork or
dam; for this reason rubber acts better
than gauze drainage.

Probing is mentioned only to be con-
demned, as in many instances the probe
acts as effectively as a hypodermic
needle in inoculating parts not already
infected.

Moist dressings of salt, boric, alcohol,
or some equally mild solution should
be used; strong antiseptics lower the local resistance and further
burden tissues already sufficiently damaged.

Curative measures for the various wound infections may be said to
be (a) general and (6) local,

(a) General Measures, — Food, sleep, a,nd fresh air are the essentials,
and each should be provided in large doses. Transfusion of blood
(whole or citrated) has sometimes been decidedly helpful according
to published reports, but my own experience has been less favorable.
It does best in the cases associated with blood-loss.

Food should be furnished often and in small amounts, rather than
less often in large amounts. It should be concentrated and fluid, con-
sisting largely of meat-soups, broths, milk, eggs, and a reasonable
amount of whisky or beer to those accustomed to using such bever-
ages. Water must be taken freely, and if necessary it can be given by
rectum in the form of a "drip" for several hours continuously,
or 6 ounces may be given every four hours or oftener. Ordinary
tap>-water acts just as well rectally as salt solution, and apparently
causes less thirst and kidney irritation. Whisky may or may not be
combined, according to need. Rectal feeding should be postponed
as long as possible because few patients are long tolerant to it.

Fig. i6. — Watch-crystal pro-
tector and adhesive to prevent
escape of purulent secretion from
one eye to another, or from a
forehead wound to the eye.

WOUNDS AND THEIR COMPLICATIONS 41

Sleep will be better if the patient is kept as quiet as possible, es-
pecially if the fresh-air treatment can be combined. Sponging, hot
drinks, body massage, and like measures are sometimes efifective. If
drugs are needed, trional, veronal, medinal, and the bromids act best.
Morphin must be very cautiously used.

Fresh air and sunshine will act well in nearly all cases, especially
if tolerance is gained by giving the patient longer stances daily, and
eventually many cases are left out of doors nearly the entire time.
In many instances exposure of the wound to the air and sim is very
effective, especially in the sepsis from burns or extensive denudation;
here also the patient should be rendered tolerant by daily increasing
I>eriods of exposure.

(i) Local Measures. — These aim to prevent the spread of infection
focally or distally, and the means at hand consist geilerally of:

(i) External applications.

(2) Incision and drainage.

(3) Sera and vaccines.

(4) Sedatives.

(i) External Applications. — In the early stages oi infection, and
before fluctuation or other local signs of pus are present, the external
use of various substances may prove of aid in (a) preventing the
spread of infection, or (b) focalizing the effects of same.

Such applications for cellulitis usually take the form of moist
dressings, and these are generally used hot at first and later are cold.
Numerous solutions have been employed, but the essential feature is
probably the moisture rather than any inherent virtue of the anti-
septic employed. Caution must be observed in the use of any
antiseptic that might have any harmful local or general effect if
absorbed, and for, that reason carbolic, bichlorid, and drugs of this
class are less generally used than formerly.

Salt, boric, and aluminum acetate solutions are very generally
used, and they are quite harmless even to denuded surfaces or when
long employed. Several layers of gauze moistened in one of these
should be applied, and in an extremity it is essential not to encircle
the part imtil it has been sufficiently protected by many such layers,
so, that the circulation will not suffer by pressure. A very convenient
method of applying such a "wet dressing" is to soak a sterile bandage
in the solution and then unreel it in criss-cross layers over the part,
and in this manner the same effect is gained as if many layers of
compresses had been used. Oiled paper, silk or rubber tissue (or
some substitute for the latter) covers the dressing, but holes should

42 TRAUMATIC SURGERY

be cut in the protective so that no poultice or cupping action occurs.
The gauze is kept moist by allowing the solution to reach it through a
glass tube shoved between the meshes, and usually this will be
required once each four or six hours. The part should be elevated,
and if a joint is involved, the support and extension from a splint
or apparatus is necessary for comfort and to prevent contractures.

My experience is that hot moist dressings are most useful in the
early stages of infection, and thereafter cold appliciations are of
greatest worth. The use of a 25 or 50 per cent, alcohol dressing
relieves pain and frequently proves of value. If a moist dressing is
used in the presence of a wound especial care is then necessary so
that the drug may have no harmful local or general effect; for that
reason carbohc or mercurial solutions are often dangerous. I once
saw a child whose face was horribly deformed by cancrum oris
developed from the continuous use of weak bichlorid lotion following
a simple infected abrasion of the cheek.

If there is much odor from the wound it can be controlled by the
use of a permanganate of potash solution of a deep pink color.
Equally effective is a solution of i dram of iodin to a pint of water, and
either of these makes an excellent irrigating medium. Magnesium
sulphate in saturated watery solution (or less strong) seems to act
especially well in erysipeloid infections.

Continuous bath or immersion treatment has not been especially
useful in my experience; at best it cannot be used for more than a
short time because it causes maceration of the parts. It is employed
practically only for the hands and feet.

Bier's cups and bands for hyperemia are sometimes useful adjuncts,
especially in the early and late stages.

Local injections about the j>eriphery of the infection were once
largely used in erysipelas infections, but the method is now rarely
employed.

Baking and other forms of dry heat are rarely used now in the acute
stages.

(2) Incision and Drainage, — The indications for these are (a) the
presence of pus and {b) spreading edema and brawniness.

Pus makes its presence manifest (aside from systemic signs) by
fluctuation^ localized pain, or distinct circumscribed induration, and
the presence of any two of these justifies exploration.

Throbbing pain, spasm of muscle, and pain on motion, if localized,
are three further symptoms found more or less frequently in conjunc-
tion with the trinity of cardinal signs previously mentioned.

WOUNDS AND THEIR COMPLICATIONS 43

Incision is to be made over the place of maximuin fluctuation, pain ,
or induration, and in direction should parallel the underlying

Fio. 17.— basing letiophaiyngeal abscess with a cotton-covered scalpel

Fic. 18. — Method of opening a deep-seated abscess: a. Locating the pus focus by
an aspirating syringe; b, enlarging the aperature by widely opened pointed scissors or
artery clamps.

vessels, tendons, and muscles unless there is good reason to vary this
ftmdamental rule. The length and depth of the cut should be ade-
quate in the first instance, so that it may not require repetition. The

44 TRAUMATIC SUKGERY

pus may often be first located by hypodermic puncture, otherwise the
skin and subcutaneous parts are alone incised by a small opening, and
through this a closed artery clamp is then thrust as deeply as desired,
and then it is withdrawn with the blades open. The incision is then
enlarged, or reinforced or connected by others, so that the pus focus
may be adequately exposed for drainage (Fig. i8).

In other cases, with or without the definite finding of a pus focus,
it rather rarely may be necessary to make one or more incisions lO
relieve tension in a swollen and more or less edematous area. In
such cases the rule is to incise to the depth of the fascial layer only,
placing each of the incisions so that they may intercommunicate
through the medium of drainage.

Flc. 19. — Abscess of breast and proper iine o
with the nipple :

n radiating as a spoke of a wheel.

Less often incisions are made so that drainage may be " through
and through," and then the drain is passed between tendons and
vessels so that no structural damage is done.

Drainage material is generally gauze or rubber.

Gauze drainage has the disadvantage of adhering to the edges of
the wound, and it also soon becomes saturated with the discharge,
and will then act as a plug or cork and defeat its purpose.

When a walled-off or circumscribed pus cavity has been emptied
of its contents, then packing it with gauze is of great value to en-
courage granulations. If there is much oozing of blood, gauze drain-
age may also be used. Thus gauze drainage should be used only
to (i) keep apart the edges of a cavity, (2) act as a hemostat.

Gauze absorbs better when moist, and it sticks less when pre-
viously soaked in sterile olive oil, albolene, or vaselin, hence drains are

WOUNDS AND THEIR COMPLICATIONS 45

frequently soaked in salt, boric, or alcohol solution or moistened by
some oily substance. When healing is to be promoted and when
drainage is rather slight, gauze soaked in lo per cent, balsam ot Peru
(in castor oil or glycerin) is a splendid application. "Medicated"
gauze (iodoform, carbolic, and others) is not much used.

Fig. 10. — Sites of pus in abscess of breast a Subcutaneous or extraglandular; b,
glandular or extramural c muscular or mural

Rubber drainage is by tubes or tissue. The former must not be
used over a long period because they cause a pressure-necrosis and
thus tend to form sinuses or erosions, leading to ulceration or hemor-
rhage. The tubes should be fenestrated or split lengthwise. If
desired, a wick of gauze may be passed through the tube, thus form-
ing the so-called "cigarette drain."

Rubber-tissue drains are very largely used because they are soft
and readily fashioned into appropriate size. If they are folded like
an "accordion pleat" more channels for drainage will be provided
than if each layer is folded in the same direction. The typical
"cigarette drain" is made by enclosing a rolled section of gauze in a
piece of ti^ue. This tissue (known also as gutta-percha tissue) is
sold in yard-square or larger lots, and is sterilized by soaking desired
sections in i : looo bichlorid for forty-eight hours. Then each sec-

46 TRAUMATIC SURGERY

tion is dried between sterile towels and rolled into a loose coil sur-
rounded by sterile gauze or placed in a sterile jar for use as desired.
It may also be kept in alcohol or a weak solution of bichlorid.

Rubber bands, such as stationers supply, make excellent drains,
and personally I prefer them because they can be boiled as required.
A discarded rubber glove furnishes good drainage material also.

Whatever material is used, it should act as a drain and not as a
plug, dam, or cork. It is better to use two or more small drains than
one large drain.

(3) Sera and Vaccines, — These have not proved very effective, and
personally, I have never derived any special good from them except
in chronic or recurrent types of infection. Apparently the so-called
''mixed bacterins" are likely to do most good, as many woxmds show
some mixed infection by staphylococci and streptococci.

Autogenous vaccines are the best, but it is difficult to prepare
them and they are of limited availability, and thus "stock" vaccines
are used generally.

Antitetanic serum is of distinct value from a prophylactic stand-
point, and it should be used whenever a wound has been contami-
nated by the soil, street dirt or stable refuse, and in all bullet and
Fourth-of-July wounds.

(4) Sedatives. — Anodynes and hypnotics are to be used judi-
ciously, and no morphin should be given unless absolutely needed.
Codein in 3^^-grain doses is excellent for pain, but it is to be remem-
bered that continued pain means pressure, and pressure means in-
flammation, and inflammation often means that the focus has not
been reached, and hence anodynes must be replaced by the knife and
drainage.

Trional and veronal (alone or in combination) and thebromidsare
the hypnotics of greatest value.

WOUND INFECTION IN DETAIL

Sjrmptoms. — These are determined by the kind of organisms, the
source, nature and location of the wound, and to a considerable ex-
tent by the physique of the patient. As to this last it suffices to say
that some patients are virtually "germ carriers" inasmuch as foci
of infection distant from the wound can often be demonstrated; such
foci very often exist in the mouth (teeth and tonsils), nasopharynx
Csinuses) and on the skin. Experiments at Colonel Depage's Am-
bulance de rOcean (LaPanne, Belgium) showed that the British
were more prone to streptococcic infection than the French, Belgian

WOUNDS AND THEIR COMPLICATIONS 47

or German soldiers. This was thought to be due to the prevalence
or prior foci of infection incident to oral sources or previous scarlet
fever or erysipelas.

It has been definitely shown that within a designated time after
the receipt of a wound bacteria begin to appear, but that within the
first few hours (varying from 2-8) few if any organisms are present.
It is also known that torn, bruised, ragged or ischemic tissues provide
quite the most fertile soil for bacterial growth inasmuch as most of the
organisms are saprophytes and cannot thrive in or on living tissue.
There are then two essential predisposing causes for infection inde-
jjendent of the source or site of the wound, these are:

1. The elapsed time.

2. The extent of the damage.

It is needless to say in this connection that improper or meddle-
some immediate treatment may add appropriate complications
and in effect produce re-infection or superinfection.

All wounds not made with surgical intent are injected and should be
regarded and treated as such.

Degrees of Infection. — For clinical purposes we can say that
there are three degrees of infected wounds irrespective of their
source, site and extent, bearing in mind that the predominating
organisms are staphylococci and streptococci, occurring alone or in
combination.

First degree or mild infection or mild cellulitis is characterized
by localized slight redness, swelling, pain and interference with
function. Wound secretion if any is scanty and the wound itself
appears reasonably healthy. Such a wound may be said to represent
a localized cellulitis or lymphangitis and there are practically no
systemic symptoms.

Second degree or moderate infection or moderate cellulitis is an
exaggerated form of the preceding, characterized mainly by more
diffuse redness and swelling with greater pain and interference with
fimction. Wound secretion is more plentiful and of a seropurulent or
purulent type. The wound itself is lustreless, or it may be gray or show
areas of sloughing with or without odor. A diagnosis of cellulitis is
evident from the redness and puffy or brawny appearance of the parts
near the woimd; red streaks may run toward the glands nearest the
wound and these are tender — lymphangitis and lymphadenitis
exist. The temperature and pulse are elevated, the patient com-
plains of fever and a sense of chilliness, the digestion and energy are
affected — the patient is sick and knows and shows it.

48 TRAUMATIC SURGERY

Third degree or severe infection or severe cellulitis is an ad-
vanced grade of the preceding, and while the local conditions may
not materially diiffer, the systemic signs are more marked — ^in a
word the patient approaches the condition we may denote as toxic
or septic, and when this state is reached, septicemia or pyemia are
the diagnostic terms. The temperature may stay relatively even
and high or may reach 105 degrees with very sharp and regular
remissions — the so-called "septic temperature" that so much resem-
bles the fever curve in certain forms of malaria, typhoid, tuberculo-
sis and malignant endocarditis. The pulse is likewise elevated.
There may be chills and sweats. Restlessness may go on into active
delirium. In the end, torpidity precedes coma and exitus.

Treatment. — The aim is to limit the spread of infection by
chemical sterilization, and having attained this to bring about clos-
ure of the wouiid spontaneously (healing by granulation) or by
coaptation (adhesive plaster or suture). Late closure of a wound
after chemical sterilization is referred to as "secondary sutiure,"
known to the French as "suture secondaire."

First degree or mild infection when acute is treated by providing
a free vent for the wound so that the edges are wide enough apart
to allow escape of secretion. This does not mean that any incision
is to be necessarily made at this stage, for to do so in the absence of
definite fluctuation would probably open up fresh channels unin-
fected as yet. A suitable drain is to be inserted and this should be
rubber and so arranged that it will drain and not cork the wound.
A hot wet gauze dressing is now applied; the solution used may be
iodin water (one dram tr. iodin to pint sterile water), or boric
solution (saturated), or magnesium sulphate solution (10-20 per cent.)
or normal salt solution. The part should be liberally covered by
many layers of gauze so arranged that no constriction occurs, and
then a splint or other device is applied assuring absolute rest as
movement of the part is almost certain to increase infection. Every
two hours this dressing should be re-moistened and this is best
accomplished by poking the nozzle of a syringe through the meshes
of the dressing. In established subacute or chronic mild infections
the use of a cold wet dressing acts just as well and perhaps better
than hot dressings. The wet dressing is to be covered by perfor-
ted oiled or waxed paper (such as grocers and confectioners use) or
oiled silk, but in no case should air be excluded otherwise a poultice
or cupping effect will occur. The entire dressing is removed in
twenty-four hours, and if the conditions are favorable, the drain is

WOUNDS AND THEIR COMPLICATIONS 49

removed and a dry dressing can be used. If infection is still present,
the dressing is reapplied and the drain is not changed unless it ap-
pears to act as a plug; in' that event it is reinserted. No incision is
made unless definite fluctuation or bogginess can be demonstrated.

Second degree or moderaie infection implies that pus is present
with cellulitis or l3anphangitis, or both. The wound is probably
without a proper vent, is pocketing, or there is a sloughing surface.
We have three methods of attack depending on the nature and dura-
tion of the infection:

(i) ActUe stage (case seen within the first few days) : drain with
rubber (tubing or tissue or bands) and apply a hot wet gauze dressing
of iodin water, boric solution or magnesium sulphate as indicated
for the preceding degree of infection. After the first twenty-four
hours, change the dressing to a cold solution of the same mater-
ial, removing the drain only if the vent is ample. Splint the part
so that complete rest is provided.

(2) Subacute stage (from the 3d to the loth day) : the cellulitis
evidences are less marked but the wound is distinctly infected and
there is a considerable exudate. Adequately drain by rubber as in
the preceding and use the same sort of cold wet dressing. If, how-
ever, the wound orifice is rather large it will be advisable to use the
Carrel-Dakin technic so that every two hours the interior of the
wound receives enough Dakin's soluticJn to completely fill every
orifice. As a substitute for this technic, we can loosely pack each
angle and crevice of the wound with narrow folded gauze strips so
that many tapes of this sort will ultimately fill the entire wound cavity.
These tapes are to be soaked in Dakin 's solution before being introduced
and no vaseline protective around the skin edges will be necessary.
This dressing is to be removed in 24-48 hours and reinserted, less
tightly, for another similar period. Two such applications will
usually leave the wound relatively clean so that further dressings
can be made with dry gauze or gauze soaked in iodin water. TMs
Dakin's solution pack must be covered by several layers of dry
gauze and one layer of non-absorbent cotton, a suitable splint keep-
ing the part at rest. For Hospital use, squares of Turkish toweling
are excellent to cover the packs. Likewise special binders (cotton
enclosed in same) to fit various parts can be ysed and then can be
washed and re-sterilized a number of times.

(3) Chronic stage (case seen after the loth day): here the con-
tinuance of the infection must be due to improper drainage, the
presence of a foreign body, virulent infection, involvement of bone

50 TRAUMATIC SURGERY

(osteomyelitis), or greatly lessened systemic resistance. The
treatment is by the Carrel-Dakin technic (see p. 52) or the Dakin
solution pack, as in the preceding. If osteomyelitis is present, the pro-
cedure will depend upon the extent of bony involvement (see Osteo-
myelitis, p. 492). The prolonged presence of streptococci can be
looked upon as reasonably sure evidence of bone involvement even
if uncovered bone cannot be demonstrated. The exposure of wounds
of this chronic type to the action of sunlight and open air is one
of the best methods of treatment. All dressings are removed and
the wound is exposed to the direct sunlight for 15-30 minutes, once
the first day, twice the next day, and thereafter for increasingly
long periods. Between these s6ances the woimd is covered by a wet
dressing of saline solution or iodin water. In no case must the
skin become sunburned. Crusts will form but the wet dressing
usually loosens them; if not, a dressing of 10 per cent, bicarbonate of
soda or 50 per cent, peroxide of hydrogen will render them sufficiently
soft for removal. When possible, wounds undergoing this form of
heliotherapy should have no covering during the daylight hours. Flies
and dust can be kept off by arranging a cardboard or wire frame over
the wound and on this a single layer of gauze is hung after the manner
of mosquito netting suspended over a bed. As a substitute for sun-
light, electric light can be lecommended, a yellow or white bulb
being used in the early stages, a red globe when granulations are well
started. The bulb should be from 6-12 inches from the wound de-
pending upon the candle power; the surface of the wound should be
warm but it must not be hot, otherwise first degree burning and ery-
thema will occur. If a reflector is used over the bulb the light can
be more definitely localized and then the distance from the wound
should be greater. Frosted bulbs do not provide the propter kind
of lays.

When the infection is under control every effort should be made to
narrow the size of the wound and this is best accomplished by adhesive
plaster strapping or by "lacing" the wound. If the latter method
is chosen, a row of hooks or eyelets on a strip of linen (Fig. 23), is
fastened to the edge of the wound by adhesive plaster or a glue com-
posed of ordinary glue 50 parts, water 50 parts, glycerin 4 to 6 parts,
menthol i part. This is first soaked for 12 hours and then melted on
a water bath. This is "Sinclair's glue." In applying this, do not
shave the hair but make sure that all oily matter is removed from the
skin with a solution made by adding four drams of washing soda to a
pint of water. Have the skin perfectly dry before applying this

WOUNDS AND THEIR COMPLICATIONS $1

strip of linen and bring it quite close to the edge of the wound. The
lacing can be made of cord or rubber.

Third degree or severe infection implies that there is a purulent
wound of severe grade with infection of equal severity, local as weU as
systemic signs existing — the condition of sepsis is present. The type
of the infecting organisms may vary, but usuaUy staphylococci pre-
dominate and may or may not be associated with streptococci. An
infection of this sort may appear very promptly after the receipt of a
woimd (within 48 hours), but most cases are the outgrowth of pro-
gressive infection due to the severity of the original germ invasion, or
to reinfection from harmful treatment.

Treatment is by ample drainage (rubber bands, strips or tubing)
making sure that all pockets are reached. If there is fluctuation
or bogginess, incision is to be made to release the pus collections
indicated by these signs. If the woimd is of a larger wider tj^pe,
especially if connected with bone, tapes of gauze soaked in Dakin's
solution are to be placed in every crevice so that the entire cavity
is filled. This dressing remains in place twenty-four hours, and
when removed, the subsequent treatment will depend upon the
amoxmt of pus and the appearance of the parts. If there is less pus
and if the tissues have taken on a more healthy look, the gauze tapes
are to be reinserted for another 24 hours. If, however, the local con-
dition is imimproved, and particularly if the area of cellulitis is
increasing, incisions must be made in the long axis of the limb so
that all available avenues are laid open for the application of Dakin's
solution through the medium of Carrel tubing (see Carrel-Dakin
Technic, p. 52). If after a further lapse of 24 hours, local and general
signs of sepsis are still progressing, the advisability of amputation
must be considered.

The indications for amputation in an infected wound depend upon
the damage to (a) soft parts, (b) bone, and (c) vessels, vascular and
neural.

(a) If the muscles and fascia are badly torn and extensively
infected, they practically have destroyed the ultimate usefulness
of the part and are an existing menace, virtually acting as foreign
bodies and they should be sacrificed. If their removal by a process
of debridement (cutting away) necessitates great destruction, ampu-
tation should be done in preference to such an extensive removal that
hopeless loss of function would be inevitable.

(b) If the bone is comminuted, or badly infected (osteomyelitis),
and if the removal of the part involved would cause ultimate crip-
pling, amputation is a better procedure.

52 TRAUMATIC SURGERY

(c) If main vessels (vascular or neural) are damaged so that
function could not be carried on after subsidence of infection, ampu-
tation is indicated.

From a clinical standpoint we know that in severe infections the
integrity of soft parts, bone and vessels are often coincidentally
menaced. The greatest menace of all is damage to important ves-
sels for in such an event septic gangrene is inevitable. ^No limb
should be sacrificed until we are definitely certain that our incisions
have liberated all possible pus pockets, and that with the local evi-
dences of our inability to prevent the spread of infection there are
likewise increasing signs of general infection.

Treatment of Systemic Evidences of Infection. — Pain indicates
pressure, due either to edema or pus under tension; the remedy is
incision and drainage.

C kills and fever are controlled by releasing pus.

Insomnia is combated by trional, bromids or codein. Morphine
is to be used very sparingly.

Septic states are much benefited by placing the patient in the
open air. Forced feeding is a very valuable adjunct in treatment.
Those accustomed to using alcohol must be provided with the accus-
tomed beverage for a time so that delirium tremens will not develop.
Despite National Prohibition Laws, surgeons still find it necessary
to be on guard against post-alcoholic complications even in so-called
''moderate drinkers."

The Carrel-Dakin Technic. — Alexis Carrel, of the Rockefeller
Institute, in working at the Hospital Rond Royal, Compiegne (about
50 miles from Paris) in conjunction with Dakin of the Herter Lab-
oratories (New York) developed a method of chemically sterilizing
infected wounds by the use of a hypochlorite solution. Substances
liberating chlorin had been used as antiseptics for decades, notably
Labarraque's chlorinated soda solution; but all these agents were
extremely irritating to the tissues and could not be employed for any
great length of time. The method of preparing ''Dakin's solution"
is now well standardized and somewhat simplified, and when made
after Daufresne's formula, with the Carrel technic, provides an
excellent medium for the treatment of infected wounds. Unfortu-
nately the preparation and use of the solution calls for greater skill
and more time than the average practitioner has at his disposal.
The solution is not very stable, it does not long retain its neutral
effectivity, and, except in specially equipped hospitals, is unobtain-
able at short notice. For these reasons the wide application of the

WOUNDS AND THEIR COMPLICATIONS

t:echnic has not and will not be practicable. The author returned
£irom France with Drs. Carrel and Daufresne after the War and
knows that these physicians are seeking a method by which the solu-
tJon can be prepared by electrolysis so that its preparation will be

Fig. 32. — Adhesive plaster strapping for wound coaptation.

Fio. 33. — Carrel-Dakin technic. Lacing a wound to coapt the edges. (Redrawn

from Carrel and Dehelly.)

liimuKiiimimmHUilllllll

Fig. 24. — Carrel- Dakin technic. 4-way distributing tubes leading under the dressing.

(Redrawn from Carrel and Dehelly.)

much simpler and its duration more lasting. Like many other new
methods, this has been abused, numerous "modifications" and short
cuts have been ofiFered, all to the detriment of the original procedure
which was based on the outcome of painstaking scientific investiga-
tion and abundant clinical demonstration. There is no question

TRAUMATIC SURGEKY

^^^^ i

Fio. as- — Cairel-DaUo technic. Various types (d ^sss distributfog tubes. (Rednwi
from Canel and Debdly.)

Fic 36. — Cuiel-Dakin leclmic. Reservoir and tubtog properly Applied. (Redrawn
from Carrel and Dehelly.)

WOUNDS AND THEIR COMPLICATIONS 55

whatever as to the value of the solution prepared and used as advised;
ittdeed in many types of infection, notably osteomyelitis, it is the
ta^thod of choice. My first war experience with it was in September,
1Q17 at the Ambulance des Allies (Annel) under the guidance of
French surgeons. This hospital was within a few kilometres of
Compiegne, and subsequently I saw the method in use at Carrel's
o^wn hospital (Rond Royal) at this place. Still later during a stay of
at month at the Ambulance de L'Ocean at La Panne, Belgium, I saw
and treated a number of cases at this remarkable war hospital which
was imder the direction of Colonel Depage and his able assistants.
This experience impelled me to say in a recent article^ that **for
ivounds already infected, gaping or with sloughing surfaces, there
is no better treatment than the Carrel-Dakin procedure. This
unfortunately requires special preparation of the solution and a
special technic in the application of it. The proper carrying out of
this technic is in effect an aseptic operation, it requires training, it is
time consuming and it therefore cannot have wide application. Aside
from the value of the solution, I believe that one of the great elements
in the success of the method is the care with which it has to be ap-
plied and the improbability of reinfecting a wound by contact with
soiled instruments or fingers. Failure to sterilize an ordinary wound
by this treatment is to be charged more to the surgeon than to the
method."

Preparation of the Solution, — Dakin's Solution of sodium hypochlorite must never
be weaker than 0.4 or stronger than 0.5 per cent. It must not contain free alkali or
chlorin. Two methods of preparation are given.

To make 10 liters take:

1 . Chlorinated lime (bleaching powder having 25 per cent, active Cl.) 200 gms.

Sod. Carbonate (dry) Sol vay loc gms.

Sod. Bicarbonate 80 gms.

2. Place in a 12 liter flask the 200 gms. of chlorinated lime and 5 liters of

water. Shake 2-3 times and allow it to set over night.

3. Dissolve in 5 liters of cold water the carbonate and bicarbonate.

4. Pour solution of the sodium salts into flask containing the chlorinate of

lime, shake for one minute and let the calc. carb. settle.

5. After yi, hour siphon off the supernatant liquid and pass it through a double

filter paper. This clear product is to be kept in a dark bottle.

To test for alkalinity: Put 20 cc. of it into a glass and add a few centigrams of
powdered phenol phthalein; shake; red color shows free alkali or incomplete carbonation.

To til rate:

To 10 cc. of solution add 20 cc. of i :io potass, iod. solution and 20 cc. acetic acid.
To this mixture add a decinormal solution of sodium hyposulphite until discoloration
occurs.

Let n equal the number of cubic centimeters of hyposulphite used; then the
amount of hypochlorite present in 100 cc. of Dakin's will equal n X 0.0375 (Carrel &
Dehelly; Le Traitement des Plaies Infectees, 2 Edit. Paris, 191 7).

^Jour, of Industrial Hygiene, July, 1919.

56 TRAUMATIC SURGERY

Method oj Using the Solution, — The procedure is based on the
essential principle that the injected area is so exposed and situated
tJiat all parts 0] it can be bathed in the intermittently injected
solution.

This means that (o) the wound is freely opened from the surface
to the innermost recesses; (6) that all foreign material has been re-
moved, be this frayed or otherwise devitalized tissue, bone fragments or
alien bodies; {c) that the wound is filled at designated periods with
the solution; {d) that any excess of solution and secretion is suitably
cared for by large dressings; (e) that each dressing is properly done
in an aseptic manner so that reinfection is prevented; (/") that
a proper check is kept on the progress by bacteriologic count or
adequate clinical signs.

No good can come of sticking one or more perforated tubes into
a wound crevice or sinus and pouring into it Dakin's solution, then
believing that the 'Xarrel-Dakin method" is being employed.
Such ritual is not the road to wound salvation, and condemnation of
the procedure based on any such practice is a charge not against the
method but rather against those who thus employ it.

Materials Used, — (i) Soft rubber tubing {Hq-H inch in diam-
eter) perforated by holes (M2~M6 1^ diameter) at intervals of six
to the inch. These tubes are tied at the end by linen thread
or are left open. Some of them may be covered in their per-
forated part by Turkish toweling so that pressure may not cause
any erosion.

(2) Glass connecting tubes for linking up the tubes in series.

(3) Vaselined gauze cut in suitable sizes (3 in. by 6 in. is conven-
ient) is used to protect the wound edges from the irritating efifects of
the solution on the sound skin; some patients do not require such
protection. These gauze oblongs are in single layers and can be
prepared by placing them in piles of six in a metal box, between
each layer spreading about two drams of yellow vaseline. The
filled box is then placed in a sterilizer and when ready for use the vase-
line will be found to have distributed itself fairly regularly into the
meshes of each separate piece of gauze.

(4) Neutral sodium oleate, watery solution, is used to cleanse
the skin edges and the wound itself at each dressing. If this is un-
obtainable, a sterile solution of a white castile soap will answer; this
however must be free of any caustic alkali.

(5) Ether is used to remove the excess of vaseline when the
sodium oleate is not sufficient.

WOUNDS AND THEIR COMPLICATIONS 57

(6) Gauze compresses of adequate size are to be so arranged
that the tubes are suitaly held in place, these to be wet in the
solution.

Pic, 17.— Canel-Dakin tecbnic. 4-way distributor and method ot attaching it to the
dressing. (Redrawn from Carrel and DebeUy.)

Fig. iS. — Carrel-DaLin technie. Linking up two 4-way distributing tubes t
reservoir. {Redrawn from Cartel and Dehelly.)

Fig. ig, — Carrel-Dakin technie. Distributing tube leading to a deep wound of the leg.
(Redrawn from Carrel and Dehelly.)

Fro. 30. — Cairel-Dakin technie. Gauze coating to prevent sloughing by contact of
tubes with raw edges. (Redrawn from Carrel and Dehelly.)

(7) A large dressing of gauze and non-absorbent cotton is to be
the final covering. These are conveniently made by enclosing pads
of cotton in a few layers of gauze thus making " pads " or " combined "
or "combination" dressings. At Depage's Clinic, squares of Turk-

TRAUMATIC SURGERY

ish toweling were placed directly on the wound, and over them a
"pad" dressing. This toweling can be washed and re-sterilized.
(8) A reservoir to contain the solution, this to be placed about

36 inches above the surface of the wound,
provided with the necessary lengths of rubber
tubing and pinch-cocks.

The diagrams suitably indicate the
essential parts of the necessary paraphenalia.
In the absence of a reservoir, the solution
may be introduced by an ordinary syringe.
Procedure, — The wound having been
properly laid open so that the solution will
penetrate, is now to have placed in it as
many tubes as may be necessary to keep
the wound surfaces freely bathed in the
hypochlorite. The tubes are so arranged
that no crowding or kinking can occur and
they are brought out through the dressing
so that they may be joined to the glass
connecting tubes and thus to the reservoir
tube. The rubber tubes are keep in place
by small gauze tapes or compresses wet in
Dakin's solution, a few layers of compresses
wet in the solution are placed on top of the
wound, then several layers of dry gauze or toweling are applied,
and over all a "pad" or "combined " dressing held in place by safety
pins or bandages. Rubber sheeting is placed under the part to

Fig. 31. — Carrd-Dakin
technic. Pipet being used
instead of reservoir. (Re-
drawn from Carrel and
Dehelly.)

Fig. 32. — Carrel-Dakin technic. Gauze packing to hold tubes in place, the skin edges
being protected by vaselined gauze. (Redrawn from Carrel and Dehelly.)

catch excess of fluid; in some cases, a metal tray will be found useful
for this purpose.

Just before the final layer of dressing is applied it is prudent to
learn how much solution is necessary to fill the wound cavity just

WOUNDS AND THEIR COMPLICATIONS

to the brim, for at each subsequent instillation we aim to introduce
enough to keep the wound just short of being flooded.

Frequency of insiiUatum is somewhat dependent upon the source,
^te and type of the wound; but generally speaking, it suffices to re-
iatroduce the solution every two hours, allowing enough to flow in
to thoroughly fill the cavity to the degree aheady ascertained.
The ordinary wound requires about lo c.c. for each tube at each
instillation. The dressings must not be permitted to become soggy
as that leads to irritation of the surrounding skin.

Fic. 33, — Carrel-Dakin technic. Circular lube for ungating a stump (left) Single
tube introduced along a sinus (nglit^ (Redrawn from Carrel and Dehelly )

Redressings are done just as carefully as if an aseptic operation
was being performed. Sterile gloves, instruments, tubes, gauze,
and paraphernalia are necessary and the fingers must not contact
with the wound nor with anything introduced into it. The old
dressing is removed with sterile thumb forceps or artery clamps
(without teeth), the wound edges are scrubbed with the soapy solu-
tion of sodium oleate, and the wound itself is then thus cleansed.
Any excess of vaseline or soap that cannot be wiped away is removed
with ether. This cleansing of the skin margins is a very essential
step as re-infection is otherwise quite possible. Fresh tubes are now
introduced and the dressing reapplied as before.

TRAUMATIC SURGERY

Bacteria counting gives satsfactory data as to the progress to-
ward recovery and the findmgs can be readily charted in a manner

Fig. 34. — Carrel-Dakin technic. Tube and dressing complete. (Redrawn from Carrel

and Dehelly.)

quite as graphic as the temperature,
pulse and respiration. To do this a
platinum loop is introduced into a
recess of the wound, the secretion is
placed on a clean slide and this is then
thinned and dried over an alcohol flame.
Later it is stained in methylene-blue
(or other stain) and the number of
cocci in a few fields coimted, their
average giving the coimt for that date.
At subsequent dressings a similar ex-
amination is made and the clinical
manifestations can thus become better
co-ordinated.

Carrel has shown that the rate of
healing can be adequately plotted and
predicted with a reasonable degree of
certainty and this process may be ap-
plied also if the conditions permit or
warrant.

When the wound is progressing
favorably, the number of introduced
tubes may be lessened, but their use
must not be wholly dispensed with until
all secretion disappears.

If the physical signs or the bac-
teriologic count indicate that progress
is not being made, the fault will be
found iq one of the following:

Fio. 3$. — Carrd-Dakin technic.
Reservoir, connecting tube, four-
way dbtributor and tubing. (Re-
drawn from Carrel and Dehelly.)

(a) Pocketing in the wound.

(6) Inadequate exposure for the solution.

WOUNDS AND THEIR COMPLICATIONS 6 1

{d) Exposed or dead bone (notably if streptococci persist).
{e) Secondary infection due to faulty technic.
Numerous substitutes for Dakin's solution have been tried, and
many near-Dakin's solutions have been placed on the market; how-
ever, the surgeon desiring to get results will do well to follow out all
the details recommended by the originators until personal experi-
ence suggests modifications.

In certain cases, the hypochlorite solution can be used in the
form of wet dressings, or it may be used in the form of wet gauze
packs or drains, these latter act especially well in bone infections.

In the treatment of empyema, the tubes must be so arranged
that a free exit is provided for excess of fluid and secretion; this
means that to each four tubes introduced, one must be untied at
the inner end.

Dicftloramine and other allied preparations have not given me
very satisfactory results because they seem of most value in rela-
tively benign and superficial infections and for the granulating stage
of wounds.

I do not believe that the hypochlorite solution favors secondary
hemorrhage; however, the pressure of the tubes may in some in-
stances tend to erode exposed vessels, and for this reason the Turk-
ish toweling above described should cover the tubes when used in
any locality where the vessels are known to be relatively uncovered.
Likewise the tubes may occasionally promote sinus formation but
this danger has only to be mentioned to be suitably guarded against.
When the tubes are used over an amputation stump or on the
under surface of a Umb, they can be made to hold more readily in
place if threaded through a few layers of gauze as indicated in the
diagram; this device was first seen in use at Depage's clinic and it
is notably effective.

ANEURYSMS

These are very rare complications of wounds, and their occurrence
is limited practically to stab, bullet, and other perforated wounds.
They occur most commonly in the thigh, upper leg, arm, and face.

These traumatic forms of aneurysm are the so-called "false" and
the "arteriovenous" aneurysm.

False aneurysm occurs when the coat of an artery has been cut
and the blood leaks out and is retained in a fluid state by a fibrous
wall or sac that forms about it, the vessel walls themselves forming no
part of this aneurysmal sac.

62 TRAUMATIC SURGERY

Arteriovenous aneurysm is an abnormal connection between aq
artery and a vein. Bullet wounds are the commonest source of origin.

Treatment is the same as for any other similar condition. (See
also pp. 688-692.)

KELOIDS

These are redundant or hypertrophied scars that often form ugly
raised ridges along the line of the original wound. Some persons are
particularly prone to them, notably negroes. No known source of
origin has been ascertained. They seem most likely to follow wounds
about the face and neck, especially if the wound originally was in-
fected or not well coapted.

Treatment. — Many spontaneously subside and others are bene-
fited by a;-ray, high-frequency, and radium applications. Formerly
the injection of thiosinamin was in vogue, but of late it is not much
employed. Operative removal is rarely successful, as the second
wound is quite likely to also become keloidal.

CONTRACTURES

Wounds that cross joints often leave scars that more or less con-
tract soft parts and thus interfere with free motion, flexion being more
usual than extension contraction. Infected wounds and burns are
frequent sources of origin, and the hands, face, and neck are most
often involved; of the larger joints, the elbow and knee frequently
suffer.

Treatment. — Any wound at or near a joint should be regarded as a
presumptive contracture-producer, and the early treatment should be
planned to guard against this sequel by adequate splintage, posture,
and early motion. In the hand and upper extremity the tendency
will be for flexure contraction, and hence the splintage should be on
the posterior surface. In the foot and lower extremity the opposite
tendency pertains, and hence splintage should be on the anleriot
surface.

In threatened finger contractions I have often found it of value to
fashion a thin board the width of the spread-apart fingers and bind it
to the back of the hand and above the wrist, sometimes making the
lower end of it notched or slit to fit each finger-tip. To each notch or
through the slits is fastened a rubber band, and this is put over the
finger-tip, and thus a continuous elastic pull is provided that quite

WOUNDS AND THEIR COMPLICATIONS 63

effectively limbers up a stiff digit (Fig. 36). The same idea can be
applied in the treatment of other stiff joints from this or other
sources. (See Figs. 225-231.)

If the contracture exists and cannot be overcome by gradual bend-
ing, then some plastic operation will be necessary. This may consist
of skin-grafting, either by an autogenous skin-flap or Thiersch grafts.

Fig. 36. — Rubber-band exerciser for stifi fingers:
passing rubber band around a splint; J, arranged to
passing rubber band through slits in a splint. Variou
for exercising special fingers oi the wrist or forearm.

I, Arranged to exercise flexors by

exercise individual extensors by
modifications suggest tbemselves

ULCERS

These are indolent, granulating, infected areas involving the skin
or deeper parts. They are very common, more so in men than
women, and are generally found in persons over forty-eight; that is,
at the arteriosclerotic age and at a time when vascular and circulatory
changes are likely to appear.

Causes. — These may be said to include three general factors:

Wounds — incised or contused when infected.
I Frost-bites.

\ Caustics.

„. . / Electric contact.
^ ^- I X-ray.

64 TRAUMATIC SURGERY

n. Inflammation.

m. Diseases.

Fevers (like typhoid).
Varicose veins and phlebitis
Cellulitis, erysipelas.
Infections.

Syphilis, tuberculosis.
Cardiovascular — nephritis.
Diabetes, gout, rheumatism.
Tropical.

« T f Tabes.

Nervous, i « . ..

I Syrmgomyelia.

Cancer.

Malignant.

Sarcoma.

From the standpoint of injury, the usual origin is from a neglected
or poorly treated small break in the skin (often a pimple or small boil)
in a person having poorly vascularized tissues due to varicose veins
or perhaps arteriosclerosis; or in those having some constitutional
disease like syphilis, diabetes, nephritis, rheumatism, or tuberculosis.

The inner border of the middle and lower third of the leg is usually
the place of election, as this provides a location normally poorly sup-
plied with soft parts, and, in addition, a site likely to be the seat of
venous stasis from gravity or posture. Many cases, however, es-
pecially in women, appear to come on spontaneously, even though the
tendency is always to ascribe the condition to a blow, however trivial
or remote it may be.

What follows refers especially to ulcer cruris, or leg ulcer.

Symptoms. — These depend in part on the origin of the process.
It has been said that ulcers of the upper part of a leg are generally
syphilitic, wholly or in part, and that those on the lower half are
varicose, wholly or in part.

Very few of the cases are seen by the physician from the onset, and
the patient usually comes with the history of a ''barked shin*' or a
small wound or excavation that would not heal despite home reme-
dies of the "carbolic salve *' and allied class. Soon the sore "fes-
tered," became red and angry, and was a source of annoyance, pain,
or apprehension.

At this stage the recent cases will usually exhibit a more or less
sharply localized reddish area of superficial infection with a break in
the skin as the focus. The central part of this area is likely to be
deeper than the margins, and is prone to be covered by a viscid pus
that may be odorous. Varicose veins may be prominent, or only a
few venules may be seen. There may be some enlargement of the
glands of the groin.

WOUNDS AND TIIEIR COMPLICAtlONS 65

If seen a liUle later (say after a week or ten days from the supposed
onset) the above manifestations may be similar, but ordinarily the
pus discharge has created a dermatitis or eczematous area, so that
from an initial small site of injury a reddened surface of large extent
may exist, causing duskiness, swelling, itching, burning, or pain; in
other words, there is a subacute infected wound surrounded by an
area of eczema.

The foregoing applies to the acute ulcerations, or those that come
on within a few weeks of the causative incident.

After the above period, cases then are of the subacute and chronic
variety, and a patient examined then will ordinarily show a more or
less circular or punched-out ulceration with a stenciled margin of
dusky red or livid blue skin, surrounded by a surface of dry or moist
eczema of varying size. The margins of such an ulcer may be sharply
or illy defined, indurated or soft, excavated or perpendicular. The
central portion of the ulcer will be grayish and covered by a more or
less tenacious pus and some bleeding may occur when the surface is
wiped, especially if there are occasional tufts of granulations. For-
merly the appearance of the margin of an ulcer was thought to be of
diagnostic importance, but there are few cases in which this sign is
wholly determinative. Punched-out, well-defined, indurated, under-
mined bilateral ulcers, especially in the upper half of the leg, are
iikely to be syphilitic.

Generally speaking, there are two types of cases — namely, the
moist and the dry. The former often constitutes the recent varitey
occurring in persons under forty-five; the dry form generally indicates
age in the possessor and in the condition itself. In persons whose tis-
sues are denuded of moisture the condition resembles often a vac-
cination-like area surrounded by dry, cracked, and parchment-like
skin.

In the recurrent type, scars of former ulcers will be visible either as
whitish puckerings or as the brownish, coppery cicatrices so typical of
luetic origin. Many recurrences are primarily due to a latent or un-
cured periostitis or osteitis, and the ulcer is but an effort to relieve
pressure and allow escape of pent-up secretion.

In the syphilitic, this recurrent type is quite likely, especially if
antiluetic treatment has been inadequately undertaken. Such ulcers
are usually gummatous manifestations. In this connection, it is well
to remember that an ulcerous wound in any part of the body may
resist energetic treatment until an antisyphiUtic regimen is instituted.

Many ulcers remain healed for varying periods, and then break

66 TRAUMATIC SURGERY

down with little or no provocation, and subsequently heal, only to
again reform.

Treatment. — This may be described as local and general.

Local Measures. — The indications are to (i) prevent the spread
of the ulcer and its secretions; (2) stimulate granulations; (3) limit
undue scarring and prevent recurrences.

The foregoing can be met by a form of treatment that aims to (a)
cleanse; (J) stimulate; (c) support.

(a) Cleansing designs to convert an unhealthy, pus-discharging
surface into a healthy, granulating area. The pus is washed off by
salt solution or iodin water (iodin i dram to a pint of water). If the
foregoing are ineflScient, pure peroxid applied on cotton and allowed
to soak through the tenacious pus will answer.

(b) Stimulation will be necessary if the foregoing does not bring a
healthy glow to the ulcer, and this may be done either by mechanical
or chemical means. Rubbing with gauze, or scraping the surface
with scissors, scalpel, or curet are examples of the mechanical means
of irritating the gray granulations. Snipping with scissors may be
needed. Chemical irritants, such as pure carbolic or strong silver
nitrate solutions, can be applied over the surface to produce a cauter-
ant effect. Whatever means are chosen, in large ulcers care must be
used not to attempt to stimulate more than one-half the surface at
the first dressing until the reactive power of the patient is ascertained.

If granulations are not grayish but fairly healthy, then the use of
gauze soaked in balsam of Peru or tar (10 per cent, in castor oil) is an
excellent application, especially as it will not adhere to the parts. If
there is an area of eczema surrounding, this should be coated with
zinc oxid ointment. Sometimes a first dressing of saturated magne-
sium sulphate solution on gauze softens the area and permits more
effective treatment later. If there is not much discharge, the use of
scarlet red salve up to 10 per cent, strength I have found satisfactory.
In my experience it is irritating to secreting surfaces and on any area
if used more than two or three times consecutively. It should be ap-
plied to the raw area only about 3 ^-i^^h thick. If the discharge is
exceedingly scanty, the margins of the ulcer can sometimes be quickly
coapted by strapping with }2-ii^ch sections of adhesive plaster, care
being taken to so overlap these that secretions may escape. Such
straps should not encircle the limb enough to interfere with circula-
tion. If there is much odor, gauze wet in permanganate of potash
(in a good pink strength) or iodin water (i dram to a pint) for a few
dressings will usually suffice. Carbolic should never be used except
as a caustic, as indicated hitherto.

WOUNDS AND THEIR COMPLICATIONS 67

(c) Support. — Whatever the medicament may be, it should be
applied to the ulcer on a folded gauze compress, with a layer of cotton
on the latter if necessary, all to be held in place by a snug roller ban-
dage that is applied from below the ankle to below the knee. The
limb should be elevated during this application and enough adhesive
plaster or pins used to prevent slipping. See non-slip bandage
(Figs. 79-81.)

In chronic cases, or where recurrence is being guarded against, the
use of some sort of stocking may be necessary. Those of rubber or
fabric are costly, they soon smell and stretch and become useless.
To provide an eflfective, cheap, and washable supporter I advise a
Unen mesh bandage, such as dealers now supply in 5-yard lengths of
varying widths. Such a bandage costs 40 cents, and while one is
being worn the other is in the wash. In the trade they call these
" Ideal " or " Green Cross " bandages. A patient soon learns to apply
a bandage like this so that it will not slip, and it is quite as effective as
a stocking. Along this same line of "support" treatment it is an
excellent plan to enjoin the patient to keep the limb elevated when-
ever opportunity presents. With this in mind, the foot of the bed at
night can be elevated on a few bricks or other support, so that by
changed gravity some of the pressure may be removed from overdis-
tended vessels.

Very few of these cases will take time enough away from work for
operative treatment designed to remove varicose veins or excise ulcer-
ous areas or for skin-grafting. Operations of this kind are certainly
curative in many instances.

General Measures. — Here the aim is to remove constitutional
causes, if possible, and to correct vicious habits and methods of Uving.

Search should be made for any cardiovascular-nephritic combina-
tion, and also for alcoholism, diabetes, syphilis, gout, rheumatism,
and tuberculosis. Oral sepsis (teeth, tonsils, gums) must not be for-
gotten as a potential source of pus in this and in other forms of pro-
tracted or recurrent infection. If any of these are found, suitable
treatment should be instituted, for these patients are virtually
"germ-carriers."

In the average case the use of the following has been found effect-
ive, as it meets the very common unity of rheumatism and arterio-
sclerosis:

R. Potass, iodid *. gr. v;

Vin. colch. rad WRxv;

Syr. sarsarp. co q. s. ?]. — M.

Sig. — One dram three or four times daily.

68 TRAUMATIC SURGERY

ERYSIPELAS

This acute infective disease of the skin and mucous membranes is
now known to be due to streptococci that gain entrance through some
more or less demonstrable break in the skin or mucous surfaces. For
a long time it was regarded as being due to an independent organism,
and because of its contagiousness patients were isolated. Some au-
thorities assert that it may be induced by staphylococci and other
bacteria, but the accepted source of origin is the Streptococcus erysipe-
latus (cultivated by Fehleisen in 1883), which is probably identical
with the ordinary Streptococcus pyogenes.

Causes and Frequency. — Formerly the "idiopathic" or medical
fofm that so commonly affected the face was supposed to be of un-
known origin, and the other, "traumatic" form, was traced to a
demonstrable wound in the skin or mucous membrane.

At present the belief is that it is always due to some break in the
external texture, and that the facial forms commonly arise from a
nasopharyngeal infection due to erosions, abrasions, or other lesions.
Practically speaking, nine-tenths of all the cases affect the face, and
the remainder the leg and foot equally often. Pueri>eral infection
was at one time regarded as occurring from "erysipelas," but now it is
known to be usually streptococcic.

There is an individual predilection to the affection, as in many
persons it often appears recurrently in association with trivial wounds
or even with nasopharyngeal "catarrh"; such persons are probably
so-called "germ carriers." It quite commonly occurs about ulcer
of the leg, and scalp invasion is not infrequent from pediculi and
other irritants.

PatftologiccUly, it is a progressive lymphangitis, and if it spreasds
deeply, necrosis occurs, resulting in so-called Phlegmonous or gan-
grenous erysipelas.

Metastases may be carried in the blood-stream to the limg, liver,
spleen, heart, and other organs.

Symptoms. — An incubation period of from fifteen to sixty hours
precedes the typical onset with a chilly soon followed by fever, which
may reach 105° F. in the first twelve hours, and which tends to remain
Jiigh, but which is remittent in type. There may be nausea and
vomiting, with malaise and prostration. The pulse is elevated.
Mentally the patient is generally active, and delirium is not un-
common in the first few days.

During this early period there may be no local signs in the wound
or other focus, but after the first day burning and tension may be

WOUNDS AND THEIR COMPLICATIONS 69

complained of, and then the invaded region is seen to be edematous, red,
and swollen, the margins of this sharp-edged area being wavy and ir-
regularly zigzag, often compared to the outline of a burned piece of
paper or the edges of burning grass. The originating focus is often
less actively inflamed than the parts distal to it. The neighboring
glands are swollen, tender, and hard. The swollen area is firm, tense,
and rather resistant, and when the finger is removed from it a yellow-
ish-white place remains. Blebs, blisters, and spots of gangrene occur
in severe cases, and serum or pus may exude from these, to be later re-
placed by a brownish scab or crust. If pus has been present in the
original wound, it becomes seropurulent or serous. When new areas
are invaded the local signs are more prominent than in the regions
previously affected.

While the spread of the process is usually more or less direct from
the original focus, it is not uncommon to have it appear some distance
away, leaving the intervening area free.

After several days the temperature begins to remit, but as new
areas develop, it again ascends, and if the attack has been severe
much systemic prostration occurs. The skin peels at the end of
the disease.

The average duration is fourteen days in persons under forty, but
it lasts longer after this period of life (Anders).

Relapses are said to occur in about lo per cent, of cases, and these
often are due to self-inoculation from scratching, the clothing, bedding,
or dressings.

Prognosis is excellent, and the average mortality is 6.5 per cent.,
the extremes being 3 per cent, in young adults and 45 per cent, in
those over seventy, with a mortality in wound infection of 14.5 per
cent. (Anders). Alcoholics are bad risks, as they often develop
delirium tremens.

Complications are most likely in connection with phlegmonous and
other severe forms that may cause local gangrene or necrosis, with
extensive burrowing of pus and much systemic poisoning.

Facial forms (commonly known in the hospitals as "Facial E." or
"F. E.") may sometimes lead to meningitis by direct spread through
the orifices at the base of the skull, or by the venous channels as a
thrombophlebitis. Following operations on the head it is not uncom-
mon to have "Facial E" appear within the first week in a wound that
up to that time appeared healthy; it is especially frequent after scalp
wounds, mastoid operations, and fracture of the nose. Most of these
cases get well.

70 TRAUMATIC SURGERY

Pneumonia, nephritis, endocarditis, and other evidences of sys-
temic invasion may also complicate.

Treatment — General measures conserve the patient's strength and
vitality, having particular regard to diet, fresh air, the use of alcohol
in those accustomed to it, and such anodynes as may be required for
pain. The kidneys are to be kept active by the free use of water by
mouth and also by rectum if occasion requires.

It is probably wisest to isolate the patient; but, in reality, there
is no more reason for so doing than in ordinary cellulitis.

Local measures have been recommended almost without number,
and cure is often ascribed to them with about as much basis as if they
had been similarly used to "hasten the desquamation'' of scarlet fever,
measles, or any other disease of self-limited type.

Wounds should receive the maximum initial and subsequent care,
and if burrowing or pocketed pus is located, incision and drainage
should be prompt.

There are, practically speaking, only two forms of local treatment
in general use, namely, wet dressings and ointments.

Wet dressings consist of many layers of gauze (made like a
mask in facial cases) soaked in watery solutions of sail, aluminum
acetate (4 per cent.), boric acid (saturated), permanganate (pink color),
iodin (i dram to a pint), magnesium sulphate (saturated or less
alcohol (10 to 25 per cent.), bicldorid (i : 5000), or carbolic (i to 2 per
cent.).

Bichlorid and carbolic are dangerous, and salt or magnesium
solutions act just as well. The gauze may be covered by perforated
rubber tissue or oiled silk.

Ointments are applied direct to the uncovered parts, or gauze
may be used for that purpose.

Lanolin and carbolic (i per cent.), zinc oxid (10 per cent.), boric
acid (10 per cent.), and ichthyol (10 to 50 per cent.) are probably most
often employed.

My personal preference is for a cold wet dressing of magnesium
sulphate in the early stages, followed by ichthyol ointment (25 per
cent.) in the later periods. K the patient is uncontrollable, and
where nurses are unavailable, the ointment is used throughout.

Blebs are opened by a sterile needle only if they are purulent or
very large, and scabs are never removed unless they harbor pus.

I have never seen any marked good from the injection of carbolic,
silver salts, or other agents into or at the margin of the inflamed area.
Serum treatment has likewise not proved of value. Recently from

WOUNDS AND THEIR COMPLICATIONS 7 1

his BeUevue Hospital experience, Seth Milliken reported excellent
results from the use of powdered zinc stearate.

ERYSIPELOID

This is a dermatitis due to inoculation of the skm by decomposing
animal matter, fish, or cheese. Crab and lobster bites are the com-
monest sources of origin, and the hand is usually the part involved.

It is apparently to erysipelas what German measles is to true
measles and scarlatina to true scarlet fever.

Rosenbach first described it, and Gilchrist believes it to be due to
a ferment, as he has been unable to determine the presence of any
organism.

Symptoms are externally like erysipelas, except that no blebs or
pustules appear unless reinfection occurs. There are few systemic
signs except pain, and there is no rise of temperature or pulse.

Treatment consists in the use of salicylic acid plaster (25 per cent.)
for three days and thereafter some simple ointment. The other ex-
ternal measures used in erysipelas have also been advised.

TETANUS (LOCKJAW)

We are chiefly indebted to Nicolaier and Kitasato for our knowl-
edge of the specific agent — the Bacillus tetani. It has been definitely
determined that the germ does not grow in the presence of oxygen
(anaerobic), and that it has a normal habitat in the soil and long re-
skts the action of heat and other agencies capable of destroying the
ordinary pyogenic organisms. In the war zone these germs were
rampant because the soil had for years been richly fertilized with
animal and human excreta. It is not a pus producer or infective
agent, and it causes very little reaction at the place of entrance, this
focus usually being a demonstrable break in the skin or mucous
membrane.

Wounds of the hands, feet, and face are the usual portals of entry,
and penetrating, punctured, and other wounds that do not gape or
bleed are the most likely to become infected, although compound frac-
tures and crushing wounds are other predisposing sources.

The germs are found only at the site of the wound, and the systemic
symptoms are due to toxins known respectively as tetanospasmin
and lelanolysin; the former produces the convulsions and the latter
destroys the red blood-corpuscles. In many respects it resembles an
alkaloidal poison. It has been shown that these toxins reach the
spinal cord only by the motor nerves, and never by the sensory

72 TRAUMATIC SURGERY

•

nerves, the lymphatics, or the blood-stream. It has been furthex'
demonstrated that the poison is carried in these motor nerves by th^
axis-cylinders, but if these are destroyed by an injury (as in a crush or'
amputation of a limb) the poison may still reach some intact motor"
nerve by diffusion into the adjacent tissues. Once the spinal cord is-
reached, the poison is deposited in the motor ganglia, spreading up-
ward from one to the other toward the vital centers of the medulla.

Varieties and Causes. — Idiopathic tetanus is supposed to be due to
the inhalation of infected material. This is very doubtful.

Traumatic tetanus is the usual variety, and, as stated, it follows the
entrance of the germs through a wound, ordinarily of the punctured,,
non-gaping, or non-bleeding sort.

Fourth-of'July tetanus is due to wounds from blank cartridges
or revolvers, and all bullet wounds should be regarded as presump-
tively tetanogenic. Similarly, all wounds likely to be contaminated
by manure or garden or street dirt are suspicious.

For purposes of description we also speak of acute, subacute, and
chronic tetanus; the first develops within ten days and the others
thereafter.

Cephalic tetanus follows wounds about the head, and in these the
cranial nerves show the earliest effects.

Certain geographic localities seem especially likely to harbor the
germs, and Anders^ states that these places are in northern New
York, the Hudson Valley, parts of Brooklyn, Long Island (notably
Huntington); southern Pennsylvania, Virginia, Georgia, southern
Louisiana, Indiana, Illinois, and southern California; and in New
Jersey there is a small section where the infection appears
endemically.

Symptoms. — There is nothing characteristic about the focus of
origin, although most wounds will be infected and sinus-like, often
found to contain dirt or foreign matter. Occasionally the initiat-
ing wound has healed before the tetanic evidences appear.

The nearer the wound to the direct pathway of the spinal cord,
the earlier and more severe the symptoms; hence wounds of the
head and upper extremity are more likely to give early manifestations
than those situated distally.

In the acute form the incubation period is between seven and ten
days, and the earliest symptom is stiffness of the muscles of the back
of the neck, with or without an accompanying chill and rise of tem-
perature. Difficulty in moving the jaw soon appears, and within a

^Jour. Amer. Med. Assoc. ^ July 25, 1Q05.

WOUNDS AND THEIR COMPLICATIONS 75

ure is to be repeated, as the antitoxin is relatively harmless. The
route of choice in the early cases is intraneural; later, intraspinal
and intravenous (750 to 3000 units). The intracerebral method of in-
troducing antitoxin has not proved of value. Antitoxin, however,
is not always obtainable, and when large amounts are required the
treatment is relatively costly. If antitoxin is unobtainable other
materials may be used, as follows:

Magnesium sulphate (Epsom salts) has been used in the same
manner as antitoxin, since Meltzer has shown the anesthetic eflfect
of this drug when used either in aflferent or efferent nerve-fibers.
Under the personal direction of Dr. Metzel the writer some years ago
had the opportunity of demonstrating the anesthetic properties of this
drug in major operations, and the employment of ,it in tetanus is
based on the anesthetic more than the antitoxic or antiseptic prop-
erties. It is used in 25 per cent, solutions, i c.c. being used for
every 20 pounds of body weight in a robust adult, or for every 25
or 30 pounds of body weight in the enfeebled, aged, or children.

Blake^ has shown that each injection may,, in favorable cases,
control the convulsions for periods ranging from twenty-nine to
thirty-seven hours. However, Camus, ^ by experiments on dogs,
reaches the conclusion that the convulsions and excitability are but
little influenced, even when this drug is used with carbolic acid to
obtain the added antiseptic effect of the latter. He verified the
efficacy of antitoxin and found it much superior to other means, even
when they had been used combinedly. T. Kocher recently reported
excellent results from the magnesium preparation, and he uses it in
15 per cent, solutions, repeating the intraspinal administration not
oftener than each twenty-four hours. He warns against using it if
no cerebrospinal fluid flows after the spinal tap, and also advises
care when it is employed with antitoxin. He regards it as in effect
a hypnotic capable of warding off danger after the toxin has pene-
trated the nerve substance.^

Carbolic acid injection^ "Bacelli's method,'^ was introduced in
1888, and consists in the subcutaneous injection of i per cent,
solutions until 80 grains are given daily to an adult. It is said to be
rapidly eliminated and, therefore, must be frequently repeated.
As is well known, this drug has analgesic as well as antiseptic
qualities. This procedure has not much vogue now and was never

^ Surg.f GyncCy and Obsl.y May, 1905.

^ Soc. dc Biol.y tome i, xxii, 1912, No. 31, p. log.

*T. Kocher, Corrcs.-Blatt f. Schw. Aerz,, Basel, xlii. No. 26, pp. 969-1000.

^6 TRAUMATIC SURGERY

very favorably regarded in this country, although the originator''^
Itah'an confreres reported fair success with the method.

Iodoform injection^ '*Kitasato*s method/' consists in the hypo-
dermic introduction of 3 to 5 grains of iodoform three times daily.

Various other drugs have also been injected, such as salt solution^,
cocain, eucain, brain emulsion, and many others.

{c) Sedatives are needed for pain and insomnia, and of these the
hromids and chloral are most often used, usually in the combination
of "B. and C. mixture,'* containing 20 grains of bromid of soda and
10 grains of chloral hydrate, every three or four hours.

ChloreUme, in lo-grain doses, is also of value. All of these drugs
are generally given through a tube put into the nose or rectum.

Morphin is »used hypodermically as needed, J^ grain being the
usual dose.

Prognosis. — Most deaths occur within the first week, and pa-
tients surviving this period usually recover, the majority of deaths
occurring from respiratory invasion on the fifth day. The mortality
in acute cases (those occurring within the first week) ranges between
75 and 85 per cent.; cases developing after the first week show a
mortality of about one-half the foregoing.

RABIES (HYDROPHOBU)

This infectious disease is due to the bite of a rabid animal, nearly
all of the cases originating from dog bites. Cats, cattle, wolves,
jackals, and all warm-blooded mammalia are capable of transmit-
ting it, but horses and swine are rarely affected. It can be trans-
mitted from animal to animal, and even birds are said to become
infected.

Pathologically there are few characteristic changes, but the cen-
tral nervous system quite regularly gives evidences of hyperemia
with hemorrhagic areas and occasionally softening, notably in the
bulbar region, where a grouping of certain embryonic cells is often
found near the central canal; these are known as "Babes' tubercles. "
The raucous membrane of the respiratory tract is generally inflamed
and a frothy mucus is often present in large amounts. A positive diag-
nosis is now regarded as being made when small inclusion bodies or cor-
puscles can be demonstrated in the Purkinje cells of the cerebellum
and in the large gangliom'c cells of Ammon's horn; these are said to
be protozoa, and are known as ''Negri bodies."

Symptoms. — The incubation period following the bite is rarely
less than twelve days and never earlier than five, the average being

WOUNDS AND THEIR COMPLICATIONS 77

forty days in man, and twenty-one to forty in dogs (Bradford).
The manifestations are said to be greatest when the bite has been on
exposed surfaces so that the saliva has not been caught in clothing,
and for this reason, and because of the contiguity of the brain, face
bites are regarded as the most likely to become dangerous; those
near to main nerve trunks act similarly, as the virus behaves like
tetanus in choosing the most direct route to the central nervous
system.

Firsi stage symptoms are irritative, so that the wound is painful
and the patient is restless, taciturn, ailing, or changed as to habits,
actions, or appearance.- Salivation may be excessive. This stage
lasts two or three days.

Second stage symptoms are those of excitement, with more or less
trouble in swallowing and some stiffness of the neck muscles.
Efforts at drinking water often induces spasm of the glottis, but all
food or drink may have a similar effect. Generalized convulsions
may follow, with intervening great mental excitement and fear of
death, or actual delirium, all of which are exceedingly exhausting.
This stage may end in death after two or three days.

Third stage symptoms are paralytic, in which the lower extremities
are first involved, and later the paralysis ascends and involves the
respiratory mechanism, ending iq death, usually within a day.
Occasionally the early stages are absent and paralyses alone exist,
constituting the so-called "dumb rabies" commonly seen in dogs.

From the onset of symptoms to recovery or death, a period of less
than a week usually elapses.

Pseudohydrophobia, hysteric or otherwise, generally occurs within
a few days of the bite, and is characterized by much frothing, bark-
ing, growling, or other canine manifestations that may last a long
time, coiivulsions occasionally being added. Such cases generally
arise from fear, and some patients are said to have died from ex-
haustion and starvation even in this spurious form.

Prognosis is extremely bad, and genuine cases are nearly always
fatal unless antirabic serum is given early. Cases may develop as
late as a year or eighteen months after inoculation (Gowers), but it
is exceedingly rare after six months (Bradford).

Diagnosis is made absolute by animal inoculation or by the find-
ing of the Negri bodies.

Treatment. — Prophylaxis is exceedingly important, and all suspi-
cious bites should be energetically cauterized or excised. Park, of
the New York Board of Health Department, from a wide experience.

78 TRAUMATIC SURGERY

advises fuming nitric acid as a cauterant, stating that **. . . in the
case of small wounds all the treatment probably indicated will be
thorough cauterization with nitric acid within twelve hours from the
time of infection. " Others advise applications of pure carbolic add,
silver nitrate, the actual cautery, strong solutions of bichlorid of mer-
cury, or tincture of iodin. Under no circumstances should such a
wound be sutured.

Since 1885 the Pasteur antirabic inoculation treatment has been
advocated, and the average mortality in 30,000 cases receiving it at
the Paris Pasteur Institute since then has been 0.5 of i per cent.*

The spinal cord of affected rabbits is utiKzed in making a graded
virus which, when injected, establishes an immunity. This treat-
ment is practically available all over the world, and in this country
the Public Health Service or local Health Departments furnish it on
demand when it cannot otherwise be obtained from commercial
drug houses. To be of maximum eflSciently it should be used just as
antidiphtheric or antitetanic sera are used, that is, as an immunizing
agent.

The general treatment requires no special comment.

Animals suspected of being rabid should be confined and observed.
If within ten days a suspected dog does not develop rabies, then the
disease dose not exist; if it does develop, the animal will die, and the
brain and spinal cord will furnish positive evidences of the exact
condition. If a rabid dog has roamed about before being suspected,
all other dogs in the community should be muzzled for from three to
six months or until no further cases develop. Compulsory muzzling
of dogs banished rabies from Great Britain in the period from
1903-07, and since then no cases have developed.

Dogs developing hydrophobia change in disposition ("furious
form ") or become paralyzed (" dumb rabies "). Long-haired animals
are the least to be effected, presumably because the virus-laden
saliva is caught in the hair.

Less than half the bites from animals actually rabid are followed
by hydrophobia.

ANTHRAX (MALIGNANT PUSTULE; WOOLSORTERS^ DISEASE)

This specific disease is rare in this country, and cases of it are
generally imported from Russia, South America, China, and India,
and these arise in connection with the handling of wool products,
hides, horns, manure, horsehair, and rugs.

* Albert, Jour. Amer, Med. Assoc, ^ May, 1913.

WOUNDS AND THEIR COMPLICATIONS 79

Koch^ in 1877, determined the specific cause to be the Bacillus
anihracis.

Symptoms. — There are three channels of infection: (i) Skin
inociilation; (2) respiratory tract; (3) gastro-intestinal tract.

(i) Skin forms are also known as cutaneous anthrax or malignant

puslulCy and occur usually in a wound or break in the skin of the

bands or face. In the war zone, infection usually occurred from the

bristles of contaminated shaving brushes. I saw but two cases and

they recovered imder the ordinary wound treatment.

The incubation period is short, and at the onset a burning or

itching small papule is seen, with a blue point in the center. In a

few hours this becomes a vesicle containing a brownish or bloody

fluid with an encircling area of redness, swelling, and induration,

and this zone later becomes purplish and gangrenous.

The pain and itching then cease, and soon a halo of bloody vesicles

appears and the original focus becomes an eschar, and the scab in

about ten days falls off or it becomes necrotic. If the area becomes

more swollen it resembles an erysipelatous patch and symptoms of

sepsis may appear, but otherwise the constitutional signs are slight.

In the severer cases the secondary vesicles may also become necrotic

or gangrenous and involve large sections.

£d€fnatous anthrax is a rarer manifestation, occurring in the loose
tissues about the eyelids, neck, and forearm, appearing as an area
of ill-defined edema without other cutaneous or systemic mani-
festations.

(2) Pulmonary anthrax is not unlike pneumonia, and is due to in-
'^a.tion of dust containing the bacilli. It is fatal in 80 per cent, of
cases within five days.

(3) Intestinal anthrax arises from eating the meat or drinking the
'^^^ili of infected animals. Aside from signs like ptomain-poisoning,
there are sometimes eruptions like carbuncles.

Diagnosis is promptly made by stains of the secretion from the
pustule, and animal inoculations kill the host within two days.
Sc^xxie cases simulate carbimcles, furunculosis, and erysipelas.

Treatment. — General measures consist in the use of Sclavo's serum,

1^ CO. or more being given into a vein adjacent to the pustule, this to

^ repeated within twenty-four hours if needed. When a vein cannot

^ chosen, the injection is given subcutaneously into the abdominal

wall. Systemic supportive agents are also employed.

Locally the pustule is excised, or, when this cannot be done, the
^ea about it is injected with 5 per cent, carbolic acid, to be repeated

8o TRAUMATIC SURGERY

•

often. Caustic potash has also been injected around the pustul^^
Prior to the use of serum the mortality averaged 25 per cent., but no ^«^
it has been reduced to about 5 per cent.

Workers in hides, wool, arid other products likely to be infecte^^=
should wear gloves and immediately sterilize all wounds; if dust i^
prevalent, a respirator should be worn and fans or other "blowers ^ '
employed to provide adequate ventilation.

GLANDERS (FARCY)

This is a specific disease due to the BaciUus mallei (LofHer and
Schutz), and is very common in horses and less so in mules, field mice,
rabbits, squirrels, guinea-pigs, cats, goats, and doves.

Contact with horses causes nearly all human cases, and the inoc-
ulation is by a skin wound or the respiratory or gastro-intestinal
tract.

Symptoms occur soon after exposure, and at first the patient is re-
garded as having pneumonia because of the onset with fever, chill,
pain in the chest, cough, r41es, and expectoration. After a week or
two hard swellings occur in the subcutaneous or muscular tissues,
notably in the flexor region of the upp)er extremity and the pectoral
and abdominal muscles. These later soften and become abscess-like,
break, and emit a sanomucoid fluid. Sometimes a pustular eruption
appears not unlike small-pox, although it never is umbilicated. The
joints may also become swollen and the patient may be looked upon
as rheumatic; synovitis may also appear, and if the joint is tapped the
turbid fluid may show the bacilli. Sometimes a nasal discharge
occurs.

After the second or third week delirium is common and the pul-
monary signs increase, and death is then not long delayed.

Chronic glanders may last months or even years, and the breaking
of the hard nodules and their ulceration may suggest gummata.
These ulcerative areas may be very wide-spread and even involve the
hard palate, face, nose, extremities, and other areas.

Prognosis is bad in the acute cases, as they nearly all die; about
half the chronic cases recover.

Treatment. — Prophylaxis aims to disinfect promptly and vigor-
ously all wounds occurring in those employed about stables or horses,
and the primary focus should be excised when possible. Antiseptic
dressings are then used and appropriate general treatment given to .
meet the constitutional symptoms. There is no specific remedy and
the general signs are treated much after the plan of pneumonia.

WOUNDS AND THEIR COMPLICATIONS 8 1

ACnNOMYCOSIS

This specific disease is common in many domestic animals, and
then is known as "lumpy jaw."

At one time it was supposed to be transmitted from animals to
man, but now infected grain is regarded as the source of origin, either
as a traumatic or actual inoculating element.

The ray-fungus found in the lesion is anaerobic, very tenacious of
life, and grows in colonies of characteristic form, like grains of fine
sand scattered through large-sized granuloma ta. These "sulphur
grain" bodies are firm, grayish-yellow, red, and occasionally green or
black, and they are readily visible and regularly present in the pus of
the abscesses.

Most cases involve the head and neck, especially the region of the
angle of the jaw, from a buccal port of entry; next in order of fre-
quency the gastro-intestinal tract is involved, and then the respira-
tory tract and the skin. Spread of the process is along connective-
tissue planes, as the disease does not progress along lymph-channels.

Symptoms. — Cervicofacial groups are the most frequent, usually
arising from some abrasion of the mucous membrane of the mouth or
from decayed teeth. Pain and difficulty in mastication are early
signs, and the muscles concerned become rigid and a boggy, hard
lump forms near the angle of the jaw, the glands not being involved.
Trismus is present and is one of the main features, together with this
very slowly progressing "lump." The skin becomes purplish, and
soon areas of fluctuation appear and ulceration occurs with the escap)e
of the characteristic bodies and the formation of sinuses or fistulae
that may enter the mouth. Pus is usually present due to a mixed
infection, and the adjacent bone may also become necrotic. Exten-
sion to the tissues about the face and neck may occur, and occasion-
ally the mediastinum may be involved, or it may travel upward and
reach the base of the skull by way of the antrum.

Thoracic farms resemble bronchopneumonia, and the thoracic wall
or its contents may become involved, and finally many sinuses may
appear. The average duration of these cases is ten months and the
mortality is very high.

Abdominal forms arise from the intestinal tract, notably the ileo-
cecal and colonic portion. The early symptoms may simulate appen-
dicitis or colitis; in others, a tumor in the right iliac fossa may be an
early sign. The skin over the invaded intestine eventually becomes
gangrenous and sinuses form from which a grayish purulent material
is discharged.

82 TRAUMATIC SURGERY

Cutaneous farms are exceedingly rare and constitute less than 5
per cent, of the cases. It manifests itself in a lupus-like manner with
a localized nodule, or as an ulcerous lesion with necrosis in one part
and dense granular infiltration in another. Later, the areas ulcerate
and sinuses form, and these discharge the typical sulphur-like gran-
ules. It is a painless process and the glands are uninvolved.

Diagnosis is made positive in all cases by finding the characteristic
granules and the ray fungus, and the slow progress of the actinomyco-
sis process is also quite typical.

Sarcoma, carcinoma, tuberculosis, and gunmiata are often hard to
differentiate.

Prognosis dep>ends upon the location and the chances of mixed
infection, the average mortality being about 47 per cent., the abdomi-
nal, thoracic, and cerebral forms being the most serious.

Treatment.— This is not very satisfactory, and consists of hy-
gienic and dietetic measures, with appropriate antiseptic treatment of
the local ulceration or sinuses^ especially iodin dressings or a weak
iodid solution, such as water, 500 gm.; potassium iodid, 10 gm.;
iodin, I gm. Iodid of potash and sulphate of copper are said to be
the drugs of choice for long-continued use. Excision of accessible
areas is also advised.

GAS GANGRENE; MALIGNANT EDEBfA; EMPHYSEBfATOUS GANGRENE-^
GASEOUS PHLEGMON; BACILLUS AEROGENES INFECTION

This is a rapidly spreading rather rare, and often fatal infection
due solely to the Bacillus aerogenes capsulatus anaerobicus of Welch
(the perfringens of the French) , which produces a gaseous infiltration
of the tissues (clinically causing the same symptoms as the bacillus of
malignant edema), or it may occur as a mixed infection due to pus-
producing or other germs. In civil practice it usually occurs with
crushing wounds, particularly compound fractures of the extremities,,
or bullet wounds. The organism predilects muscle tissue and inva-
sion is along muscle and fascial planes so that from a given focus the
spread may be into muscle groups or along a single muscle. Inter-
ference with circulation (vascular lesions or tourniquet), extensive
laceration and death of muscle with the presence of dirt and other
foreign matter (notably clothing) all combine to make likely the
spread of this form of infection. It is practically unknown in the
scalp, face and nack, but very common where the muscles are long or
segmented as in the thigh. In a fatal case of mine it appeared nine
days after a multiple fracture of the pelvis with lacerations of the

WOUNDS AND THEIR COMPLICATIONS 83

vagina and urethra. Less often it has followed simple hypodermic
punctures of the skin and abdominal and other operations.

The source of origin is supposed to be the human or animal intes-
tinal tract, and the war furnished vast numbers of cases as the soil
was richly manured. A great nimiber of organisms were held re-
sponsible for this "gas infection;" for practical purposes the Bacillus
of Welch is sufficiently denominative. Horseless vehicles, asphalt
pavements and chemical fertilizers have done much to reduce the
frequency of this malady, one of the scourges of the war.

Symptoms. — These occur promptly, and usually within the first
twenty-four hours the region of the wound will be found swollen,
bluish, and edematous, and a fine crepitus will be felt over the in-
volved portion. Most of the wounds emit gas-bubbling pus that is
often brownish and characteristically fetid, and ocasionally a definite
crackling can be heard as the bubbles burst. Blebs sometimes ap-
pear and the original area of swelling grows rapidly, so that within a
few hours the whole extremity may double in size, crepitation being
present throughout. The purulent contents of the wound have a
tendency to separate the muscles or lift them from the parts beneath,
and the soft parts become cadaveric in appearance. X-ray examina-
tion will early show the presence of gas.

There is great systemic prostration and the temperature and pulse

are much increased, and most of the patients die within a few days,

the emphysematous swelling meanwhile having become quite general.

There are apparently cases of lesser virulence in which the onset is

later and the process much less general and severe.

In the war there were numerous instances of an attenuated, less
massive process, a sort of local gas gangrene characterized by
limited swelling, brownish discharge, fecal odor and a grayish wound;
this form doubtless occurs in dvil life also.

Treatment* — General measures are those given to cases of sepsis.
Proper initial sterilization of wounds doubtless prevents many cases
that may have been contaminated by intestinal secretions and thus
^e presumptively regarded as dangerous, especially if there has been
much laceration of muscle or interference with blood supply.

Inasmuch as the bacillus is anaerobic, the essential thing is to al-
l<>w free access of oxygen, and for that reason the wound and the
P^ about it are freely incised and debrided, liberally flooded by hy-
^ogen dioxid or strong solutions of permanganate of potash, and then
"^c part is dressed by gauze soaked in these oxygen carriers. When
the limb is involved, the propriety of immediate amputation must be

84 TRAUMATIC SURGERY

considered, and this becomes imperative if wide incisions, drainage,
and dioxid or permanganate are ineffective. The level of amputation
should be above the zone of emphysema, as a rule, and the stump
should be allowed to gap>e widely, as any attempt at coaptation may
defeat the object of the procedure.

Recently the treatment by wide incison, debridement, drainage,
Dakin's solution, or permanganate has been nearly as adequate as
amputation if undertaken early and vigorously, many surgeons hav-
ing demonstrated the efficacy of these conservative measures.

It appears that the presence of calcium salts renders the action of
the bacteria and their spores more active by breaking down natural
defenses to which the name " cataphylaxis " is given (Bulloch and
Cramer; Proc. Royal Soc, London, May, 1919). This theory aids
in explaining why one terrain more than another seemed to induce
this infection in the war zone.

SPOROTRICHOSIS

This local infection was first reported by Beurmann, Paris, 1903,
and to date about 200 cases have been recorded in literature. Ham-
burger^ has stated that some 58 cases are now recorded in America,
but that the disease is in reality much more prevalent, and is probably
often confused with actinomycosis, blastomycosis, and other forms of
granulomata.

It is due to the sporotrichium, which may become localized in the
external soft parts, joints, bones, the lungs, kidneys, and other vis-
cera. It occurs chiefly in farming districts, and inoculation is by a
wound, usually regarded as trivial, as from a nail, barbed wire, or
some farming implement.

Symptoms. — The onset is exceedingly slow, and the first sign is a
** pimple'* at the site of a visible or forgotten wound. Here a subcu-
taneous painful nodule appears about the size of a split pea, and with-
in a few weeks similar nodes are seen directly above the original and
in line with the lymphatics. These gradually grow larger, and after
six or eight weeks they break down and discharge a small quantity of
viscid bloody pus and remain ulcers without constitutional signs.
In time these nodes may extend the length of the limb and may in-
volve the deeper lymphatics also.

Beurmann states that there are clinically four varieties: (a) Local-
ized sporotrichosis^ with sporotrichotic chancre and ascending lymph-
angitis and lymphadenitis; (6) disseminated gummatous sporotrichosis ^

^ Jour. Amer. Med. Assoc. j Nov. 2, 1912.

WOUNDS AND THEIR COMPLICATIONS 85

witJ:i diffuse nodulation and later cold abscess formation and no ulcer-
ation; (c) disseminated ulcerative sporotrichosis y with ulcerations like
tul^erculosis, syphilis, and other lesions; (d) extracutaneous sporotri-
chosis, with manifestations in mucous membranes, muscles, bones,
]Oii\ts, kidneys, and lungs.

Laboratory diagnosis is essential, and a local and general eosino-
philia seems quite characteristic, and eosinophils have been noted in
the original chancre, the pus, and circulating blood. The organism
is of very slow growth and can be cultivated on glucose agar, giving
characteristic branching, septate mycelium and pear-shaped spores.
Treatment. — lodid of potash internally and iodid solution ex-
ternally (water, 500 gm.; potassium iodid, 10 gm.; iodin, i gm.), are
advised by Beurmann. The ulcerated areas respond to iodin applica-
tions, and the whole therapy is thus one of iodism, and the drug is to
be given internally for at least a month after all visible lesions disajv
pear. Salvarsan or neosalvarsan may later prove to be an eflScient
form of treatment.

The use of quinine in one per cent, solutions (acidulated by
acetic add) as a wet dressing is also said to act favorably.

INFECTIONS OP THE HANDS

These occur so often that special mention of them will be made,
with particular attention to the diagnosis of the type and focus of
infection as determining the method of treatment.

Causes. — The largest number occur from apparently triAdal abra-
sions or wounds that bleed but little and are wholly disregarded or
reinfected by self-treatment with non-sterile materials. Many of the
cases follow pricks from needles, pins, nails, glass, crockery, splinters,
and other materials that carry infection more or less deeply and just
as effectively as if deliberately inoculated by a hypodermic syringe.
Deeper, longer, and more or less gaping wounds that bleed are far less
likely to cause infection than the preceding, unless they have been
sutured without adequate sterilization or drainage. A considerable
number follow "hang-nail" infection and many are of unknown ori-
gin. Bruising alone without obvious breaking of the skin also is
responsible for another small group of cases.

Certain occupations predispose to rapid and severe infections be-
cause the hands are more or less constantly covered with infected
material. Butchers, hostlers, laborers, and house-wreckers seem es-
pecially prone, and the infections apparently become most virulent
in those whose skin is calloused. The wearing of gloves and employ-

86 TRAUMATIC SURGERY

ments in which grease and oil smears the hands apparently confers a
certain immunity.

Anatomy and Pathology. — ^A rational and simple d^cription of
the probable channels of infection has been given in Kanavel's work
on Infections of the Hands, and his deductions will be very largely
used in what follows. Hoon and Ross^ admirably state their expe-
riences with KanaveFs methods, and their statements are to some ex-
tent herein embodied also.

Given, then, an infection of the hand, pus may give rise to: (i)
Superficial infection or (2) deep infection.

Superficial infection consists of:

(i) Felons, — Infection of the connective- tissue dosed space that
forms the pad of the tip of the front of the fingers.

(2) Paronychia, — Also called "run around;" infection of the sub-
epithelial space at the side or base of the nail.

(3) Subepithelial Abscess, — A purulent collection, usually at a
finger-tip.

(4) Carbuncles, — Usually on the dorsal surface, proceeding from
hair-follicle infection.

(5) Collar-button Abscess, — ^Also called "shirt-stud abscess,"
"frog felon," and "en bouton de chemise," an abscess at the web of
the palm under the dermal and epidermal tissues.

(6) Tlienar and Hypothenar Space Abscess. — Purulent collections
on the outer and inner side of the palm respectively.

Deep infection consists of:

(i) Lymphangitis, — Infection along lymph-channels.

(2) Tenosynovitis. — Infection along the tendon sheaths.

(3) Fascial Space Infection, — There are six well-defined spaces
capable of harboring pus, and these are:

(a) Dorsal Subcutaneous. — ^An extensive area over the extensor
tendons on the back of the hand.

(b) Dorsal Subaponeurotic, — Shaped like a cone with the small
end at the wrist and the broad end at the knuckles, and lying between
the extensor tendon and the metacarpals.

(d) Thenar — On the radial side of the middle metacarpal, lying
deeply in the palm just above the abductor or transversus muscles.

{e) Middle Palmar, — Between the metacarpals and deep flexor
tendons, reaching from the middle metacarpal and overlapped by the

* Annals of Surgery, April, 1913.

WOUNDS AND THEIR COMPLICATIONS 87

ulnar bursa and separated from the thenar space by a firm partition,
«xcept at the proximal end, where a small isthmus leads under the
tendons and ulnar bursa into the forearm.

(/) Web Space. — Subcutaneous, at the web of the palm, with pro-
longation into the lateral margins of the fingers.

S1}PEKE1CIAL XKBECnOSS

(i) Felons, Bone Felons. — These are inflammatory conditions of
the connective-tissue space forming the pad of the front of the
finger-tips.

Kanavel and others have demonstrated that the epiphysis of the
distal phalanx is supplied by a branch of the digital artery before it

Fig. 37. — Felon of finger: 0, Relation of vessels and tendons to bone of last joint;
note blood supply to epiphy^ and diaphysis; b, abscess zone — note line of incision
reaching fatty pad and pus; e, unilateral incision; d, bilateral or finger-split incision
and rubber-band drain.

enters this connective-tissue space, but the diaphysis of the phalanx
receives its blood-supply after the artery enters this space. This
arrangement accounts for the frequent involvement of the bone in
neglected, severe, or improperly treated cases — the so-called cases of
"bone felon," for the swelling within the space shuts off the blood-
supply of the diaphysis and not of the epiphysis, because the artery to
the former only functionates after it enters this crowded space, and
hence necrosis and osteomyehtis frequently occur. (Fig. 37, a).

Causes. — Usually the sources are trivial wounds of the tip of the
finger, especially small punctures from needles, pins, tacks, nails,
glass, splinters, and other more or less pointed objects. Very rarely
a bruise without a break in the skin is responsible. Many patients
are unable to state the source of origin.

88 TRAUMATIC SURGERY

Symptoms. — Throbbing pain in the finger-tip, soon followed by
swelling, redness, tenderness, and loss of function. A more or less
localized cellulitis may also occur. Within forty-eight hours fluctua-
tion is usually present.

Treatment, — Preliminary applications of wet or other dressings
very rarely abort the process, and thus prompt incision and drainage
is the best procedure. A general anesthetic should be given when
possible, preferably nitrous oxid or ether. The incision advised by
Kanavel is efficient, as it amply opens the closed connective-tissue
space and leads to littlp subsequent deformity. This incision is over
the site of greatest localized pain or fluctuation and is always made on
the lateral margin of the digit down to bone. If there is general in-
volvement of the entire finger-tip, an incision is made on both sides.
No squeezing, irrigating, or manipulation should be done. Drainage
should be provided by a fold of rubber tissue or a small rubber band
(stationer's type) or a piece of rubber glove. A hot wet dressing of
boric acid or salt solution is then applied and the part elevated.
This dressing is daily changed, and when granulations begin the drain
is removed and a dressing of gauze is applied soaked in balsam of Peru
and castor oil (lo to 50 per cent.) or gauze smeared with sterile
vaselin. If the bone is denuded of periosteum and loose, it can be
removed, remembering that the diaphysis alone will be affected; in
such an event the finger will be stubby, but the joint will be unim-
paired. Healing is often promoted by the use of a Bier or Klapp
suction cup, and baking is also sometimes useful. Exposure to
sunlight ajid air is perhaps of all measures the most valuable at this
stage of granulation.

Dorrance^ advises an incision at the tip of the finger just in front of
the overhang of the nail, and thence carried straight upward so that
the pad of the finger is practically bisected vertically (Fig. 37). This
appears to be a method most useful in the severer cases only.

(2) Paronychia; "Run-around." — This is an infection in the
neighborhood or bed of the nail.

Causes. — A * 'hang-nail" is the usual source, and many of them fol-
low ill-designed manicuring efforts (Fig. 38).

Symptoms. — Pain at one edge of the nail, soon followed by redness,
swelling, tenderness, and localized abscess. Some remain circum-
scribed and exude a few drops of pus on pressure, but others "run
around'' the base of the nail and give rise to a quite sharp cellulitis.

^ Jour. Amer. Med. Assoc, May lo, 191 3.

WOITTOS AND 'ntETR COMPLirATIONS

Treatmeni. — They are rarely aborted b}' wet or other dressings.
Incision and drainage is generally needed, and an anesthetic {nitrous
_(ixid or ether) should be given.

1. 38. — lofectioD 01 a. distal plialani: a, Cro5s-sr<:lion showing normal structures; h,
location of commnn infections.

—Paronychia incision lines: a, Bilateral forms; h. unilateral forms.
i-Kwiavel advises a lateral incision, passing upward from the base
Q and so placed that the nail may be exposed, but not cut (Fig.
i^ome cases one lateral incision is enough, but usually each

90 TRAUMATIC SURGERY

margin of the nail must be incised and then the skin over the matrix
is rolled back as a flap. The bed of the nail is then raised by scissors
and enough of it cut to allow escape of the pus beneath (Fig. 40). A
folded strip of rubber tissue or a rubber band is inserted and the skin-
flap replaced. The dressing is completed by loosely applying several
layers of gauze soaked in hot saline solution or boric add. Daily
dressings are made, and when the discharge lessens, the rubber drain
is shortened or removed, and then the part is covered by gauze
smeared in vaselin, albolene, or 10 per cent, balsam of Peru in castor

FlO. 40. — a, IncUion for paronychia; h, flaps retracted and a portSon of tn&trix ftbout
to be excised. This procedure is available for ingrowing nails also.

oil or glycerin. Motion of the adjacent joint should be made early to
prevent stiffness. Children and others often develop lesions of this
sort in rapid sequence, and such cases often present deflnite signs of
syHtemic infection, and the general condition then requires much
attention; plenty of fresh air and sunshine, suitable forced diet, and
tonics should be given, and in some instances injections of autogenous
or Htork vaccines are of great value,

(,t) Furuncles, Boils, Carbuncles. — These localized collections ol
pUrt (furuncles and boils) are often seen in the location of hair-follicles
mill hfni'c the dorsal surface of the fingers and hands are generally
involvni. If the process is deeper, multiple, and more severe, then it
In of the nirbunclc type (Fig. 41).

('iiH.tcv, — The infection is ordinarily of the staphylococcus type,
lint il hart Iit'i-n demonstrated that virulent streptococcic cultures may
IiiillU'f iiirbumles when rubbed into the tissues.

Tliv hair-follicles and the sweat-glands alike may be sources of
Iilffi'tion, but a break in the skin is very rarely a demonstrable source
of orif{ii), and hence wounds and bruises and other acute traumata are

WODNDS AND THEIR COMPLICATIONS 91

very rarely causative agents. Constant, repeated, or chronic irrita-
tion is the most likely cause, and in many cases a depleted condition of
the system doubtless plays a part. This, however, is by no means
constant, as "crops" of boils and carbuncles often attack athletes and
others in the best of physical condition.

Symptoms. — Furuncles and boils begin like a pimple and soon get
larger and more painful and develop a white center of pus, a hair-
follicle ordinarily standing in the center of this area of localized necro-
sis. They often are multiple or appear in series more or less close to
each other in point of time.

l\ (I (1

mi f«i (^

Fig. 41. — Usu&l location of pus foci near finger-tip: a, Outside base of nail; b, within
base of nail; c, under body of nail; d, in linger pad.

Carbuncles may be regarded as multiple subcutaneous boils, and
they begin with pain, throbbing, redness, heat, and swelling, and
these signs may last some hours or days before elevation of the skin or
pus points become visible. They sometimes are manifestations of a
diabetic, nephritic, or other systemic condition, especially if recurrent.
The infection ordinarily travels downward in one of the columnar
adiposs and spreads in the subjacent fat and proceeds to undermine
to a variable extent, gradually filling the loose meshes under the skin
until it overflows toward the surface along the various columns, thus
accounting for the numerous pus points seen in the lesion. The
central part of the subcutaneous process becomes necrotic, this con-
stituting the "plug" or "core." The surface of a fully developed car-
buncle is somewhat zonal, the center being necrotic; around this is an
area of punctate, pus-exuding tissue; still beyond is a bluish area of
venous stasis, and the outside rim shows an area of inflammatory
reaction constituting a periphery of induration. Much consti-
tutional weakness with fever and chills often accompanies the condi-
tion, and in the aged or weak the outlook may be quite serious. In
passing, it may be stated that carbuncles of the neck, and particularly

92 TRAUMATIC SURGERY

of the face, are even more dangerous because of septic sinus
thrombosis.

Treatment, — Boils sometimes can be aborted by a hot wet dressing
of saline or boric acid solution. The injection of carbolic and other
solutions into their center is advised by some. To me this seems just
as painful and far less certain than the curative incision. Once the
lesion is established, incision and drainage (rubber wicking or band) is
the best remedy. Hot wet applications of boric or saline solution
complete the dressing. Cupping is often very valuable. Recurrent
cases are sometimes benefited by autogenous or stock vaccines.

Carbuncles cannot be aborted, and early liberal incision with ade-
quate drainage should be made at once. An anesthetic should be
used, nitrous oxid being the best. The incision should be deep and
often crucial, extending beyond the edges of the indurated area far
enough to penetrate to the necrotic base. Any loose plugs of pus
should be removed. Spurting vessels should be tied, but oozing will
be cared for by the dressing. The edges of the four flaps created by
the + -shaped incision should be undermined by scissors and then
elevated, the whole cavity being packed with gauze wet in saline or
boric solution. If there is little oozing the gauze may be smeared in
vaselin or albolene. The cyanosed or necrotic skin should not be
excised until it definitely breaks down, and its vitality will often
prove surprising and gratifying if left alone. Cupping will be of
service. No squeezing should be done. When the sloughs have
separated, healing will be promoted by filling the cavity with pure or
diluted balsam of Peru, vaselin, or albolene. Surface granulations
yrW be encouraged by scarlet red ointment, and grafting will be
needed only in very extensive cases. Exposure to air and sunlight
will be very helpful. The general nutrition must be well watched.

This treatment applies also to carbuncles of the neck and else-
where. In some cases exsection of the entire necrotic area with
subsequent suture may be advisable.

Collar -Button Abscess, Shirt-stud Abscess, Frog Felon. — This is
an abscess located at the web of the finger, and it commonly occurs in
working-men or others who have calloused palms. The nature and
site of the lesion is well indicated in Fig. 55. The peculiar dumb-
bell shape is due to the hypertrophy of the epithelium, which makes
a dense sheet under which the pus spreads, and a subdermal infection
passes through this to the epidermal tissue, where a second abscess
develops, thus giving the collar-button appearance to the pus collec-
tion. The process may be reversed, locating primarily in the epi-

WOUNDS AND THEIR COMPLICATIONS 93

dermis and thence spreading to the dermis ; according to Kanavel, it
is jx)ssible that this latter process is the more common.

It is frequently an occupational occurrence due to constant irrita-
tion of the area, leading to cracks or lowered resistance of the surface.

Symptoms. — Pain, swelling, redness, heat, induration, and fluctua-
tion occur, causing loss of function of the involved portion. Atten-
tion must be directed to areas of involvement on the dorsal surface
also, so that burrowing pus may there be detected promptly.

Treatment. — Incision and driinage at the web and finger junction
should be made early. Ethyl-chlorid spraying affords sufficient anes-
thesia. Drains should be of rubber tissue or rubber bands. The
dressing is of gauze wet in salt or boric solution.

Thenar and Hypotfaenar space Abscesses. — These generally occur
from punctured wounds, and ordinarily the pus readily escapes to the
surface without serious damage. Much swelling of the dorsum of the
hand occurs in some of these cases, and this may lead to incisions im-
proi>erly placed, esp>ecially in the thenar region.

The hypothenar space is a closed area, and infections here are
generally direct implants and tend to remain as localized abscesses.

Treatment is incision and drainage.

DEEP INFECTIONS

Lj^mphangitis. — This is an inflammatory condition of the super-
ficial or deep lymph-channels.

Causes and Symptoms. — Some break in the skin, usually a super-
ficial wound or abrasion, starts the process. Most cases occur in
the fall and winter, and workmen and others with calloused hands
furnish the largest number of cases. The usual infecting agent is the
streptococcus or staphylococcus, but dual infection is very common ;
such a "mixed infection" usually indicates a prolonged attack.

It is important to remember that from any given point the super-
ficial lymphatics take the shortest route to the dorsal surface, hence
very marked signs appear on the posterior aspect, although the focus
lies anteriorly.

The onset is usually prompt, and often within a few hours the
process is well developed, and it is. rarely delayed longer than twelve
hours from the period of infection. Locally, the part is reddened
and swollen and the characteristic red streaks are seen passing up-
ward from the zone of infection to the nearest glands. These streaks
are rarely continuous or numerous, and on the ulnar side (little and
ring finger) they lead to the epi trochlear glands, which are found to be

94 TRAUliATlC SDKGESY

swollen and tender. The lymphatics on the radial side (thui
and index-finger) lead to similarly swollen and tender axillary glani
Infection beginning in the middle finger may lead to either t
epitrochlear or axillary glands. Generally speaking, involvement
the radial side is more likely to be severe because infection is carri
more directly into the main circulation.

The usual signs of systemic infection often occur, such as malai
headache, fever, restlessness, thirst, and sometimes chiUs and a
siderable prostration.

In some cases the origiaating focus cannot be located, but (»i
narily it is apparent as a swollen, red, hot and tender area, and a go
deal of swelling generally is found on the back of the hand, notal
when a finger is the portal of entry.

In the deeper types of involvement the foregoing signs may
exaggerated and the whole extremity may then be intensely swell
and brawny, resembling erysipelas^ this is the so-called "phlegmonc
lymphangitis."

Whatever form is present, it is important to exclude lettosytuni
and abscess of the fascial spaces by noting that the fingers can
moved painlessly, and that pressure along or functionating of
dividual tendons does not cause localized or added pain, and tl
there is no localized bulging, pain, or fluctuation of the main fasc
spaces. Rarely tenosynovitis and fascial space infection m
develop from lymphangitis. Kanavel is of the opinion that fron
to 1 5 per cent, of the cases become localized as abscesses, either of i
tendon sheaths, fascial spaces, or glands.

Infections of the thumb, index, and middle fingers seem m'
likely to be associated with systemic symptoms, because the radiati
lymphatics reach the axilla before meeting any check, and thus I
general circulation is more readily reached than if the process hall
at the elbow, as in infections of the ulnar side which are stayed
the epitrochlear glands.

Deep Lymphangitis. — This is much less common than the p
ceding superficial form. The deep lymphatics follow the course
the brachial artery and its branches as a rule. Many of these ca
are associated with superficial lymphangitis, and they generally i
of severe type, resembling erysipelas. They produce high fever a
profound systemic depression from a generalized toxemia. Loc
ized abscesses are rare, but metastases are common and septic prn
monia is not an infrequent sequel.

Systemic infections of this general type are espedaUy liable to

}

WOXJNDS AND THEIR COMPLICATIONS 95

/ata.1 in those over fotty-five years of age, and in alcoholics, nephritics,
or tie debiUtated. Abscesses are likely to develop in various parts
of the body, the kidneys become sejiojisly embarrassed, and a
"general sepsis" often occurs.

TreatmenL — Early Cases. — Here is it understood that no pus focus
exists, and treatment is indicated for relief of pain, swelling, heat, and
radiating streaks ; this is the non-suppurative variety. If there is an
init.iating focus, as an open wound, this is first suitably sterilized by
swabbing with iodin and then drained by rubber tissue or rubber
bands. It and the area involved are liberally covered by gauze
moistened in a hot saturated solution of boric acid or normal salt
solution, many layers being applied, reaching much beyond the red-
dened area. The entire dressing is covered by paraffined paper,
oiled silk, or rubber tissue, holes being cut so that a syringe may be
inserted and the gauze remoistened without changing the entire
covering. Usually such remoistening is required every four hours*
This same treatment is given cases in which no incision is indicated
or in which no wound of entry exists. Care must be taken not to
cut off circulation by bandaging, especially in the forearm. In.
some cases a 25 or 50 per cent, alcohol dressing seems to act bet-
ter. Carbolic solutions must never be used, and in fact, that drug
should be used in surgery only as a cauterant. Antiseptics of various
kinds, like bichlorid, have no inherent virtues over salt or boric
add. In an odorous wound, tincture of iodin (i dram to i pint of
water), or a good pink solution of permanganate of potash, or i per
cent, creolin will abolish odor.

The part is kept at rest, and for this purpose a broad dorsal or pal-
niar splint is very effective, and elevation of the extremity should be
insisted upon.

Bier^s bandage Sometimes seems of value if used early. It is ap>-
plied by taking turns of a broad rubber bandage from the elbow to
the axilla, making pressure enough to restrict the venous return. It
^ Worn for several hours, and in some cases is kept in place as long
^ righteen hours. It should not be tight enough to cause persistent
(v pam, (2) cyanosis, (3) coldness, (4) tingling, (5) loss of function.
•" any of these are continuous, the pressure is too great and damage
^ result. The constriction must be broad, so that the nerve-
^Pply will remain imdamaged. If beneficial, it can be removed
^d reapplied as occasion demands. A good working rule for
^^g it anywhere is: on six hours, off one hour; off during night or
when patient is away from direct observation.

96 TRAUMATIC SURGERY

Incisions in Later Cases, — Opinions vary as to their value except
in the presence of definite induration, fluctuation, or other evidences
of pus collection. The theory is that a vertical incision in the area
of redness, or one transverse to the lymphatic streak will allow the
escape of serum and tend to direct bacteria to the surface. This is
questionable, and in many instances such a procedure op>ens up new
channels of infection,, and it cannot reach bacteria already at a
distance from a place of known or unknown entrance. Personally,
I never incise unless pus has collected.

Occasionally along the line of the lymphatics (especially on the
back of the hand) may be seen small bean-sized areas of swelling and
tenderness without fluctuation; it is an error to incise these, as usually
a chill and increase of fever follows such interference. If incisions
are to be made, the spread of infection may to some extent be limited
by the use of a Bier bandage before making the incision and allowing
this to remain in place from twelve to eighteen hours.

General' Measures. — Food is of great importance, and these pa-
tients should be fed often, preferably liquids and easily digested
stuffs like milk, soups, broths, eggs, and the like. Feeding every
three hours is a good practice — a little at a time in a very concentrated,
palatable, and inviting form. Rectal feeding must be used when the
stomach is intolerant. Large amounts of water must be provided,
and this can be given rectally by the "Murphy drop method" if
desired.

Fresh air acts well in all forms of sepsis, and these patients do
better if kept out of doors all the time with adequate protection.

Drugs ^ like quinin and strychnin, I believe act well^ they should
be given in capsule or tablet form in doses of 3 grains of quinin and
yio grain of strychnin every four hours. Whisky is often oi
great value, and my habit is to prescribe )'2 ounce every four hours
with the above tablet or capsule. In alcoholics it is an essential,
and then should be used in combination with sodium bromid, 2c
grains, and chloral hydrate, 10 grains, every four hours, until the
patient sleeps or the tremor of the tongue and fingers is controlled.
If not well tolerated, it may be given by rectum.

Serum and vaccine treatment is not of proved value in acute cases,
but appears to be somewhat beneficial in those of long duration.

Summary, — Incisions are inadvisable unless focal evidences ol
pus exist.

Hot moist dressings of boric acid give the best results.

General treatment must not be forgotten, notably fresh airj

WOUNDS AND THEIR COMPLICATIONS

forced feeding, plenty of water, and, in alcoholics especially, some
whisky.

The main diagnostic clues to the location of pus in infections of
the hand are furnished by the following table, bearing in mind that
circumscribed or "point pain" on pressure or motion is the one best
indication as to the maximum site of trouble and this consequently
becomes the main guide as to the place of incision.

Signs

Ulnar bursa

Radial bursa

Mid-palmar

Palmar thenar

Dorsal thenar

space

Wound loca-

Little finger.

Thumb. Along

Middle or ring

Index finger.

Dorsum of

tion.

Along inside

outside of

finger. Along

Along outer

thumb. Dor-

of palm.

palm.

middle of

sum of Radial

palm.

side of hand.

Tenderness on

From tip of

Prom tip

Over centre of

Over centre of On dorsum be-

pressure and

little finger to

thumb to

palm. Reaches

tween ist and

motion loca-

above wrist;

above wrist.

only to below

ad metacar-

tion.

most marked

. Extending

wrist. Ex-

pals. Abduct-

near annular

thumb and

tending mid-

tending index

ing thumb

lig. and on ex-

wrist very

dle and ring

finger very

painful. Pain

tension.

painful.

fingers pain-
ful.

painful.

sometimes
over palmar
thenar region.

Swelling ede-

Near annular

Near wrist.

Centre of palm

Outside of palm

Dorsum be-

ma redness lo-

lig.; redness

Dorsum swoll-

bulges. Dor-

bulges. Dorsum

tween 1st and

cation.

here very sug-

en mainly on

sum much

over index and

ad metacar-

gestive. Dor-

outside.

swollen and

thumb region

pals bulges.

sum swollen.

red.

swollen and
red.

Redness and
edema in same

area.

Incision loca-

Along line of

As in s>reced-

Split web be-

Incise just

tion.

bursa, most

ing.

tween middle

above thumb

above web on

tender place

and ring fin-

web upward

dorsum of

first.

ger to knuckle

toward origin

thum b for

level. split

of thenar

about I inch.

other webs if

height.

parallel to ist

needed.

metacarpal.

Drainage loca-

Rubber tissue

As in preced-

Through inci-

As in preced-

Through inci-

tion.

under annular

ing.

sion after

ing.

sion toward

lig. and to

spreading by

third metacar-

depth of focus.

artery clamps.

pal.

In using the above table, we note that the last five columns list
the fingers separately or together, and that infection of a given finger
is likely to involve a contiguous bursa; thus from a given focus the
probable symptoms and their zonal location can be determined.

Ulnar and radial bursa are often involved together.

Palmar thenar and mid-palmar space are often involved to-
gether.

TSAUMATIC SUSGERY

Fig. 43- — Tendon sheaths o[ palm anJ their usual arrangement, Ihat on the left beinft

WOUNDS AND THEIR COMPLICATIONS 99

Radial bursa and palmar thenar space infection sometimes
hard to differentiate.

(2) Suppurative Tenosynovitis. — The involvement of a tendon
sheath may occur primarily, but is ordinarily an example of pro-
gression from an adjacent focus. It nearly always occurs on the
palmar surface, especially in the sheaths of the distal and middle
phalanges. Many of the cases are of the streptococcic variety and
bone necrosis is apt to be very prompt, and once it occurs the future
functional value of the finger is quite problematic.

Causes, — Many arise from trivial punctures that bleed little if at
all; others are due to open infected wounds that originally invade
the sheath or soon reach it because of contiguity.

Tendon Sheath Infection. — The most important sheaths are on
the flexor surface, thus:

{a) The tendon sheaths for the index-, middle, and ring fingers,
extending from near the middle of the distal phalanx to a line joining
the inner end of the distal palmar crease and the outer end of the
proximal palmar crease, "Kanavel's line" (Figs. 42, 43).

(J) The tendon sheath for the thumb with its prolongation in the
hand via the radial biursa, reaching to the lower end of the radius.

(c) The tendon sheath for the little finger and its prolongation in
^e palm via the ulnar bursa, reaching to the lower end of the ulna.

(d) The interconmiunication of these sheaths.

The six synovial sheaths on the dorsal surface are not surgically
very important, and they are sufficiently well indicated by reference
^o the diagram (Fig. 44).

It has been shown that extension to the forearm of infected mate-

nal from the deeper portions of the hand is from the ulnar or radial

bursa or the midpalmar space, and that pus from either of these foci

Evades the same area of the forearm. This lodgment of pus is under

^e flexor profundus digitorum tendons and muscle. About 3 inches

up on the forearm the pus begins to invade the intermuscular septa,

P^^sing first to the area about the median nerve, and later to the area

abaiat the ulnar artery and nerve, and here it lies between the flexor

^^^T>i ulnaris and the flexor profundus. This is about 4 inches up on

^^ forearm. From here it may pass along the vessels and nerves,

particularly the median nerve, or, more commonly, it may extend

dis tally along the ulnar artery under the flexor carpi ulnaris and ap-

p^T subcutaneously about 3 inches up on the ulnar side. Uncom-

ti^^nly it may extend downward along the radial artery. The larger

portion of the space is about 2 inches above the wrist, and the most

WOUNDS AND THEOt COMPLICATIONS lOI

superficial parts are on either side just volar to the uhia and radius.
The floor of this space is formed by the pronator quadratus at the
wrist and the interosseous septum above. The space may hold H
pint or more of fluid. The only other distinctly separated space is
that comprising the subcutaneous tissue (Fig. 45).

Symptoms. — It is often dificult to differentiate between tenosyno-
vitis, lymphangitis, and fascial space infection, but the cardinal signs
of any tendon sheath invasion are:

1. Fain limited to the course of the sheath.

2. Flexion of the involved flnger, especially at the web.

3. Pain on extension, notably at the palm.

'IG. .46. — Test for tendon infection or division: a, Index flezoi active; b, u

-A well-marked case will exhibit a more or less swollen hand, with
Pwiiaps a dirty wound at a finger-tip, swelling of one border of the
P^^*Ti, and much edema on the dorsal, surface; in other words, the
tencksynovitis may coexist with a fascial space abscess or lymphangi-
"^- Careful examination will probably show that the most exquisite
P***». occurs on pressing along the front of the finger or by attempts
iiia.<3e to straighten or manipulate it (Fig. 46). If the infection
■^ *ielimited, the chances are that it is of the staphylococcic
vaK-5«ty which tends to produce a plastic exudate, thus making the
P''^*<:;ess quite local and gradual in onset. If however the develop-
n^^'Sit is rapid and quite general, the infecting agency is probably
str^ptoco^-fiic, and this is characterized by a purulent exudate of
n^^rked virulency. This sort of infection has a marked tendency to
spread to adjacent spaces, and when it thus bursts from the sheath
0*e cessation of pain may delude the patient and physician much

102 TRAUMATIC SUHGERY

in the same way that a ruptured appendix yntk subsidence of pun
may give a sense of false security and a belief of danger passed.

The possible lanes the infection may traverse in respective fingeis
are given in Fig. 45.

The diagnosis of such extension is often quite difficult, but in the
main depends upon the presence of swelh'ng, localized pain on pres-
sure and motion, and the finding of fluctuation in advanced cases.

Treatment. — This depends upon the stage of the process, the type
of infection, the presence or absence of an original wound, and to some
extent, on the tendon involved.

Fir.. 47. — Tourniquet applied to induce
hyperemia of forearm or hand, after the
method of Bier.

Fig. 48.— Line of inciNon for teno-
synovitis of a finger: a, Dbtal phalanx;
b, medial phalanx; c, proxim&I phalanx.
Note that the incisions do not cross the
patmar creases and are placed laterally.

Any operative procedure should be done with the aid of a general
anesthetic— nitrous oxid, ethyl chlorid, or ether being given the pref-
erence. In most cases it is impossible to make an adequate explora-
tion or incision with local anesthesia, and if the treatment is to be
effective it must be adequate. Small incisions are useless and result
nearly always in added destruction and re-operation, often at a time
when the patient is in poor condition to resist further interference.
It is generally better to operate in a bloodless field, and for that reason
a wide rubber bandage makes a good tourniquet, and it may be al-
lowed to remain in place several hours, to be then gradually loosened,
so that Bier's hyperemia effect is obtained (Fig. 47).

The incbion should be made as soon as tendon involvement is
recognized, as further delay is dangerous and may lead to irreparable
damage.

WOUNDS AND THEIR COUPLICATIONS IO3

The £ist cut is made at the place of known infectiob, and the
tendoa is reached on the lateral and not on the Jront aspect of the

Flc. JO. — The various reservoirs for pus collections in the hand, palmar and dorsal
I'i'iices. The dotted lines indicate the proper incisions. The dotted line between
Mgm shows the through and through incision for web space infection. Note the
tadency toward finger fieiioQ in all forms.

finger (Fig. 48), If necessary a lateral incision can be made on the
opposite side of the phalanx also.

104 TRAUMATIC SURGERY

The sites for incisions to open various tendon sheaths are indi
cated in Figs. 49-52.

Care must be used in making the incision sufiBdently long an.
deep, but if possible it must not cross the creases between the joint
of the fingers, for that would open up the joint to infection and resu!
in much loss of function. When the sheath is opened, pressure abov
it will show whether pus has spread beyond the limits of the indsior

Fig. 51. — Lines of incision to drain pus collec-
tions at web and midpalm, showing "Kanavel's
triangle" of midpalmar space.

and if so, an opening must be provided higher up. The location
these additional incisions is indicated by the diagram.

It is almost never necessary to attack the tendons of the disl
phalanges.

Index-, middle, and ring-finger extension to the lumbrical space (
the outer side may lead to thenar space involvement, and the indsii
that opens the lumbrical space can be extended to the thenar ak
If this is inadequate, the incision may then be continued behind t
web of the thumb to the base of the latter, and then the point of :
artery forceps is thrust across the front of the index metacarpal, t
blades opened, and this then will drain the thenar space without ma
ing an opening in the palm. If the forceps are pushed beyond t
ring-metacarpal bone the middle palmar space will be opened ai
infected.

WOUNDS AND THEIR COMPLICATIONS lO^

If the infection has entered the lumbrical space between the in-
dex- and middle finger the incision should be made into the ulnar side
of the sheath, li the spread involves the back of the hand, an inci-
sion over the dorsum opposite to that on the palmar surface should be
made, and at times it may be necessary to cut right in through the
web.

Proxunal extension demands that the original incision be ex-
tended along a director so that the middle palmar or thenar spaces
may be reached if necessary. This extension of the incision is made
about 3^ inch proximal to the line joining the ends of the distal
palmar creases, an artery forceps being thrust into the space under the
tendon.

LiMe finger extension is treated as in the preceding, except that one
long incision on the inner side of the finger seems better than two of
smaller size.

Extension along the tendon toward the wrist demands incision, as

indicated in the diagram, keeping well toward the inner side of the

palm. When the anterior annular ligament is reached, pressure

above will show if pus has gone into the forearm. If it has, a point on

the palmar surface about i J^ inches above the tip of the ulna styloid

^ chosen, and here an incision down to the bone is made. A closed

artery damp is then thrust through this, across the front of the fore-

^^^ to a corresponding level of the radius, and then the clamp is im-

Pi^ged against the skin and cut down upon. This gives a side-to-side

^P^ning under the tendons, and free drainage will be afforded by en-

^^ging the skin wounds up to about 2 inches in length. Care must

^ Used so that the incision does not invade the radial or ulnar artery.

^s incision adequately opens the upper end of the ulnar bursa, and

"oxxx it drainage can be obtained laterally and even into the lower end

^f th.e space. In some cases, where the bursa is solely involved, the

^^r portion of the incision alone will prove adequate. The operator

n^^ist be on guard in such a case to make the incision deep enough to

Tea.eli the area under the profimdas, as this section between the flexor

P^<>f undas tendons, the interosseous septum, and the pronator quad-

tatus is always first involved when extension occurs upward. If the

l^^ral incisions seem inadequate, it may be necessary to provide

drainage upon the anterior surface, and thus the annular ligament

may have to be cut, and this should be done as far toward the ulnar

side as possible.

In all these cases adequate drainage is afforded by strips of rubber

tissue or pieces of rubber band, or strands of gauze soaked in vaselin.

I06 TRAUMATIC SURGERY

Many cases require no drainage, and under no circumstances should
dry gauze or heavy tubing be used.

Extension further into the forearm is treated by incisions planned
as shown in Fig. 49. Those on either side just above the wrist
(as indicated above) are particularly useful.

The majority of cases require incision more often on the ulnar
than the radial side. Usually an incision between the ulna and the
flexor carpi ulnaris half-way up the forearm is the most satisfactory
if upward spread has occurred, and it may be lengthened to 3 or 4
inches. This incision, together with the lateral cuts just above the
wrist, affords enough drainage for nearly all the cases, and the com-
bination is much more effective than a series of cuts on the 6exor or
radial surfaces. Occasionally a subcutaneous incision just above
the flexor surface of the middle of the wrist may be needed.

If secondary hemorrhage occurs, it is nearly always from the ulnar
artery, and then it is generally best to ligate this vessel promptly if
the bleeding is severe or the patient depleted; otherwise pressure by
gauze may be effective.

Thumb long flexor extension is reached by an incision beginning at
the proximal phalanx, thence reaching through the muscular bellies
of the thenar eminence, and thence upward to within i inch of the
lower border of the anterior annular ligament. Here the incision
stops because the rnotor nerve of the thenar muscles is in very close
proximity.

The upper end of the radial bursa can be drained through the
side-to-side incision above advocated for ulnar bursa involvement.

Necrosis of the tendons may make an anterior incision advisable,
and in this event the line lies }i inch outside the middle of the flexor
surface. If the tendon is whoUy necrotic, time will be saved if it is
removed without waiting for it to spontaneously slough out.

After-treatment. — Irrigation of the part, if necessary, is made
with boric or saline solution, but no strong antiseptics are used.

Drainage, as stated, is by rubber tissue, rubber bands, or vaselin-
soaked gauze. Drains should be removed as soon as possible.

Dressings are of gauze soaked in hot boric or saline solution.
They are used for only a few days as they cause maceration, and dry
gauze is then substituted. If there is odor, permanganate solution
(a good pink color), or iodin (i dram to a pint of water), or i per cent.
creolin may be used.

A dorsal splint well padded keeps the fingers in extension, but at
each dressing the digits are gently flexed to prevent adhesions. If

WOUNDS AND THEIK COMPLICATIONS

107

the tendons at the wrist have been exposed, the hand is so dressed
that it bends backward at a right angle to prevent prolapse of the
tendons and consequent deformity (Fig. 53).

Adhesions are prevented by early passive motion, and this in
many cases should begin at the first dressing and must never be de-

PiG. S3. — Dorsal flexion o( wrist to prevent retraction of Sexor tendons in suf^urative

tenosynovitis.

layed beyond the third day. Motion may begin actively about the
same time, and this is rendered less painful if gently performed with
the hand immersed in hot water. Later, massage, baking, baths,
and exercises may be prescribed. Bier's suction cups and Klapp's
apparatus are also of value.

Ftc. 54. — Fascial spaces oi palm and lines of

(in black), to expose pus therein

FASCIAL SPACE HIFECTIONS

These may occur primarily or in association with tenosynovitis
(Figs. 54, 55).

Treatment is at first by wet dressings of saline or boric solution,
in the hope that pus formation may be prevented or hmited. If

io8

TRAUMATIC SITRCERY

however an abscess has formed, indsion and drainage must 1
instituted.

Middle palmar space abscesses are preferably reached by an ii
sion along the little, ring, or middle finger lumbrical canals whict»-
lead to this space. The choice of the canal of entrance will depemK.
on which area shows the maximum involvement, but ususally as.
opening in the space between the ring and middle finger gives besfz
drainage. The diagram shows best the sit&
of the incision. Roughly speaking, the in-
cision is prolonged a thumb's breadth and a
half up into the palm; then an artery clamp
is pushed under the palmar tendons, the
blades are opened, and the pus escapes.
Drainage is maintained by rubber tissue or
bands or by gauze soaked in vaselin.

If in addition the thenar space is involved,
then the forceps are introduced as above,
and pushed through the thin wall betweea
the palmar and thenar spaces at the proximal
end, the point coming out on the back of the
hand between the thumb and index meta-
carpals. Through-and-through drainage
then is inserted.
If the middle palmar and subaponeurotic spaces are involved to-
gether, then the pus lies always over the interosseous space between
the ring and middle fingers. Hence the incision is in this space, the
cut being through the palmar aponeurosis where the middle palmar
crease crosses the space, and through this the point of the forecps is
thrust to the dorsum and rubber drainage inserted. By thb pro-
cedure the vessels of the palmar arch and the ulnar bursa escape.
Thenar space abscess requires early drainage, and this is easily
provided by an incision on the dorsum to the radial side of the middle
of the index metacarpal, and through this a forceps is passed to the
palm and a rubber drain inserted, so that it lies across the flexor
surface of the index metacarpal. This incision does away with any
palmar opening and subsequent scar thereon.

DORSAL SUBAPONEUROTIC SPACE ABSCESSES

The incision is on the dorsum in the intermetacarpal spaces,
inasmuch as the tendons overlie the metacarpals except in the little
finger. If the infection has spread upward under the annular liga-

Fic. SS- — "ColUr-button"
or we]>-space abscess.

WOUNDS AND THEIR COMPLICATIONS IO9

•

ment, the pus then will lie upon the pronator quadratus and under
the flexor profundus tendons, and the attack then is best made by
lateral incisions about 2 inches above the respective styloids, as
already indicated.

HTPOTHENAR SPACE ABSCESSES

These are always localized and well walled off, and can be reached
by simple incision over the maximum site of pain or fluctuatioti.

After-treatment in these fascial space abscesses resembles that of
the other infections.

Hot saline or boric dressings are used for a few days, and drainage
is removed as soon as possible. Wet dressings macerate the parts
and cannot be satisfactorily employed after three or four days, and
then oiled or dry gauze is substituted. The part is kept at rest until
pain and spread of infection disappears, and then passive motion
should begin, ordinarily some motion should be performed on the
third or fourth day.

CHAPTER II

CONTUSIONS

A contusion or bruise is the subcutaneous rupture of small
blood-vessels due to direct or indirect violence. Blows and falls are
the common producing causes, and the richer and more superficial
the blood supply, the earlier the external manifestations.

Symptoms. — Pain, swelling and, discoloration are common to all,
and these vary depending upon the source and site of the injury, and
to some extent upon individual susceptibility as some persons have
"softer skins" than others.

Pain occurs at once, and is due to injury to the nerve-endings
and later to pressure irom effusion. At first the pain may be numb-
ing or cause tingling or pressure sensations, or it may become very
acute at once. Later the bruised part may throb, pulsate, tingle,
or evince more or less "dull pain." Some tissues when bruised
cause more pain than others, the testicle, finger-tip, and knee mar-
gins being exceedingly sensitive. The more circumscribed the im-
pact, the greater the pain, as a rule.

Swelling appears within a very short time, due to effusion of
blood or lymph and the interference with circulation. The extent
of swelling is dependent upon the source and site of the contusion
and to a certain degree also upon treatment. Superficial bruises
cause instant swelling; deeper bruises may show no such sign for
several hours, especially after indirect or transmitted violence.

Discoloration is due to hemorrhage and effusion, and in amount
depends upon the source and site of the contusion, and to some degree
also upon personal tissue resistance. The site, depth, and extent of
the effusion determines its color, and the nearer the surface, the
eariler and more red will it appear. Deeper hemorrhages are likely
to cause bluish or black mottlings. The discoloration may be cir-
cumscribed or diffused and it may follow muscle or fascial planes or
broadly trickle over wide areas.

If circumscribed and more or less encapsulated, it is known as a
hematoma^ and this may vary as between a "blood blister" due to a
pinched finger and a huge "bump on the head" from a severe blow.

Diffused discoloration is called ecchymosis or suggillation, and is
characterized by mottling of relatively large areas.

CONTUSIONS III

The earlier the appearance of discoloration, the more superficial
tie bruising; but the extent is no adequate gauge of the size of the
ruptured blood-vessels nor of the amount of escaped blood, for a
tiny ruptured vessel in one area may cause more discoloration than
a large ruptured vessel in another more compact region. The typical
eiample of ecchymosis is a "black eye;" and the commonest site
of a hematoma is the scalp. If the discoloration of a part is due to
congestion (intravascular in distribution) it will temporarily dis-
appear on pressure; if due to ecchymosis (extravascular in distribu-
tioa) it will not disappear on pressure.

After a time the color tone of discoloration fades from black or
deep blue to violet, to yellow, and then to normal, and in some
regions this fading process may extend over many weeks or even
months.

Hematomata usually spontaneously subside and less often be-
come infected and end as abscesses. Occasionally they undergo
cjrstic or fibroid changes, and when the latter occurs they may
simulate certain types of new growth; still more rarely they may re-
i>ult in myositis ossificans, 2l tumorous formation containing bone.
(See p. 498.)

Treatment. — This may be summed up by the terms rest, pres-
sure, lotionsy and massage.

Rest is provided by keeping the part quiet in an easy position,
supported if necessary by a dressing wet in the chosen lotion and
perhaps held also by a bandage or small splint.

Pressure is most useful in hematoma formation, and this is best
provided by compresses, bandaging, or adhesive strapping.

Lotions should be cold, and compresses of ice-water are as good
^ any; alcohol or lead and opium and a host of others may also be
used. Some persons prefer hot applications, but in the early stages
cold is more valuable. An ice-bag is often an excellent aid.

Massage is advisable for pain and it also dissipates ecchymosis
^d promotes circulation.

Hematoma formation usually subsides imder continuous pressure,
^d too early aspiration or incision often converts a simple into
^ complicated affair, and I have seen several cases where meddlesome
^^d unaseptic interference has done permanent damage. Caution
^ especially necessary in dealing with hematomata near joints and
along the shin; but wherever they may be, no aspirating or incision
should be made without strict attention to surgical cleanliness.
The most dependent part of the hematoma is to be attacked under

113 TRAUMATIC SUSGESY

these operative necessities, and the aspirating needle or small knife
enters at the junction between the swelling and the sound skin
and not at the summit of the swelling. If the contents can be wholly
removed it is needless and harmful to inject irritants into the hema-
toma zone, for as a rule any sac requiring irritating injections will
sooner or later demand complete ezsection. If an organized clot
or cyst forms, obviously the treatment is modlhed to include full
dissection.

Finger nail bruises with hematoma formation (subungual bena-
toraa) are usually very painful, and numbers of them subsequently
lead to infection, and for that reason in severe forms early incisioo
through the base of the nail is an appropriate form of treatmait, as
the nail will be ultimately cast off as a rule. The involved part of the
nail may also be trephined instead of incised, so that the "conj
blood may escape (Fig. 56, b).

Contusions of special regions are elsewhere considered.

CHAPTER III

SHOCK

TfflS is a temporary depression or collapse of the vital forces due
to p)sychical or physical trauma, and in which alteration of blood-
pre^ssure is a cardinal feature due to vasomotor inhibition or
exl^austion.

Causes. — The term "collapse" is sometimes used for cases due to
non-surgical causes; and the terms "surgical shock," "ordinary
shock," and "psychic shock" are also used by others with the same
etiologic distinction in view.

It is maintained by some that shock is due to inhibition of the

vasomotor centers, and collapse ensues upon exhaustion of them;

hence the former occurs immediately and the latter gradually.

To some extent every sort of psychical or physical violence is.

attended by shock, but that inflicted by injuries to the abdominal and

cranial cavity is usually of a more severe grade than when elsewhere

iJ^posed. Crushes of limbs are also frequently associated with high

grades of shock, as is any injury accompanied by marked hemorrhage.

Every serious injury, however, is not necessarily attended by severe

^Wk, as it is a matter of common experience that some very trivial

physical injuries are accompanied by much psychical shock.

During excitement, as in anger, battle, work, or play, shock may
be very slight, owing to mental pre-occupation, even though the in-
jury is essentially of very severe physical type.

Occasionally shock does not appear after an accident until the
patient becomes conscious of an injury by the comment of an on-
looker, the trickling of blood, or the sight of a wound.

Any injury capable of blocking or crushing the peripheral nerves
or trunks is less likely to produce shock than if the nerve-supply is
suddenly subjected to other forms of damage. Crile has shown that
shock can be almost entirely abolished if the nerves are injected or
blocked prior to traumatizing a part.

The vasomotor tone or pressure of the blood-vessels is maintained
by a complex nervous mechanism determining their dilatation (vaso-
dilators) and contraction (vasocontrators), and it is known that one
determining element of shock is a lowering of blood-pressure and a
8 113

114 TRAUMATIC SURGERY

consequent deficient blood-supply to the parts aflfected. For this
reason, injury to the abdominal, thoracic, and cerebral cavities is
likely to be shock productive because of their highly organized and
intimate relationship to the vasomotor nervous mechanism.

From a practical standpoint surgical shock often indicates hemor-
rhage even though it may not be manifest externally.

The exact process by which shock is caused is a matter of con-
siderable controversy; this discussion however is of more acadenuc
than practical interest in traumatic surgery.

Symptoms. — Obviously, there are all grades, and these are usually
spoken of as mild, moderate, and severe, the particular type being deter-
mined by the extent and duration of the respective manifestations.

We speak also of primary or immediate; and secondary, late, or delay-
ed shock.

A typical case presents rather a characteristic api>earance, in that
the patient immediately after the accident is unconscious or nearly so,
the surface of the body is pale, cold, and sweaty; the expression is anx-
ious, the eyes are shut or widely open; the pupils are dull, usually di-
lated, and slowly responsive; respiration is shallow and feeble and
often intermittently sighing; the pulse is weak, compressible, and often
irregular, and may be slow or rapid; if arousable, mental confusion or
torpidity is the rule; sometimes the sphincters are relaxed and
nausea and vomiting may occur; the temperature is subnormal or
slightly elevated at first. After some minutes, or later, these patients
gradually become aroused, their color returns, the mind clears, the
pulse and respiration strengthen, and they recover.

Other much more severe grades may remain in a state of mental
and physical depression or mental torpor for many hours and even die
in deepening coma from shock alone, although death from this source
independently is quite rare and should not be accepted as a sole cause
in the absence of an autopsy.

In some instances a condition of apathy is replaced by one of
irregular activity of a somewhat delirious type, this occurring,
especially with head injuries and in alcoholics; this is the so-called
erethistic as distinguished from the apathetic or ordinary form, and
it is very closely allied to traumatic delirium.

Thus, all varieties are met with, from that of the mild grade, show-
ing pallor, giddiness, yawning, nausea, and fainting, to that of a
9noderaie grade, with the preceding accentuated together with cardio-
respiratory changes and mental apathy, and thus on to a severe grade^
with actual abeyance of vital functions.

SHOCK

IIS

Local shock ocoirs notably from bullet wounds in which the part
in. jiired becomes paralyzed as to motion and sensation, and may so re-
im.SLin for many hours or even days; it is a very rare form in civil

prsLctice.

Secondary or late shock generally is an indication of bleeding or
sep>sis, and usually appears within the first forty-eight hours after an
accident which perhaps up to that time had been unattended with
serious symptoms. Sometimes it is a postoperative manifestation
from the anesthetic, or operative trauma causing extension of in-
fection or bleeding.

YiG. 57. — Hot-water bags or bottles applied for shock. Note protection of the skin

by pads and elevation of the foot of the bed.

Shock and hemorrhage often coexist, especially in that claiss of ac-
cident to which the diagnosis "internal injuries" (or "concealed hem-
onhage") is given. This notably occurs in abdominal and cerebral
injuries, and the differentiation is often very difficult and always in-
portant, as the treatment depends much on whether the case is one of
shock solely from hemorrhage or shock from physical and psychic
causes with hemorrhage also. These patients are usually in a marked
state of shock when first seen, and the abdominal cases frequently are
tympanitic, tender, and show marked localized or general tenderness
or rigidity, and the diagnosis of intra-abdominal hemorrhage and
probable torn viscus is entertained.

In many instances it is injudicious to operate even if the indi-
cations were clearer, and accordingly, the shock alone is treated and
the patient watched. If improvement is reasonably prompt, and es-

ii6

TRAUMATIC SDKGEEV

pedally if the onset directly followed the accident, the condition i.s
probably shock in the main; if, however, the reverse pertains, aD«r
if the blood-picture is one of acute anemia with a low hemogloH:^
percentage or a high white cell count (leukocytosis) and a progressiv"^
onset of symptoms, then the element of bleeding must be give»=:
greater consideration.

Shock patients get better, while bleeding patients ojten get worse durin,^
treatment and lapse oj time.

Fig. 58. — Subpectoral infusion of normal saline, glue
for shock, hemorrhage, acidemia, anuria

Treatment. — The associated injuries are given adequate but not
too prolonged treatment, and every effort is made to handle exposed
or damaged parts with all due gentleness, and if much time will be
necessary for temporary repairs, it may be wisest to use an anesthetic.
Theoretically, anesthesia may induce shock, but practically the
reverse is true, and many times I have had the patient's pulse and
general condition improve when fully narcotized. Obviously, no
postponable operative work should be undertaken until shock is
passed. A hypodermic of morphin to a conscious patient is a prime

' SHOCK 117

requisite. The foot of the bed is raised and hot applications are

applied to the protected surface of the body (Fig. 57). Adrenalin is

one of the best cardiac stimulants for subcutaneous use. An ampoule

o/pituitrin, or of camphor in oil will be helpful. Camphor and ether

act promptly. Salt solution by rectum, with or without adrenalin,

is another of the most efficient means at hand. It may be used by

lie so-called "drop method" of Murphy, in which 30 or more drops

per xninute are allowed to enter the rectum by a small tube, and this

is continued until the volume of the pulse is satisfactory. Plain

Wt^x- seems to act just as well as normal salt solution. The "gum-

t^x«. 59. — opening vein at bend of elbow (or infusion: a. Vein exposed; b, cat^t
'°°P {iMSKd under vein; c, dbul end of vein ligated; d, infusion needle introduced and
»w>«a.t to be fastened by catgut ligature.

****»e solution" used for a time in the war zone gave me very unsatis-
factory results. Another and more usual method is to slowly intro-
''"Ce into the rectum 6 to 8 ounces of saline or plain water with 2 or
"**~« ounces of whisky, this to be repeated in one-half hour or less, if
''^^'Jed. Saline solution may also be introduced under the skin by a
"^^^Jle piercing the outer side of the upper thigh or the mammary
™Sldn (hypodermoclysis— Fig. 58). In very severe cases a vein
*t the elbow is opened and salt solution administered intravenously
(.saline infusion — Fig. 59) . Comatose patients will absorb and
benefit from adrenalin in a watery or saline solution (i : 100) dropped
every few seconds on the base of the tongue. Transfusion is very
larely applicable, but when feasible the blood can be most readily
introduced as in an infusion, using 50 c.c.of a 2 py cent, solution
oi sodium citrate to each 500 c.c. of donor's blood; this is the so-
called "dtrated blood" method. The citrate and the blood admix-

Il8 TRAUMATIC SURGERY

ture can be kept several days without deterioration. Pituitrin,
I ex. hypodennically, acts well in many instances.

Mild cases get well by simply using rest and elevation, hot applica-
tions, and small doses of aromatic spirits of ammonia or whisky.

Prognosis.— Ordinary cases recover withm a few days, and the
outlook is then gauged by that of the associated injuries.

Severe cases take a longer time, and if hemorrhage is coincident,
the resulting anemia may be quite depleting. Fatal cases are gener-
ally associated with severe injuries, and death is xisuaUy due to a
combination of causes rather than to shock alone.

CHAPTER IV

INJURIES OF THE JOINTS

WOUNDS

They are mainly due to penetration of the joint by cutting instru-
ments, missiles, sharp fragments, bullets, compound fractures, and
infected contusions.

Symptoms. — The signs depend upon the manner and the site of
the injury and the presence or absence of infection.

In non-infected wounds, the signs of penetration are mainly based
on the escape of glairy synovial fluid, with evidences of synovitis or
joint inflammation, together with such contusion remnants as diffused
or localized discoloration.

In infected wounds, the above signs exist, plus the redness, swell-
ing, heat, localized pain, and disturbed function so universally
indicative of inflammation or cellulitis. An initial chill may denote
the onset of the trouble, and elevation of pulse and temperature are
always present. Later signs are those of a purulent synovitis with
the escape of pus from the site of joint entry, and by this time
constitutional signs of a more or less septic type are well advanced.

The Blood-Supply in and Around The Joints^

The accompanying series of skiagrams (Figs. 6o-6q), showing the
blood-supply in and around many of the important joints, were made
in the x-Ray Department of the late Dr. John B. Murphy ^s Clinic at
Mercy Hospital, Chicago, by Dr. George W. Hochrein. These
skiagrams aid in the accurate determination of the blood-supply and
its relations to the various joints, and are a great aid in determining
the position of the flap pedicle used in arthroplasties. The whole
series comprises a unique and valuable collection in applied anatomy,
and was used at the clinics of Dr. Murphy in his work on the bones
and joints.

* The illustrations with descriptive legends were taken from "Surgical Clinics of Dr.
John B. Murphy," Volume II, No, 4, August, 1913.

119

Fic. 60. — The blood -supply ia and around Ihe left Hhoulder-joint.
artery (A. subclavia); Thyroid axis (mvncus thyreocervicalis). Not visible; 3, super-
ficial cervical artery {A. ccrwcalis auperficialis); 4, suprascapular artery (A. transvcna
KBpulie); a, transverse cen-ical artery (A. transversa colli), j. Axillary artery (A.
arillaris): 14, Acromiothoracic artery (A. thoracc^acroniialis); 7, long thoracic artery
(A. thoracalis lateraliB); S, subscapular artery -(A. subscapukris); g, doiaalis scauulie
artery (A. circumflcxa scapulie}; 10, antetic)r circumflex artery (A. circumflexa humeri
anterior); 11, posterior circumflex artery (A. circumfleiia humeri posterior), u,
Brachial artery (A. brachialis): 13, Superior profunda artery (A. profunda brachii).
The dark area over the chest wall was caused by an eiitra\'asalion of injection fluid
under cover of the pcctoralis major, from pectoral branches of the acromiolhoradc
artery. 6, Anastomosis on the dorsum of the scapuU. The anastomoses about the
acromion and about the surgical neck of the humerus can be dearly distinguished.
(Surgical Clinics of John B. Murphy.)

— . — The blood-supply in and arngnd Ihe Hyht dliQiv joint (lateral view), i,
BBcliii] artery (A. brachialis): i, Superior profunda arlery (A, profunda brachil); 3,
"""ior profunda artery (A. coUatcrdis ulnaris superior); 4, anastomotica magna artery
(-!■ coHitcralia ulnaris inferior), s. Radial artery (A. radialis): 6, Radial recurrent
*''")' lA. Tccurrens radialis). 7, Ulnar artery (A. ulnaris): 8, Anterior and posterior
"''* wurrent arteries (A. recurrentes ulnares), by common origin — common inter-
**'Nu artery (A. inlerossea communis); 9, anterior interosseous artery (A. i

I Whrts); to, posterior interosseous artery (A. interossea dorsalis);

■ODoit artery (A. interossea recutrens). (Surgical Clinics of John li. Murphy.)

r ,122

%tAiniATIC SURGERY

1
1

1 L^i

1 Fig. 6j.— The blood-aupply in and around iht right Elbow-joint (doreo
I I, Brachial artery (A. brachialis)! a, Superior profunda artery (A. profunda
1 inferior profunda artery (A. collateralis ulnaris superior); 4, anastomotica n
1 (A. coUateralU ulnaria inferior). 5, Radial artery (A. radialis): 6, Rati
1 artery (A. reeurrens radialis). 7, Ulnar arler>- (A. ulnaris): 8, Anterior a

1 osseous artery (A. inlerossea communis); 9, anterior interosseous artery (/
B volttris); 10, posterior interosseous artery (A. inlerossea dorsalis); interoaseo
^^^^ artery (A. interosaea reeurrens). (Surgical Climes of John B. Murphy.)

vcdarvi
brachi
agnaai

a! recui
odpost

L inten

INJURIES OF THE JOINTS

— The bluod-suppty in and around the righL foieami (lBt<
Y (A. ulnaris): i, .Vnterior interusseous artery (A. interossea volaris); 3,
[:Brpal aclery (ramus carpeus volaris) ; 4, posterior ulnar caqial artery
(""M carpeuB docBalis) : 5. deep palmar ariery (ramus volaris profundus). 6. Radial
•""y (A. radialis) : 7, Superficial \olar artery (ramus volarisi siiperficialis) ; 8, postreior
ndiiluipal utery (ramus carpeus dorsalis). (Surgical Clinics of John B. MiirphyO

TRAUMATIC SURGERY

Fig. 64. — The blood-supply in and oround llu' i< ' ' ' .1 ' imikL 1, Llnar

artery (A. ulnaris); a, Anierior interosseous atlety (A. inicrossca vniarisJi 3, posterior
interosseous artery (A. inlerossea dorsalis); 4, posterior ulnar carpal artery (ramus car<
peus dorsalis); 5, deep palmar artery (ramus volaris profundtts); 6, superficial palmar
arch (tircus volaris superlicialis). ;, Radial artery (A. radiaiis): S, Anterior radial
carpal artery (ramus carpeua volaris); g, superficial volar artery (ramus bolaris super-
fidnlis); 10, posterior radial carpal artery (ramus car|'"s dorsalis); it, \-orsalis pollicis
artery (ramus dorsalis pollicis); 17, dorsaLis indicis artery (ramus dorsalis indicis); 13,
first volar itielacarpol artery (A. metacarpea volaris I), dividing into the princeps
pollicis arlery (A, princeps pntlicis) and the radiaiis indicis artery (A. volaris indicis
radiaiis); 14, deep palmar arch (Areus volaris profundus). (Surgical Clinics o£ John
B. Murphy.)

FtC 65. — The i)kiod -supply in ;vnd around inc Itit hip-joinl. i, Spermalic artery
spctntalka intcroa); i, common iliac artery (A. iliaca communis). 3, Internal iliac
ry (A., hypogaslrica): j, Iliolumbar artery (A. iliolumbalis); 6, gluteal artery (A.
superior); 7. obturator artery (A. obturatoria); 8, sciatic artery (A. glutora in-
t); g, internal pudic artery (A. pudenda iuteraa). 4, Extcmal iliac artery (A. iliaca
10, Femoral artery (A. femoralis): i(. Deep femoral arlcty (A. profunda
.1. external circumflei artery {A. circumflexa femoris lateralis); 13. internal
artery (A. circumflesa femoris inedialia); 14, first perforating artery {A. per-
toians prima). (Surgical Clinics of John B, Murphy.)

MATIC SURGERY

Fio. 66. — The blood :.u)jpl) lu .iiid jtound the right kDee-joint ( an leropos tenor
.view}. 2, Anastomolicu magna aitciy (A. genu supremaj, from deep femoral, i,
Popliteal artery (A. poplitea): 3, External superior articular artery (A. genu superior
lateralis); 4, inlernal superior arlicula.r artery (A. genu superior medialis); s.ajygos
articular artery (A. genu media); G, external inferior articular artery (A. genu inferior
lateralis); 7, internal inferior articular artery (A. genu inferior medialis); 8, sural arteries
{Aa. surales). 9, Posterior tibial artery (.\. tibialia posterior). 10, Anterior tibial
artery {A, tibialis anterior): 11, Posterior tibia] recurrent artery (A. recurrens tibialis
posterioi); xi, anterior tibial recurrent artery {A. recurrens tibialis anterior). (Surgical
Clinics of John B. Murphy.)

Fio. 67. — The blood-supply in and around Ihe tight knce-joim (lateral view). 2,
Aoftstomoticn magna artery (A. genu suprccnu), from deep fetiiorat. 1, Popliteal
artery (A. poplitea): 3, Estemal superior articular artery (A. genu superior lateraiis);
4, internal superior articular artery (A. genu superior mediulis); 6, external inferior
articuUr artery (A. genu inferior lateralis); 7, internal inferior articular artery (A. genu
in/nior medialis); S, sural arteries (Aa. surales). 9, Posterior tibial artery (A. tibialis
pnsterior), 10, Anterior tibial artery (A, tibialis anterior): ir. Posterior tibial recur-
rent arteiy (A. rccurrens tibialis posterior); n, anterior tibial recurrent artery (A,
remirens tibialis anterior). (Surgical Climes of John B. Murphy.)

Fic. 68.^The blootl-supply in and around Ihe right ankle-joint, i, Posteriot
tibial artery (A. tibialis jxislerior): a, Peroneal artery (A. peron^jj, comraunicating
artery (ramus communicans) ; 4, anterior peroneal artery {ramus perforana); 5, pos-
terior peroneal artery (A. malleolaris posterior lateralis); 6, communicating artery,
jmning termination of peroneal artery and posterior tibial artery. 7, External plantar
artery (A. plantaris lateralis); S, internal plantar artery (A. plantaris medialia); 10,
anterior tibial artery (A. tibialis anterior). 13, Dorsatis pedis artery (A. dorsalia pedis):
II, External tarsal artery (A. tardea lateralis). (Surgical Clinics of John B. Murpby.)

INJURIES OF THE JOINTS

Fig. 69. — The blood-supply in and around ihe liphi lout. 1, fusierior tibial artery

(A. libialis posterior); 2, Peroneal artery (A. peroniea); 3, communicaling artery (R.

conunun icons), connecting posterior tibial and peroneal arteries; 4, anterior peroneal

&rlco* (K. pcHorans); j, posterior peroneal artery (A. malleolaris posterior lateralis);

6, inlerrial malleolar artery (A. malleolaris posterior medialis); 7, internal calcaneal

I arteries (rami calcanci medialis). S, External plantar artery (A. plaittaris lateralis):

I 9, Calcaneal arteries (rami calcanei); 10, plantar arch, giving off the plantar interosseous

, arteries (Aa. metatarses; plan tares). 11, Internal plantar artery (A. plan taris medialis),

dividing into two branches at the anterior border o( the calcaneus, iz, Anterior tibial

artery (A. libialis onlerior); 13, Internal malleolar artery (A. nialleobria anterior

medialis); 14, eitemal malleolar artery (A. malleolaris anterior lateralis). 15, Dotsalis

pedis artery (.\. dorealis pedis): 16, Exlemul tarsal ortcrj- {\. tarsca lateralis); 17,

dorsal aoaatomoius (rele dotsalis pedis); 18, metatarsal artery (A. arcuata). (Surgical

Clinics of John B. Klurphy.)

130

TRAUMATIC SURGEKY

Treatment.^ — In the non-infective recent variety the essentials
are: (i) Disinfection by liberally applying tincture of iodin to the
area of and about the wound; (2) application of a dry sterile dressing

Fig. 70. — Adhesive strapping and weight extension for traction on leg, knee, or lower
thigh.

of gauze and cotton and bandages, (3) placing the part at rest by a
splint with the joint in such a position that (a) drainage is most
efficient, (6) the joint is immobilized in the best posture in the event
of later inflammation or fixation. The knee-joinl is most commonly
affected, and the limb should be put in
the position of extension and held thus by
traction (Fig. 70). In the elbow ^nd ankle
the position (or splintage should be at a
right angle.

In the infeclive variety the preliminary
liberal use of iodin is made, and drainage

Fig. 71. — Through-and-
thniugh rubber tubing drainage Fig.
of the Lnee-joint.

—Unilateral rubber tubing drainage of the
knee-joint.

should be early provided In the presence of signs of sepsis. If
possible this should be through the original wound ii it be in
a dependent position; otherwise the joint should be wisely opened
at a ate where the discharge can be most effectively released
(Figs. 71, 72), Any procedure of this sort must be undertaken

_ J

IN7USIES OF THE JOINTS

131

under the most aseptic precaution, preferably during full anesthesia.
Vertical incisions are made lateral to the joint and are placed to per-
mit through-and-through irrigation by hot saline, or iodin water, as
the extent of the infection may suggest. Irrigation is unwise unless
there is a free vent. No fingering within the joint should be made
unless absolutely indicated. Fene-
strated rubber tubing or folded gutta-
percha makes the best drainage;
whatever is used, two such drains
act better than one (Fig. 73). A
plentiful moist gauze dressing (saline
or iodin water), with cotton and
oiled silk and hose bandaging is then
applied, a splint serving to keep the
parts at rest.

Under no circumstances should
• a doubtful wound about a joint be
probed, stitched tightly, or sealed by
any form of occlusive dressing.

The dressings should be changed
at the end of twenty-four hours, or
earlier if the local or systemic signs
warrant. If then, drainage seems
inefficient, a long closed artery clamp
is to be thrust through the drainage
opening and withdrawn with the
blades opened. Such a procedure
may result in the escape of pent-up
pus, and this pocket must then be
cared for by a special drain of the
rubber tubing or guttapercha tissue
type named If despite this, further
invasion proceeds, additional incis-
ions must be made wherever de-
manded in order to forestall the loss of Umb or life. If following these
numerous vertical incisions, the septic process threatens to extend, then
the joint must be freed by transverse incisions, exposing the interior to
inspection so that the limb can be bent as if on a hinge (Fig. 74).
All infected fod are then in sight and pockets of pus and sloughs re-
moved. The joint thus opened is then loosely packed with gauze
tapes wrung out of saline, iodin, or permanganate (i : 2000) solution.

Fig. 73, — Sites tor joint drainage
by the through-and-through intro-
duction of rubber tubing.

132

TRADMATIC SURGERY

and the whole enveloped in a huge wet dressing with the joint hinged
widely apart and held in that position by a suitable support.

This type of treatment is most applicable in the knee-joint,
which is exposed by severing the patella tendon as well as other soft
parts. If the joint thus exposed shows areas of osteomyelitis or
extensive cartilage involvement, then the propriety of disarticula-
tion or amputation must be entertained. The wisdom of these last
operations depends mainly upon the type of infection and the systemic
state of the patient. If the in-
fection is of the streptococcus or
some equally rapid and virulent
type, further delay is hazardous.
even though the systemic condition
appears favorable. If the reverse
pertains, then further attempts to
save the limb may be made. Many
of these cases do better with early
resection or amputation than with
ess active treatment necessitating
prolonged attention that may end
with persistent sinuses and a joint
so distorted as to be practically
useless. In the knee-joint espe-
cially, early opening of the joint
by a transverse incision across the patella tendon and the lateral
ligaments often stops the progress of an infection that otherwise
would demand amputation of the thigh.

Unfortunately any bisecting incision leaves an almost useless joint.
The exposure gained by vertically splitting the patella (Jones's
operation) gives an adequate exposure and is not nearly so disabling.
Active Mobilization Without Drainage.^ War experience has shown
that adequate incision, free irrigation of the joint, no drainage and
immediate active movement of it bring about better results than the
foregoing type of treatment. Willems of Belgium has been the
principal advocate of this procedure and his plan is to drain the joint
by making it perform the accustomed functions of flexion and
extension so that at each act of motion the pus will be actually
squirted out of the joint interior through properly placed drainage
orifices. He also advocates repeated aspiration of certain infected
joints as a preliminary to unilateral or bilateral incisions. After
each aspiration, ether is injected in a quantity equal to one-third

Fig. 74. — Drainage of knee-joint
hypertleiion (Mayo's method).

INJURIES OF THE JOINTS 1 33

the amount of fluid extracted. I have seen this method employed
many times in the war zone and have used it with the wounded
myself and can certify that it is a method worthy of application in
dvil life. The British military surgeons modified the procedure to
the extent of less strenuously moving the recently aspirated or
irrigated joint, but still applied the principle of no drainage realizing
that the drain very rarely performed the intended function, that it
acted as a foreign body, that it often brought in as much infection as
it brought out. This modified activation caused the patient each
day to bend the joint (placed on a piUow) a little higher until, in
the case of the knee, a right angled position was reached. Then this
angle was daily decreased until full extension had been attained.
After ten days of this treatment, very active, unsupported use of
the joint was enforced. Willems insists on motion from the outset,
even applying a loose dressing so that the patient is unrestrained
when coming out of the anesthetic. In knee cases he makes the
patient walk without any dressings and under this form of treatment
I have seen the pus ejected at every step; the parallel is suggested of
purulent pleurisy in which inspiration and expiration imitate exten-
sion and flexion. Certainly the chances of pocketing are very much
lessened by this method, notably the tendency for pus to gather in the
pQpliteal and posterolateral recesses of an infected knee.

Exposure, as stated, is best obtained by lateral incisions; if
these are inadequate the U-shaped incision of the French is very
satisfactory; in this the lower ends of the lateral incisions are joined
by a convex incision which cuts through the patella tendon thus fold-
ing back the knee pan so that the joint is widely exposed.

After the intra-articular commotion has subsided, the drainage
incisions are subjected to secondary suture if the openings do not
si>ontaneously close. This however must not be attempted in the
presence of strepteococci Re-effusion after such a closure can usually
be controlled by aspiration, with or without the injection of ether.

Systemic Treatment, — ^This is directed to fortifying the patient
by appropriate drugs and a concentrated diet. In cases of prolonged
sepsis I am a believer in the efficacy of iron, qainin, and strychnin,
and the judicious use of alcoholics and such anodynes as may be
needed to allay pain and provide sleep. In those who habitually use
alcohol the early use of bromids and chloral will ward off threatened
delirium tremens. If it is possible, these cases of joint infection
should be out-of-doors, with the limb exposed to the air and sunlight.
I have never seen any especial benefit from continuous irrigations or

134 TRAUMATIC SURGERY

immersions. Traction to keep joint surfaces apart should be early-
employed. As soon as practicable, drainage should be withdrawn
and the limb restored to a position where function will be best con-
served in the event ot ankylosis.

When all signs of local inflammation have subsided, massage
will be notably effective, and often surprisingly good results will follow
it and intelligent active and passive motion. Persistent sinuses
do well under air and sunlight exposure, or forced aspiration
by Bier's cup, or the injection of bismuth paste (vaselin and bismuth
subnitrate equal parts), introduced by an ordinary syringe with a
catheter or other tube, so that the cavity is filled to overflowing with
the paste heated to a syrupy consistency. "Bipp" is advocated
strongly by British military surgeons, this being a combination of
bismuth subnitrate ( 2 parts) , iodoform ( i part) , petrolatun (12 parts) .

Many of these cases with persistent stiffness, with or without si-
nuses, do well under the daily use of Bier's constricting band applied
above the affected part. A wide rubber bandage acts best, and it
should be' applied with the limb elevated and left several hours if (a)
no pain results and (b) if the parts do not become cold or (c) too pale or
too engorged. In the event of contractures, suitable operations can
be contrived to render the joint more functionally active.

SPRAINS AND Strains

A sprain is the sudden violent stretching of the soft parts about
a joint, and is accompanied by swelling, disturbance of function,
and usually by discoloration, and is frequently associated with some
tearing of the fibres about the part affected.

A strain is practically a lesser degree of the foregoing, and gener-
ally proceeds from a less sudden and violent form of violence and in
a part where joint excursions are more limited.

Lawn tennis arm is a strain of the pronator radii teres.

The glass arm of baseball players is a strain of the long head of the
biceps.

Rider ^s leg is a strain of the adductor of the thigh.

Commonly the ligaments about a joint are the parts involved,
but the tendons, synovial membrane, or the soft parts may be alone
affected. The condition is one of inflammatory irritation manifested
by characteristic signs of varying extent.

Causes. — Ordinarily they are due to indirect violence, as from a
sudden twist or undue use of a joint. Exceptionally they follow
direct violence, but then the condition is usually a part of a joint
contusion, dislocation, fracture, or other injury.

INJURIES OF THE JOINTS I35

Symptoms. — ^These depend upon the nature of the injiuy, the
joint involved, and the individual. Common to iaJl are swelling,
most marked over the site of maximum tension and usually of a puffy
variety. Discoloration is always present, at first of a reddish variety,
later becoming bluish or ecchymotic. Pain occurs at the instant
the joint is moved beyond its normal limits, and may be local to the
|>art chiefly involved or quite general. Sometimes the pain is acute
enough to make fainting imminent, and pallor, vomiting, and signs
of shock often co-exist. In mild forms pain is not complained of
until elicited by pressure of the examiner's fingers or induced by
joint action. Impaired Junction usually is present to some extent,
and may be due to pain, swelling, or stiffness.

Diagnosis is to be made from fracture, dislocation, synovitis,
and bursitis.

About the wrist and ankle it is especially needful to be on guard
to exclude bony injury, notably that form of fracture termed by
some writers "sprain-fracture," by which is meant the so-called
"periosteal fracture," in which a small flake of bone is pulled away
by a tendon or ligament. In cases of doubt, or in the absence of
x-ray confirmation, it is wise to regard such an injury as a fracture
and treat it accordingly.

Treatment. — To a great extent this depends on the joint affected,
the nature and extent of the sprain, and the individuars age and
occupation. TwcJ general forms of treatment are applicable, de-
pending upon the foregoing factors.

The rest treatment consists in the application of some immobi-
lizing dressing to the joint, such as a padded starch or light plaster-
of-Paris dressing or adhesive straps after the first twenty-four hours,
or when swelling and acute inflammation have subsided under the
application of an ice-bag, cold-water dressings, or a lotion of the
lead-and-opium type. This immobilizing dressing is allowed to
remain until the swelling decreases, as then it becomes loose and of
no further support. Usually this is within a week, and it is then
replaced by a lighter form of a similar immobilizing dressing, which
remains in place a week or ten days longer. Thus, at the end of
three weeks this stiff dressing is permanently removed and light
massage daily given, to be followed in a few days by deeper and more
general massage with passive motion. When these manifestations
are well borne, active use of the joint is gradually permitted, the
I>art being supported by a bandage, straps of adhesive, or other
removable dressing. At this stage a woven linen mesh bandage is

136 TRAUMATIC SURGERY

particularly useful because it is elastic, washable, durable, cheap,
and much more preferable than the so-called "elastic supporters. "
The patient may desire to wear some support for several weeks, and a
strap of adhesive plaster or a few turns of a linen mesh bandage will
answer for this purpose.

If any stiffness results, alternate douching with hot and cold
water followed by brisk massaging with hot camphorated oil, ("the
Scotch douche"), will be found effectual. By this form of treatment
disability is more or less complete for three weeks and may last
six weeks. Thereafter there will be some partial disability lasting
two or three weeks longer, during which period the patient is
gradually assuming his full duties. Disability is obviously shorter
for those who do not require to actively use the damaged joint at
work.

The aclive treatment method depends for its success upon the
early use of massage and moderate use, in an effort to promote
prompt absorption of the exudate and thus prevent adhesions or
stiffness. Hence, at the onset the joint is immersed in very hot
water or hot boric solution for five to thirty minutes and then mas-
saged with hot camphorated oil for five to fifteen minutes with light
upward strokes. The limb is then elevated, and straps of adhesive
plastei are applied so that they overlap at right angles and completely
encircle the joint to well beyond its margins (Fig. 78-84). After
this moderate increasing use of the part is encouraged. If the adhe-
sive becomes loose, it is tightened or otherwise reinforced so that it
constantly affords snug pressure. Under no circumstances must the
adiiesive so encircle the joint as to constrict circulation.

After the pain and swelling have to a considerable degree subsided
it is permissible to remove the adhesive plaster and use douching
twice or more daily with hot and cold water, followed by mas-
sage with warm camphorated oil. From this time onward the treat-
ment does not differ from that outlined in the foregoing method.

Needless to say, care should be observed for a time in the use of
the joint and it should be favored whenever possible.

Chronic Sprains. — Many persons have a "sprain tendency" due
to the natural joint relaxation, pre\ious joint injury or disease, or to
clumsiness incident to structural causes or improper footgear. Such
cases are frequent among those having unilateral or bilateral flat-feet
or other pedal deformities. In a joint of this character there is gener-
ally more or less preliminary puffincss or actual swelling, with or with-
out pain and tenderness on use or manipulation.

INJURIES OF THE JOINTS I37

Symptoms. — These resemble those of the acute variety in the
main, except that the manifestations are likely to be in exaggerated
form, although the pain is frequently less marked.

TreatmerU. — Preventive measures are most important, and those
with "weak joints" should guard themselves against recurrence by
joint supporters and proper shoes. Fat people who wear low shoes
with high heels are frequent victims of their own vanity. Those
operating gasolene engines often need special wrist supporters when
cranking automobiles, motor-boats, or other gas engines. These
recurrent cases do best when placed in a well-padded starch or light
plaster-of-Paris dressing immediately, but these are instantly split
if swelling or other signs of obstruction circulation appear. Such a
dressing will get loose in a few days and can be replaced by a similar
dressing to be worn a week longer. By the end of a fortnight an ad-
hesive plaster strapping can be applied and use of the part gradually
encouraged. When pain on moderate use ceases, this dressing can
be replaced by some form of support that should be used long enough
to permit the joint to regain its normal tone. Athletes or others who
are subjected to occasional rather severe use of such a joint ought to
habitually wear some form of elastic or leather brace device.

SPRAmS OF SPECIAL JOINTS

The ankle, knee, wristj elbow, shoulder, and back, in the order
named, are most subject to sprains.

Ankle Sprain

Causes. — A sudden misstep, as in walking on an uneven surface
with a "turning of the ankle;" or a similar result in stepping from
one level to another, as off a curbing or stairway, or a fall on the
foot. Generally the external part of the joint is most affected, as
the ankle usually bends inward. Frequently the central part of the
joint is coincidentally involved with either of the lateral portions.

Treatment. — K seen at once, immerse the joint in very hot
water for 10-30 miiiutes. Then massage with hot camphorated
oil and bind a compress soaked in the latter tightly over the joint.
Repeat this immersion, massage and pressure twice daily and
when swelling begins to subside, use the adhesive strapping and
make the patient walk from the beginning in carrying out these
''active treatment" measures best adapted to rugged workingmen
and athletes. If seen later, the interlacing adhesive plaster dressing
|X>pularized by Gibney acts best for the average case (Fig. 78,-4,

138 TRAUMATIC SURGERY

B, C). In applying this the foot is bent beyond a right angle and
sharply inverted and held in that position while i-inch wide zinc

Frc ( — The nlemal annular ligament of the
ankle and the art <iciall> di tended synovial mem-
brane of the tendons which it conhnes. (Genish's

Ftc. 75.— The
ligament of the ankle und the
synovial membranes of the ten-
dons beneath it artijicially dis-
tended. [Gerrish's Anatomy.)

Fio. 77.— The external anniila
the ankle and the artiriciaHy distended synovial
membranes of the tendons which it confiDes.
(Gerrish's Anatomy.)

orid ("Z.O.") adhesive is applied. This posture can be maintained
by the patient when no aid is at hand if a bandage is tied

to the big Jj

INJURIES OF THE JOINTS

Fig. 78. — Adhesive piaster dresstn); (basket weave) for ankle injuries. A, Firs
vertjcal strap applied behind malleoli level. Note method of holding foot in flexed
tDveision by a bandage aiuund loe held by patient. B, First tiansversc strap applied
close to sole. C, Successive layers applied. Note channel for circulation purposely
left along doisum. As many more layers as seem necegsary may be applied.

14© TRAUMATIC SURGERY

toe and the latter is pulled upward while the relaxed foot rests with
the weight on the calf of the leg. The first strap begins about 8
inches itbove the external ankle, passes down in the groove behind
the external malleolus under the tip of the heel, and up in the groove
back of the inner malleolus to the inner side of leg, a few inches
higher or lower than the place of starting. The second strap begins
below the instep, at the base of the middle toe, and passes back just
above the level of the outer sole and around the tip of the heel under
the external malleolus and along the inner sole to within .''2 inch of

I'm. 70.— Applying the non-slip bandage. One end held free.

ihi' »torling-jx)int. The third strap overlaps the first by half its
width. The fourth strap likewise overlaps the second, and so on,
until (he whole joint is enclosed in the manner indicated in the
illimraniR. Spiicc for circulation must be left }^ inch wide down
the Imat of the leg and foot. A snug bandage (such as the non-slip,
hIiuwu In Fig. 79-81) will cause the straps to firmly shape themselves,
ttnd iho fwit can then be elevated on a pillow and an ice-bag strapped
ovi'T (he joint for several hours. After from three to ten days the
HlTBpii get loose and they can be wholly replaced or their margins
»U1 and tightened by several 8-shaped pieces of adhesive or a linen

INJURIES OF THE JOINTS

Fio. 80. — Applymg the con-slip bandiige. I-'ret end being overlapped.

Fic. 81.— Applying the non-slip bandage, i'rec end used as a lie to last turn of the

142 TRAUMATIC SURGERY

mesh or gauze bandage. After ten to fourteen days a linen mesh
or other more or less elastic supporter may be comfortable. Pre-
liminary shaving of the part will make the plaster mold better and
aid in its removal. The use of gasolene, benzinj ether, wintergreen,
or camphorated oil helps to make the removal of plaster less of an
ordeal.

Diagnosis.^Many of these cases are often 'associated with a
chipping of the tip of the internal or external malleolus, and are then
known as sprain-fractures. This type of case requires longer immo-
bilization, as it is unsafe to permit actual use under three or four
weeks. Caution is needed in excluding a. fracture of either malleolus
without displacement; this is especially necessary where the violence
has been great or where the symptoms are in excess of an apparent
sprain. In cases of doubt a radiograph should be obtained; if this
is impossible, it is wiser to regard and treat the case as one of frac-
ture until the contrary is proved. Localized or "point" tenderness
is very suggestive of fracture, for the tenderness of a sprain is usually
quite generalized.

KiTEB Sprain

This usually is manifested as a synovitis.

Causes. — Ordinarily it is due to a wrench or twist of the joint in an
effort to prevent a fall ; or from the latter, so that the leg is more or less
twisted under the body. The external portion of the joint is more
often affected than the other parts, and frequently there is coincident
spraining of a portion of the capsular ligaments. It is practically
impossible to diagnose sprain of the lateral ligaments of the joint,
although rupture of these often occurs with dislocation. A synovitis
is a usual accompaniment and ordinarily is the predominant feature.

Treatment. — If seen early the limb should be maintained in a per-
fectly straight position by a padded posterior splint reaching half-way
up the thigh and down the calf respectively. Over this are placed
plentiful compresses of ice-water, camphorated oil or lead-and-
opium lotion, a tight bandage encircling splint and compresses. The
limb is then elevated on the pillow placed lengthwise, so that the
heel projects beyond its edge, the upper end of the pillow passing
well above the hollow of the knee; in minor grades a pillow splint
used as in Fig. 82 will answer. An ice-bag strapped over the splinted
joint is often equally efficient. After twenty-four hours swelling
and pain may subside enough to permit additional constriction of
joint in an effort to restrain effusion. As soon as the acute symptoms

[the I

;oms I

INJURIES OF THE JOINTS 143

subside (generally within a few days) the limb should be shaved for a
foot either side of the joint and an interlacing of i-inch wide " Z. O."
adhesive plaster applied. The first strap begins about 6 inches behw
the joint, on the oufer side of the calf, and is carried over the front
of the joint just below- the tubercle of tibia and attached to the inner

m mm. I

Fio. 83 — Pillow splint for knee-jomt injuries.

posterior margin of tHe thigh, about 6 inches above the joint. The
second strap begins on the inner side bi the calf, about an inch
internal to the beginning of the first strap, then across the front of the
joint to the outer part of the thigh, about an inch away from the end
of the initial strap. The third strap overlaps the first by half its

Fio. 83.— -Adheaive strapping of knee.

wdth; the fourth strap overlaps the second to a similar extent,
and additional straps are then criss-crossed until the whole joint
13 finnly encased. Caution must be observed in leaving a sufficient
gutter on the posterior of the joint for circulation (Fig, 83). Over all
anendrcling snug bandage is applied and the limb kept elevated. An
ice-bag can be used if desired. Any abrasion or wound is suitably

144

TRAUMATIC SURGERY

protected by a few thicknesses of sterile gauze after iodin has been
freely used.

This dressing can be tightened when necessary by additional
broader straps, or wholly reapplied after it has become loose. Mas-
sage will be advantageous if employed early, and in most cases it can
be borne after a few days. When pain on moderate passive motion
ceases, it is safe to allow restricted active use with the joint suitably
protected by adhesive strapping. Later a linen-meshed bandage,
elastic, or leather knee-cap can be used, and this should be worn until
pain on usage subsides. Swelling and occasional twinges of dis-
comfort may persist several weeks, notably in those whose occupation
requires persistent bending of the parts.

In selected cases with effusion, the fluid can be aspirated, and
at all events immediate motion of the joint is begun, gradually
increasing the range of same.

Athletes often need some such form of support for long periods to
prevent recurrence, especially in such sports as jumping, hurdling,
football, baseball, and running, A swollen, relaxed, somewhat tender
knee is so commonly found in athletes, especially football players,
as to be known as the "football knee;" this often means a slipping
cartilage or other intra-articular damage.

In recurrent or old cases it is sometimes wisest to completely im-
mobilize the joint in a light circular or anterior and posterior molded
plaster-of Paris splint. This should extend well beyond the margins
of the joint, and if made removable, massage and vibration can be
given as desired. This splint can be worn as long as tenderness on
pressure exists, and then adhesive plaster or some form of knee-cap
may be substituted, Ichthyol or iodin ointment applied on com-
presses b useful to remove remnants of pain or swelling. Likewise,
baking of the joint and alternate douching with hot and cold water are
helpful.

Dia.gaosis.^Bursitis is generally so well localized as not to be con-
fusing, at least after a few days. Slipping cartilage usually occurs
under lesser grades of \-iolence, the past history, sudden onset and
"the locking of the joint" in a flexed position are quite characteristic.
Later, localized swelling and tenderness corresponding to the site of
the cartilage clears away doubt as to the actual condition, and some-
times the displaced cartilage itself can be felt.

Gonorrheal and riteumalic syno^ntis are always to be thought of
and even regarded as probabilities if the symptoms are disproportion-
ate to the violence inflicted.

INJtJKIES OF THE JOINTS I45

Tubercular, syphilitic, and neuropathic knees generally give associ-
ated symptoms of value, especially in old and recurrent cases.

Fracture can generally be readily ruled out, although some cases
associated with massive synovitis may simulate fractured patella for
a time. Likewise the symptoms may occasionally suggest a fracture
of a condyle of the femur, or of the upper end of the tibia or fibula, but
a careful examination will early disprove any suspicions of this sort.

Wrist Spraih
Causes. — Usually due to a fall on the outstretched palm or a
twist of the hand with the parts above the joint more or less £xed.
The external and anterior portions of the joint are most commonly
involved.

Fig. 84. — Adhesive strapping of wrist.

n^atment — If seen early, the adhesive strapping method is the
one of choice. Strips of i-inch "Z. 0." adhesive are passed criss-cross
over the posterior and lateral margins of the shaved joint in such
a manner as to completely encircle except for a small trough to allow
for circulation (Fig. 84). Most patients appreciate support more if
a thin pad is placed under the adhesive where it crosses the back or
margins of the joint. The hand should be slightly inclined toward
the side of the affected ligament during the application of the adhesive.
A snug gauze bandage and a sling complete the dressing. An ice-bag
can be used if desired. Pain and swelling more quickly subside
when light massage is given through the adhesive, and the latter is
removed in a week unless it becomes loose before then. Some passive
motion is early permissible. Another similar adhesive strapping is
now applied, and the patient is instructed to daily move and massage
the joint. At the ehd of a few days more active motion is permitted,
the joint meanwhile being protected by a cuff of 2-inch adhesive, or
a leather wristlet, until pain on motion subsides. In cases seen
late, especially those giving a history of recurrent sprain, or .in
rheumatics, children, the aged, or the nervous, the foregoing active

146 TRAUMATIC SURGERY

form of treatment may not prove as satisfactory. In such cases a
light encircling plaster-of-Paris or starch splint may be used after the
local signs have receded tmder the use of an ice-bag, cold compresses
(water, alcohol, or lead and opium) Such a splint should not reach
beyond the finger webs, and must not be worn longer than ten days
or a fortnight, otherwise .adhesion may cause a troublesome stiflFness
more difficult to relieve than the initial injury. On removal of the
chosen form of immobilizing dressing, massage with hot olive or cam-
phorated oil should be given for ten to thirty minutes, and then
the original splint reapplied, now so split that it encircles only
one-half the joint. This is removed daily for massage and passive
motion, and at the end of the week is discarded for a wristlet of
leather or adhesive, active use from then on being encouraged up
to the hurting point.

Diagnosis. — Fracture of the lower end of the radius or ulna, with
little or no displacement, often gives similar signs in the first few days.
Differentiation can generally be made early by ascertaining the pres-
ence or absence of (i) localized tenderness; (2) false motion; (3)
change in the level of the styloids; (4) alteration in the transverse
wrinkles on the front of the wrist; (5) localized ecchjonosis. Sca-
phoid fracture is distinguished by noting the absence of fulness and
hard bulging of the "snuff box" region at the outer side of the joint.
K doubt still exists, a radiogram may be needed.

Sprain-fracture is more difficult to differentiate than the foregoing;

however, the treatment outlined for ordinary sprain will generally

suffice for this injury, and in some cases only an :*;-ray examination

can be decisive.

Sprain of the Back

This usually occurs in the middorsal or dorsolumbar region, al-
though it occasionally occurs in the cervical section.

Causes. — A wrench of the spine from a sudden twist or bend is
generally the cause; most of the cases follow the so-called "jack-
knife" posture, in which the shoulders are sharply bent forward or
backward while the rest of the frame remains more or less rigid.
Many of these cases follow stooping forward motions that are quickly
followed by efforts at regaining the upright position with some weight
in the hands or arms. I have seen several induced in this manner
in parents who have bent sharply forward to the crib or floor to lift
a child and then, while regaining the balance, a lateral twist occurs.
Workmen with crowbars or other levers frequently sustain the same
sort of sprain.

INJURIES OP THE JOINTS

Treatment — Strapping well above and below the involved part
with criss-crossed 2-inch wide adhe^ve plaster is the method of choice.
The adhesive lacing should extend well beyond each axillary level
margin to be most effective, the spine being bent backward during the
application (Fig. S5). Patients should be encouraged to walk as soon
' as the adhesive is applied, and the straps need not be removed short
of two weeks unless they become loose or cause irritation meanwhile.
During the time they are in place massage is very effective, and so is
"ironing the back" with a heated flat-iron while the patient is prone.

Fig. 35. — Adhedve strapping for a sprained back; a, Criss^cioss strapping; ,
verse overlapped strapping.

On removal of the strapping, brisk massage and some increasing
passive motion can be employed. Vibration and electricity and the
actual cautery are adjuvants in the later or rebeUious stages. Many
of these cases apparently derive some comfort and support by later
wearing a leather, flannel, or fabric encircling binder. In the rheu-
matic, suitable diet and a course of salicylates arc of aid.

The so-called traumatic lumbago is a typical form of back-sprain in
which induced rigidity of the back by adhesive strapping is very
effective. Severe cases of this and allied forms may sometimes derive
greater comfort by the use of a light plastcr-of- Paris or starch cast or
other form of spinal jacket.

Camptocormia (bent back), is characterized by lumbar pain and
forward flexion of the body with or without lateral inclination; no
organic lesions are present and a neuropathic basic generally exists
so that treatment is like that accorded the hysterical contractures.

148 TRAUMATIC SURGERY

In war literature it is variously known as camptocormia (Souques
and RosanofiF-Saloff) , spondylose antalgique (Sicard), campto-
rachis (Laiguel-Larastine and Courbon), antalgic spinal distortion.
I have seen but one case in civil life.

Diagnosis. — Pain in the hack can arise from such a variety of ^
causes that its persistence should call for an investigation as to the
probable coexistence of former abdominal visceral prolapse, such as a
movable kidney, enteroptosis, or pelvic displacement. Even such
an apparently remote cause as flat-feet should not escape notice, nor
should spinal deformity be forgotten. Many of these patients may
be wholly unaware of these added factors and be honestly mistaken in
ascribing their symptoms to an acute sprain, when, in reality, their
suffering is of gradual onset and dependent upon structural or patho-
logic factors apparently remote or anatomically distant. Manifestly
a patient with an ordinary sprain wUl not respond to treatment
directed alone to the sore spot if the fault lies in a part or viscus
reflexly the source of irritation; hence these cases of "lame back'' are
often an expression of a distant source of trouble. It is not to be
forgotten that ''pain in the back" is likewise a frequent accompani-
ment of the hysteroneurasthenic group of sjonptoms, of neuritis,
and of actual spinal cord lesions. For these reasons prolonged pain
following the accused injury should put us on guard as to the possi-
bility of other and more potent causative factors. Many of these
patients on inquiry will give a history of occasional attacks of a
similar sort which they interpreted as rheumatism, undue exertion,
posture, or a variety of causes, which, in reality, sprang from a
developing distant source.

If passive movement painlessly enables the back to be straight-
ened, then the spinal ligaments are undamaged; if, however, more
pain is caused on bending than straightening the back, then the
trouble is probably related to the spinal ligaments (Gould).

Rheumatism is also an element that frequently calls for differentia-
tion, and persons of the "uric acid diathesis" will sometimes not
respond to local treatment alone and need the additional benefit of
diet and antirheumatic medication.

Intercostal neuralgia and neuritis will ordinarily result in little con-
fusion from a differential standpoint.

Sacro-iliac Sprains

Because this joint is normally well protected and enjoys very
little motion it is very rarely injured except by severe falls with the

INJURIES OF THE JOINTS

149

thigh in abduction, or by iinusual crushing or wrenching forms of
violence in which other injuries also occur.

For a time it was quite popular in some circles to call many
injuries of the lower back "sacro-iliac injury," but of late the diagno-
sis has properly become much restricted. See also p. 230, "Sacro-
iliac dislocation."

Symptoms. — These relate to sharply localized pain on motion or
pressure, accentuated by walking, rising, or sitting, and these are
often coupled with backache or weakness. Abducting the thigh and
pressing the wings of the ilium together induce localized pain over
the joint.

Chronic sprain in this joint is the commoner manifestation, and
is oftenest seen in women whose pelves are strained by pregnancy,
and in those who have a relaxed mus-
culature or a tendency toward visceral
prolapse. Curvatiure of the spine or
shortening of the lower extremities may
impose pressure enough to cause sjonp-
toms of chronic sprain.

Treatment. — In the acute variety
the parts are to be given rest by en-
casing them in straps of adhesive or
plaster of Paris, passing completely
around the pelvis (Fig. 86). After such
a dressing has been worn a fortnight,
a corset of leather or elastic can be substi-
tuted, and gradually dispensed with.

In chronic cases the true source must be ascertained, and if relaxa-
tion is alone at fault, some form of molded leather or metal corset
will be effective in the vast majority of cases.

INJURY OF TENDONS
WOUNDS, TEARS, RUPTURES

Tendons may be lacerated or actually severed, as by knife, axe,
glass or saw cuts, or they may be subcutaneously ruptured by sudden
twists or by severe joint injury ordinarily associated with fracture
or dislocation.

Symptoms. — In those cases associated with open wounds, the signs
will be obviously those of any laceration plus the visible or demon-
strable severance of the tendon and the accompanying loss of func-
tion. In the larger joints (like the knee and ankle) the signs are

Fig. 86. — Adhesive strapping of
sacro-iliac region.

ISO

TRAUMATIC SURGERY

apparent, but about the smaller joints (like the wrist and ankle) pro-
longed search is often necessary to determine the full extent oi the
tear of the tendon involved. This is especially so if much time has
elapsed or if infection has ensued, so rapid is the tendency for the torn
ends to retract. Without a dissecting incision it is often quite im-
possible to determine what degree of laceration actually exists.

In cases of subculmteous {closed uvutid) tendon injury the diffi-
culty is less in large joints where damaged functon and increased
range of motion render diagnosis fairly easy in the earlier stages be-
fore effusion or inflammation occurs; but in smaller joints, or where
numerous tendons are grouped, the signs are confusing enough to
make diagnosis only tentative in the absence of inspection through an
operative incision.

In general, the symptoms common to all are: (i) Signs of sprain.
synovitis, or both; (i)" abnormal motility; (3) localized pain or
tenderness; {4) ecchymosis, frequently quite late and diffuse.

Treatment. — The object is to (i) coapt; (2) immoblize; (3} restore
function.

In severance of isolated or large tendons, posture or manipulation
will sometimes coapt the torn parts, and adhesive plaster or starch or
plaster-of-Paris splints will afford the needed immobilization during
the process of uniting. Depending on their ^te, size, and function,
tendons will knit in from ten days to four weeks. The pritnary treat-
ment may well follow that given for the active method outlined for
sprains, this to be followed (when swelling and reactioi; lessen) by a
snug starch or plaster-of-Paris bandage. The first dressing should
not remain longer than a week; if the swelling permits, it need not be
used more than a few days. The starch or plaster dressing can be
slit down the middle after the first week and then removed for
massage, and later for passive motion. When pain on gentle manipu-
lation is at a minimum, active motion can begin gradually, and then
the splint gives place to adhesive straps or bandages. Massage and
use will ordinarily overcome joint or muscle stiffness and restore tone
to weakened parts. In that class of case where retraction is too
great to be overcome by manipulation or posture, then the treatment
must be operative and of the type mentioned below.

Open Rupture of Tendons. — Where a wound in the skin is present
and the severence of the tendon is obvious, treatment is by suture.
If the original wound is sufiBcient to expose the tendon it is quite
likely that little or no retraction has occured; generally the original
wound requires enlarging, and this must be adequate enough to

INJURIES OF THE JOINTS

Fig. 87. — Tcndoplosty methods.

:. SS. — Tendon lengthening: a, Tendo Achillea; b, tendon bridging; 1, interposilior
of thread trellis; d, tendon splitting and transfer.

M'l 'iik.

152

TRAX'MATIC SURGEKY

permit identification and coaptation. Assuming that the tendon »
unrelracted, then it can be joined by chroniiccatgut, kangaroo tendon,
fine silk, or linen sutures meshed in the tendon ends after the manner
shown in Figs. 87, 88. Plain catgut will not hold long enough and,
therefore, should not be used. If retracted, then much search may be
necessary to find either the proximal or distal end, especially about
the wrbt, where an interval of several inches is not uncommon.

In the search (i) follow up the sheath with narrow forceps and tr>-
to pull an end into view; (2) massage the muscles toward the wound
in an attempt to "milk" the tendon into the field; tight bandaging
from above down may aid Jn thb; (3) probe the sheath as far as the
opening in it appears to extend, and then cut down upon the point
of the probe by a fresh incision, or prolong the original incision along
the probe.

If the gap is too great to be bridged over when traction is made,
then length can be gained by any of the schemes indicated by the
illustrations (Fig. 87, 88). If the tendon is too small to allow these
methods, then a trellis of twisted silk or catgut can be interposed as
shown in Fig, 88, c, or a strand of fascia or periosteum can be sub-
stituted. Failing still to unite the torn tendon, it can be attached
to (i) an adjacent tendon; (2) stitched to the periosteum; (3) buried
subperios tally. Whatever the method, strict asepsis must be
practised and every attention given to providing proper drainage
and relief from tension where needed. Even in the presence of a
wound requiring daily dressings, provision can be made to splint the
part in an overcorrected position so that union may occur. Small
tendons unite in two weeks sufficiently to discard the splint or reten-
tive apparatus; large tendons need support a month or six weeks.
Massage and passive motion will test the union and determine when
active use may begin.

SUBCtTTAHEOUS HTJURY OF SPECIAL TEHDOHS

The Achilles tendon may rarely be ruptured by a forcible fall on
the heel or wrench of the foot.

Symptoms.— Immediate pain and disability ensue, with swelling
and ecchymosis soon thereafter, together with loss of plantar fiexion.

The plantaris tendon of the calf of the leg is frequently torn by a
sudden twist of the leg, as in stepping on an uneven surface or from
one level to another, or by more active use of the part, as in running,
jumping, or hurdling.

Symptoms. — Immediate sharp pain at the inner side of calf ap-
pears, often accompanied by faintncss and actual falling. There is

mjUKIES OB THE JOINTS

I S3

difficulty in walking, and on examination tlie calf will be swollen
and present localized tenderness on pressure and pain on motion.
Later, varying frorn ten to thirty-six hours, there will be diffuse
ecchymosis that may affect the whole of the posterolateral margins
of the limb and a hematoma may form at the site of rupture.

The soleoB group of the calf of the leg may be ruptured by vio-
lence similar to that of the foregoing, but greater in degree.

Symptoms are those of plantaris injury, but more marked, and
generally there will be a visible or palpable sulcus at the place of
disruption, generally at the middle of the limb.

Fic. 89. — Ruptured biceps muscle and method of catgut suture.

The patellar tendon is not frequently ruptured by a sudden con-
traction of the knee while walking, tripping, running, or stepping
from one level to another; occasionally it is torn by direct violence in
a fall or blow on the knee, but then it is ordinarily associated with a
fracture of a small portion of the lower edge of the patella, this then is
an example of so-called "sprain-fracture."

Symptoms are those of tendon rupture elsewhere, plus bursitis or
synovitis, and elevation or excessive vertical mobility of the patella.

The quadriceps tendon occasionally is ruptured, at its lower
third or just where it joins the patella, by some form of direct vio-
lence, such as a blow or a fall astride an object, or by indirect vio-
lence, as from a sudden powerful twist or wrench.

The symptoms are similar to those given for the foregoing.

154 TRAUMATIC SURGERY

The adductors of the thigh are occasionally torn at their extremi-
ties or centers by indirect violence, such as forced abduction postures
due to falls or other maneuvers simulating "doing the split." The
symptoms are as narrated above.

The biceps and triceps are occasionally torn at their origins,
insertions, or intervening parts by sudden jerks or twists of the
shoulder, arm, or elbow; rarely are they involved by direct violence.

The symptoms resemble those named for involvement of the calf
and thigh tendons (Fig. 89). ^^H

INFLAMMATION OF TENDONS ^^|

This occurs in the form of tenosynovitis (thecitis) due to primary
injury of the tendon, but ordinarily it is a secondary manifestation
following infection or prolonged immobilization, as in fractures or
dislocations. It may be also due to rheumatism, gout, gonorrhea,
syphilis, and tuberculosis.

Fig. 90 — Gangli

In a localized form, over an isolated area of a tendon, a circum-
scribed cystic swelling may occur, known as "ganglion" or "weeping
sinew." This may rarely follow a single blow upon or a twist or
wrench of the part, but generally it is a slowly developing swelling of
unknown origin that may be ascribed to constant use of the affected
tendon. The back of the wrist and palm are the favorite locations,
and less often the flexor surfaces of the wrist are affected; they seem
to be commoner in relatively idle young women than in working-men
(Fig. 90). Certainly they are rarely seen as acute sequels ot localized
trauma. Sometimes they are multiple, and are then called "com-
pound ganglion," and such swellings on pressure can be made to
pass from one level of the joint to another, these, however, are more
likely to be tubercular in origin. Sec also p. 501, "Ganglion."

Treatment. — Occasionally (i) pressure maintained by adhesive
or other strapping (aided by a gauze pad, coin, or cork) is effective.
They can be (2) ruptured by a sharp blow struck while they are tense;
the edge of a book is usually chosen for this purpose. Oftentimes this

INJURIES OF THE JOINTS 1 55

treatment acts well in recent cases. (3) Injection of iodin occasion-
ally answers. Removal by (4) incision and complete dissection of
the sac imder local anesthesia is the only radical method of cure. To
accomplish this a semilunar incision will give better access than a
straight incision. Rarely can the cyst be excised intact, but in any
event the operation to be effective must remove all or most of the
cyst wall. Recurrence is not infrequent even under radical
procedures.

TBNOSTNOVmS

This may manifest itself as a simple irritative lesion or as the
sequence of some infection. The wrist and the ankle are most com-
monly affected in the simple form, and a sprain, fracture, or disloca-
tion is the usual source. Certain occupations may induce the
condition by continued pressure.

Symptoms. — Following irritation of the tendon sheath its lining
becomes roughened and later an effusion forms, this being the same
process that occurs in any other serous membrane. The early signs
are pain and stiffness on motion, followed by grating or creaking;
later, the swelling and fluctuation denote effusion.

Treatment. — On removal of the source of irritation, resi is
provided; if necessary, adhesive strapping or bandaging will best ac-
complish this. If ejflfusion is present, care must be taken not to per-
mit adhesions to (otm on subsidence of the fluid. Early massage
and use prevent as well as cure cases of this sort and make chronic
manifestations unlikely. In old cases, with fixation more or less
complete, forced massage and calisthenics will accomplish much if
the patient is willing each day to stretch the parts a little more than
the day before. Baking and alternate douching with hot and cold
water are also serviceable. In very resistant cases anesthesia may be
needed to forcibly overcome contractures. In such an event mas-
sage and passive motion must begin very promptly, otherwise the
condition will become reestablished. The infective form is a sequence
of wounds, and has been mentioned in connection with Infected
Wounds, notably under the heading Infections of the Hands.

Tubercular and syphilitic forms may also occur and give symp-
toms typical of these respective processes in other parts of the body.

BURSITIS

An inflammation of the bursa may occur acutely as the result of
a single direct injury, but generally it is the outcome of persistent or
repeated trauma, or a result of irritation from pressure or overuse.

IS6 TRAUMATIC SURGFRY

Sjrmptoms. — Common to aJI acute forms are (r) swelling, usually
localized and often associated with contusion evidences like redness
or ecchymosis; (z) pain on pressure or use; {3) fluctuation without
attachment to overlying or deeper parts; (4) interference with
function.

In the chronic forms, globular swelling and more or less fluctua- -
tion, pain, and impaired function are the ordinary manifestations.

Treatment. — In the acute form, rest and cold wet dressings fol-
lowed by pressure of adhesive straps or bandaging usually suffices,
the pressure to be repeated until the effusion is squeezed out. In
the chronic form (i) aspiration of the fluid via hypodermic needle or
trocar; (z) aspiration, and injection of 2 per cent, formalin in
glycerin, iodin (^}^^ per cent.), or iodoform and glycerin; (3)
exsection of the sac.

Many of these ancient cases are bothersome and annoying rather
than painful or serious, and cosmetic rather than surgical necessities
bring them to the attention of the surgeon. Merely from an esthetic
standpoint, they are often better left alone.

—Prepatellar bursitis (hi

Special Forms o? Bursitis
Prepatellar bursitis {housemaid's knee) sometimes occurs acutely
from violence producing a sprain of the knee, such as a wrench, fall,
or blow (Fig. 91). Commonly it is due to pressure in kneeling, but
nowadays it is rare since the advent of mops, vacuum cleaners, and
other household labor-saving devices. The other bursa; about the
knee are less rarely alTected (Fig. 92).

INJUMES OF THE JOINTS

157

Olecranon bursitis occasionally occurs from elbow sprains or
blows on the summit of this joint (Fig, 93). OrdinarUy it occurs in
occupations requiring pressure over this area, as in miners; hence
the name "miner's elbow."

Fig. 93. — Olecranon bunitis: o, External location; b, internal location.

Subacromial bursitis occurs usually from twists of forcible abduc-
tion motions of the upper arm, but occasionally also from direct forms
of violence. Codman, Brickner, and others regard it as a fruitful
source of shoulder disability. The visible evidences of the condition
are usually indefinite, although slight swelling may occasionally exist
below and in front of the acromion. The best single evidence of the

ISS

TRAUMATIC SITRGERY

Fig. 04.— PUstti sjjica anj retention of abduction by posture without splints.
(This and the following draivings, Figs, ^4-104, are from the articles of W. M. Brickner
who has mnde aa intensive study of this lesion.)

Fig. OS-— Plaster

INJURIES OF THE JOINTS

159

lesion is localized pressure pain over the bursa, and this is increased
by efforts to abduct or rotate the arm. Calcareous deposits may
occur, and these often show quite plainly in radiograms.

Treatment is by external cold applications, the arm being held in
forcible abduction (as in Figs. 94, 95). If, after a reasonable trial,

Fig. 96. — Subacromial bursitis (rndiographic appearance}.

s proves ineffective, operation may be resorted to after the plan
own herewith from Erickner's writings.
Personally, 1 regard this form of bursitis as rather rare and
' VDuId not resort to operation in the absence of very convincing radio-

— Subncrumiil tiumlis (radio-
graphic appears

graphic evidences that fully fitted the clinical signs (Figs. 96, 104).

Very many of these cases subside under rest more or less enforced-
Heel bursitis, at the insertion of the tendo Achillis, may rarely
llollow a sprain or a blow; but generally it is sequential to ill-fitting
Kboots, high-heeled slippers, or "ties" (Fig. 105).

INJURIES OF THE JOINTS 1 63

Ankle bursitis may infrequently follow a sprain or a blow; usually
posture is the real factor, as in tailors, hence the term "tailor's ankle.'^

Big toe bursitis is practically always due to pressure from tight
shoes, resulting in the common "bunion," with or without the accom-
panying change in the bones at the metacarpophalangeal joint (Fig.
106). There seems to be a marked congenital and family predis-
position to this tjpe of swelling.

Fig. 105. — ^Tendo Achillis or calcaneal bursitis. Fig. 106. — Hallux valgus or bunion.

Hip bursitis^ over the tuberosity of the ischium, is generally a
pressure occupational irritation, and boatmen occasionally develop
it.

Infected Bursae. — These occur in connection with wounds or as
metastases, and in effect are abscesses and are treated by puncture or
incision and drainage. Rheumatism, gonorrhea, and tuberculosis are
often causative factors.

SYNOVITIS

Every joint is lined by a smooth two-layered serous membrane
secreting enough viscid synovial fluid to properly lubricate the joint.
When this membrane becomes irritated there is an increase of fluid,
and synovitis is produced; in common parlance, there is "water on
the joint." If blood is also present we speak of hemorrhagic synovitis.
If infection occurs, purulent synovitis is the term employed.

Causes. — It may result from indirect violence, as in sprains,
ruptured ligaments, slipping cartilages, dislocations, or fractures; or
from direct violence, as by a blow or a fall upon a joint. The joints
most commonly involved are the knee, shoulder, and elbow. Aside
from injury there are many other producing factors, notably rheuma-

164 TRAUMATIC SURGERY

tism, gout, gonorrhea, syphilis, tuberculosis, and certain diseases of
the central nervous system like tabes and syringomyelia.

Acute and chronic forms are recogm'zed.

S3nnptoms. — These can be conveniently divided into periods or
stages, called (i) ascent, (2) stationary, (3) subsidence. Commoli to
all c^uie forms are: ' .

(i) Swelling limited to the extent of the synovial pouch.

(2) Redness, occasionally present, and it may be associated with
ecchymosis when arising from either direct or indirect violence.

(3) Fluctuation or bogginess,

(4) Pressure tenderness or pain,

(5) Increase of joint motion,

(6) Diminished active and passive function.

(7) Atrophy of adjacent muscles is generally a later manifestation,
but is generally present within a week, to some extent at least.

In the chronic form the main signs are:

(i) Swellings less globular or marked than at first.

(2) Muscular atrophy.

(3) Fluctuation to some degree, or it may be placed by crepitation
due to the presence of joint bodies of small size; or there may be a
palpable foreign body from organized effusion.

(4) Tenderness or pain on manipulation and motion.

(5) Diminished function,

(6) Audible grating or creaking is not uncommon.
In extent, synovitis may be of three degrees:

First degree, where the joint outline is somewhat broadened.

Second degree, where the joint outline is greatly broadened.

Third degree, where the joint outline is obliterated and the joint
structures arc more or less separated.

Treatment. — This aim is to (i) reduce the effusion; (2) restore
function; (3) prevent recurrence. These designs can be summed up
l>y the terms (a) rest, (b) immobilization, (c) functionation. Inas-
much as the knee and shoulder are most commonly involved the
treutnient given them will be detailed later. Synovitis of the other
joints can be treated after the manner indicated for sprains.

Course and Prognosis. — The average duration is from two to
twelve weeks, depending upon the site and extent of the effusion,
the patient's age, occupation, physical t>T)e and tendency toward
other ailments, and upon the treatment. Certain cases treated too
long or too short, or because of constitutional tendency, readily
have recurrences and develop a more or less well-marked habitual

^_r<Ul<

mjUKIES OF THE JOINTS 165

swelling that ordinarily is more inconvenient tlian actually painful
or disabling. This type is common in the athletic, the rheumatic,

id the syphilitic,

SynoviTis OF the Kjtee
In addition to the usual and ordinary symptoms, this presents in
typical cases the classical signs of "floating patella" and "clicking
patella" (Fig. 107). These manifestations are brought out by

Fig. 10?.— Eliciting the " tap " or " click " of the floating patella in synovitis of the
Note htiw the palmv .ire used to gather the fluid under the floated patella ao
(inuLT m^iy iitriu^s and elidt the "tap" or "click."

ot the rialit knee.

crowding the upper and lower edges of the synovial sac toward each
other by the examiner's hands, and while so doing a flick on the
patella will elicit the "click" or "tap" and at the same time demon-
i^te the floating (Fig. 108). In this region particularly, a massive
fusion disproportionate to the accused injury should put us on guard

i66

TRAUMATIC SirBGERY

lest we overlook the true etiologic factor, such as rheumatism, gonor-
rhea, tuberculosis, or some disease of the central nervous system
capable of causing a " Charcot's joint" (Figs. 109-111).

by culling Iht quadriceps t(

Treatment. — For the first few hours it may be well to put the
knee at rest merely by placing it in the hoUow of a long pillow (Fig.
82), an icebag resting over the part, but being separated from the
skin by a towel or layers of gauze. It takes one to five days for the

INJURIES OF THE JOINTS 167

effusion to reach its maximum, but early pressure may prevent
further exudation if the following form of "rail-fence" dressing
(Fig. 112) is applied at once. This is made by applying an encircling
layer of absorbent cotton (or sheet-wadding or cotton-batting)
about the joint at least 6 inches above and below the swelling.
Several ordinary bass-wood splints meanwhile have been soaking
in hot water to render them pliable, and now a splint is split longi-
tudinally in three or four pieces. These are laid vertically around

—Structures of knee-joint, sagittal s>

the anterolateral margins of the joint, about J-^ inch apart, over the
absorbent cotton, and then a tight muslin bandage secures them in
place. An ice-bag surmounts the patella if any comfort is derived
from it. The limb is then placed on a hollowed long pillow or rests
on the bed between sand-bags, the foot being raised as much as the
patient will permit. Such a dressing provides a surprising amount
of equally distributed transverse and vertical pressure, and it is
capable of easy regulation according to necessity. The outside
bandage can be tightened daily if the absorption will permit. Occa-
sionally 1 have placed these slats on adhesive before applying them,
and in that fashion they are somewhat more easily handled, but
then they must be applied dry, and for that reason do not mold
quite so well.

l68 TRAUMATIC SUBGERY

When pain on pressure subsides (usually in two weeks or less) it
is wise to give massage daily to still further promote absorption. A
week later some passive motion can begin, and as soon as this is
borne comfortably the patient can be allowed to bear weight and later
walk, the joint being encased then in adhesive plaster or a linen-meshed
or rubber hand;igc or fitted knee-cap. Some such support is usually
df-ircil jind ;iiTords comfort and confidence during further convale-

Flc. 11 a. — The "rail-fence" dressing for synovitis of Ujo knee, A layer of absorb-
ent cotton encircles the joint and on this boss wood strips i inch wide (from a split
WBt splint) are laid and bandaged. As the swelling subsides, the bandage is retightened.
Note the method of keeping the knee in eitension, allowing free use of both hands.

scence. When the period of walking is reached, the patient can by
self-massage increase the joint tone and restore muscle power; hot
camphorated oil is good for this purpose. Allowing a forcible jet of
hot and then cold water to spray on the knee is excellent; a piece of
rubber-hose attached to the faucet answers for this. If joint stiff-
ness occurs despite these measures, the use of an ointment of ichthyol
(lo to 2$ per cent.) or iodin will be of value. Electricity and vibra-
tory massage are quite valuable and baking is notably efficient.
Persistent swelling and stiffness will be less likely if massage is begun
as soon as pain on pressure and shght manipulation ceases. The
average case responds well to the foregoing "active form" of treat-
ment. However, in the young or the aged, or with some nervous

INJURIES OF THE JOINTS 1 69

types of individual, or where co-operation is not accorded for a
variety of reasons, it may be necessary to a more *' passive form" of
management. In such. a contingency the pillow and ice-bag can be
used xmtil the swelling reaches the maximum (generally by the end
of the third day), then an encircling plaster-of-Paris splint is applied,
reaching from the center of the thigh to the center of the leg, the
joint being weU padded. The foot is then elevated and the cast is
worn until it loosens. Then (usually in two weeks) it is cut down the
center and removed and a slit of a couple of inches is cut from it, and
it is then tightly reapplied for a week longer. At this removal,
massage certainly should begin, and repetition of it on alternate da3rs
will be grateful, the cast can be worn in the interval if desired.
From then on the treatment designs to "limber up" the joint and
strengthen the weakened and atrophied muscles.

Strapping of adhesive plaster may prove of value after either the
"rail-fence" or plaster splint.

It is rarely necessary to aspirate the fluids in such an event the
parts should be washed with alcohol, then dried with sterile ma-
terialy and then coated with iodin. The place of pimcture can be
previously cocainized or frozen with ethyl chlorid ; generally neither is
needed. A mixture of equal parts of ice and salt laid on the joint pro-
vides an eflBicient improvised freezing method for this or any regional
anesthesia. The aseptic aspirating needle is introduced at the infe-
rior lateral margin and the fluid is encouraged to escape by down-
ward pressure xmtil no more exudes. An aspirating needle may be
substituted. After all the fluids escapes, the injection of i to 3
drams of 2 per cent, formalin in glycerin (prepared twenty-four
hours in advance) is recommended by some ; likewise a similar amount
of tincture of iodin. But this "injection method*' is more properly
applicable to the chronic forms. Whatever the treatment, the
patient must be cautioned against undue use of the knee for a time
and is advised to be properly and safely shod.

In the chronic and recurrent forms the outward manifestations
are generally less marked, but often a huge swelling causes few sub-
jective complaints. In this type the joint will permit very active
and prompt pressure, and for that reason early use of the ** rail-
fence" splint can be advised. If despite firm pressure the effusion
tends to persist, aspiration may be employed, but every aseptic pre-
caution must surround its use, as the knee-joint is particularly sus-
ceptible to septic invasion. The needle or small trocar is introduced
after the manner indicated above, and when the fluid is removed the

170 TRAUMATIC SURGERY

formalin or iodin may be introduced. The puncture is then sealed
by cotton and collodion, gauze or adhesive, and then the part is
rubbed to bring the injected material into every portion of the
synovial sac. It is thereby hoped that reaction will ensue, thus
inducing an increased blood-supply and absorption. Reaction after
this may manifest itself in the form of increased local eflfusion, and
occasionally by systemic symptoms, with fever and malaise for a few
days. In this interval the joint is at rest and covered with a moist
cold saline dressing or an ice-bag. Thereafter massage and motion
are to be instituted in the same way as indicated for the subsidence
period in the acute forms. I have recently treated several acute
cases by immediate aspiration, requiring the patient to actively
move the joint after all the fluid has been withdrawn. Re-effusion
is treated by re-aspiration. This procedure has very materially
shortened the disability.

Synovitis of Shoulder

This is often quite diflScult to differentiate from contusion, sprain,
arthritis, subdeltoid bursitis, and ruptured capsular ligaments; and,
indeed, it may coexist with one of these. The ordinary symptoms of
synovitis are present, but disturbance of fimction (elevation beyond a
right angle notably), atrophy, and swelling, in the order named, are
the main signs. As an entity it is comparatively rare.

Treatment. — Rest, with the arm abducted or at the side, or the
forearm in a sling or other support, with a cold wet dressing or ice-bag
on the shoulder-cap, is needed imtil the period of ascent passes, and this
usually requires from two to five days. During the stationary period
light massage can be given if pain is not produced; otherwise the arm
is kept at the side by a sling, and cold or hot fomentations (like lead-
and-opium wash) can be used until massage is allowable. Passive
motion gradually commences, rotation and abduction being first em-
ployed; circumduction and overhead extension will be the last to be
regained. Active motion is advisable only within short range at first,
and its progress can be gaged by having the patient stand at arms'
length from the wall and each day place a mark thereon to denote how
high the part is raised. Caution must be given to incline the body
toward and not from the wall, for in the latter the whole shoulder-
girdle will be moved and not the shoulder-joint alone.

Hemorrhagic Synovitis
This occurs rarely and is generally an associate of fracture or dis-
location about the joint, as in a fractured patella or olecranon, or
dislocation of the knee, shoulder, or elbow.

INJURIES OF THE JOINTS 171

Symptoms are those of eflfusion, and the condition is differentiated
with difficulty from ordinary synovitis in the absence of incision or
aspiration.

Treatment — This is the same as for other forms of synovial eflfu-
sion in the absence of associated injury; in this latter event the man-
agement is that appropriate to the accompan)dng complication.
Aspiration of the synovial sac is more likely to be needed in this form
than in ordinary synovitis, and there is great likelihood that
infection will supervene demanding incision. This form occurs also
in certain anemias and in other constitutional ailments.

Purulent Synovitis

Generally this is secondary to simple or hemorrhagic synovitis,
and most commonly follows the introduction of germs into the syno-
\aal pouch by wounds or punctures. Occasionally a simple synovitis
is made purulent by ill-designed attempts to aspirate an ordinary
effusion. It may be an associate of an infected fracture or dislocation
and sometimes is a metastatic manifestation, as in pyemia. The
staphylococcus is the ordinary offender, and it may appear metastatic-
ally from a distant focus that may or may not be traumatic ; for ex-
ample, tonsillitis, may be a source of origin. From constitutional
sources it may arise from gonorrhea, tuberculosis, and other systemic
diseases of non-traumatic origin.

Symptoms are similar to those in ordinary synovitis plus more
local heat and redness. Usually there will be fever, chills, and signs
of sepsis; some cases, however, may be practically afebrile.

Treatment. — This is by aspiration or incision and drainage; the
first is preferable if the pus is not coagulated.

Chronic Synovitis

Generally this is sequential to an acute attack, but it may arise
also from a variety of constitutional causes, notably rheumatism,
gonorrhea, tuberculosis, syphilis, arthritis deformans, and certain
forms of anemia and nervous diseases. A well-defined type occurs
from relaxed joints or the muscles about same. Foreign bodies with-
m the joint (slipping cartilage, joint fringes, and the like) also are
causative. At puberty, menstruation, and menopause periods this
form of joint eflfusion may also appear. Another form, often
bilateral and periodic, occurs often enough to be given the special
name of ''intermittent hydrops."

172 TRAUMATIC SURGERY

Symptoms.— These resemble those of the acute form, except that
the signs are less pronounced, but atrophy may be. more marked.
The things most complained of are weakness and pain on undue use or
motion; while the part is relatively at rest there is comment as to
the swelling alone, as a rule. The joints usually show more or less
peri-articular thickening, and their motility is often impaired by
some plastic or fibrous exudate occasionally causing an audible and
palpable crepitus or creaking. Exacerbation is common and baro-
metric changes are often complained of. Many of these cases show
gait defects, and nearly all of them feel more comfortable after the
joint has been "limbered up" by moderate use.

Treatment. — This depends largely on the duration and previous
management, and a good deal on the age, occupation, and co-opera-
tion of the patient. An ordinary case that arises solely from injury
will respond well to efforts designed to (i) remove the fluid; (2)
restore muscle tone; (3) support the joint and prevent recurrences.
The fluid can be removed by any of the means suggested in the acute
form until it is demonstrated that these pressure and rest objects are
imattainable except by more drastic measures. Aspiration under
perfect asepsis is then advised, with or without the injection of iodin
or formalin-glycerin, as mentioned hitherto. To restore muscle tone
and strengthen relaxed and shrunken soft parts we employ massage,
vibration and electricity, and some motions that will not too severely
tax the joint. Douching alternately with hot and cold water is
excellent. To support the joint the wearing of a linen-meshed ban-
dage or knee-cap is advisable, this to be removed on retiring.
Caution is to be given about making sudden flexion movements or
maneuvers that will tax the joint.

In cases arising from other sources the treatment must be aimed at
the originating source, it being remembered that the tendency is often
to accuse an injury when the actual cause may be some unknown
or known constitutional difficulty. This is especially true in rheu-
matic, gonorrheal, syphilitis, or tabetic cases, either of these may be
at the basis, and cure will be impossible until they are recognized and
treated.

ARTHRITIS

This is an inflammation of the articular surface of a joint, often
showing a tendency toward involvement of other adjacent joint
structures.

Causes. — Primarily it may arise from injury by direct violence, as
by a blow or fall directly on the joint; less often, indirect violence is at

INJURIES OF THE JOINTS 1 73

fault, as from a wrench or pull on the joint. Secondarily, it may oc-
cur from some inflammatory focus ordinarily adjacent, but occasion-
ally at a distance; thus, it may accompany a synovitis or ostitis of the
same joint, or be a metastatic process from a distant focus, as from
oral or other sepsis. Aside from injury there are numerous other
causes, notably rheumatism, gout, gonorrhea, tuberculosis, and
syphilis. Typhoid, pneumonia, and influenza are also factors of
origin.

Forms. — Acute, chronic, and purulent (septic) arthritis are
recognized.

Symptoms. — In the acute variety there is the history of direct or
indirect joint trauma, followed by swelling, redness, pain on pressure,
heat, and diminished motion. The patient complains of initial pain
that may have been exquisite enough to cause pallor, fainting, nausea,
or vomiting, and which later decreased, but is aggravated by use of
the part. Certain joints or portions thereof when injured seem to
cause more pain than others; this is notably true of the inner side of
the knee. If the violence has been severe, diability may be
complete and demand immediate aid. If the injury is general to all
parts of the joint there will be added the signs of synovitis. The
symptoms given may be present only over a portion of the joint, as,
for example, on a lateral or superior margin; when generalized, an
effusion into the synovial pouch usually coexists.

The chronic variety grows out of the acute form and presents simi-
lar signs, but to a lesser degree, notably as to freedom from local heat
and extreme tenderness or pain; crepitus is generally elicited and it
may be audible. The peri-articular soft parts are generally more
rigid than normal and there is a general feeling of thickening;
measurement may demonstrate an increase from 3^^ inch upward.
Less enlargement than this minimum may be a normal variant due
to age, physique, occupation, and the natural effect of usage, as
between a right or left limb. If the enlargement is to be regarded
as normal there is likely to be similar variation in the adjacent
musculature. Many of these chronic cases, especially if recurrent,
show marked limitation of motion due to adhesions in or about the
joint; muscular or ligamentous contractions may coincidently or
independently exist. Limitation of motion usually means atrophy
of muscles even though the articular parts are enlarged. Knobbed
irregularities about a joint indicate an ancient process as a rule.
A chronic synovitis may coexist.

The purulent form {sepjic arthritis) may be a primary process

174 TRAUMATIC SURGERY

following joint puncture (as by wound or bullet); generally it is a
secondary manifestation of an adjacent or distant pus focus. The
first evidence may be a chill followed by fever, and soon follow the
local signs of synovitis, except that the eflfusion usually exceeds the
synovial pouch limits. Local heat, pain, redness, and fluctuation,
with marked loss of function are quite prominent, and atrophy of
adjacent muscles is usually an early manifestation. The constitu-
tutional signs of sepsis (fever, increased pulse, chills, sweats, prostra-
tion) may be mild or severe, depending upon the invading organism
and the extent of involvement. Staphylococcus infection is the rule,
and this may run a relatively slow course. Streptococcus infection
is the exception, and runs a more rapid course. The gonococcys
and the bacillus of tuberculosis, influenza, and typhoid are frequent
originators.

Cotu'se and Prognosis. — The acute form tends to get well speedily
and may leave no remnants. The chronic form may be slow and
usually results in some demonstrable thickening, crepitus, adhesions,
contractures, and occasionally atrophy. All these may exist to a con-
siderable degree without producing disability. The purulent form is
serious and generally results in a damaged joint with more or less dis-
abiUty. Treatment modifies the outlook; and freedom from consti-
tutional disease or infection often is a determining factor as between
a subsequent perfect or a imperfect articulation.

Treatment. — Acute Arthritis, — The indications aim to provide (i)
rest and immobilization; (2) restoration of function.

The first is attained by putting the joint at rest in a position to
conserve the greatest function in the event of adhesions or ankylosis.
' The average case can be first treated by encircling the joint with cold
moist gauze compresses wrung out of water, saline, solution, lead and
opium, or 50 per cent, alcohol. The limb is then elevated and held
immobile by soft bandages or a light removable splint, extension being
provided to keep the joint surfaces apart. To those who cannot
stand cold, heat may be used after the same manner. Some cases
respond well to extension and the use of an ice- or hot- water bag alone.
After a time the local signs permit the use of gentle massage once
daily, the joint afterward being wrapped in compresses wrung out of
any of the above-named lotions. As soon as pain on massage lessens,
some passive motion is used, and later active motion is increasingly
allowed. At this stage immobilization in an adhesive plaster dressing
or a light starch or plastcr-of-Paris cast is agreeable. Such an
mmobilizing dressing should not be left unadjusted longer than a

INJURIES OF THE JOINTS 1 75

week, and preferably should be of a removable type to allow early
massage. Some support must be given the joint until such time as
moderate motion does not cause pain or swelling. Adhesions
rarely form under early massage and passive motion; if they do
occur, the methods mentioned below will aid in further restoring
j'oint action.

Chronic arthritis^ being generally the outgrowth of the acute
variety, has to some extent the same treatment, especially if of the
recurrent type. The main element is to prevent adhesions and undue
atrophy; particular attention must be given extensor muscles, as
they deteriorate faster than the flexors. Ichthyol ointment (lo to
50 per cent.) applied liberally on gauze is effective; iodin ointment
(10 per cent.) or imguentum hydrargyri ammoniaci are also service-
able. Alternate douching with hot and cold water, followed by
massage, is of prime value. Gradually increasing passive and active
movements are to be urged. In the interval between treatments a
splint or other retaining apparatus will be needed, and the limb must
be kept in a position insuring greatest usefulness in the event of
ankylosis. Baking, mechano-massage, vibration, and electricity all
play a useful r61e. In aU forms of arthritis the systemic treatment
must not be forgotten, and a suitable dietetic and hygienic regimen
will be helpful. In the rheumatic and gouty much benefit will be
derived from some such combination as:

IJ. Kali iodidi gr. v;

Vin. colch. rad. fl njjv-xx;

S>T. sarsarp. co.

Aqua aa q. s. 3 j. — M.

Sig. — One dram three or four times a day in water.

After pain and swelling have abated, an adhesive plaster, linen or rub-
ber or woven bandage will be a comfort until joint strength is restored.
This dressing can be removed at night.

Purulent {septic) arthritis must be treated actively by (i) exten-
sion, (2) incision, and (3) drainage. The incision should be made on
a lateral dependent side of the joint, and in the majority of cases a
general anesthetic will be necessary. The sites of incision for the main
joints are indicated by the diagram. (Fig. 73.) After the joint has
been emptied by pressure, a normal saline irrigation may be used to
flush out the cavity; if the exit is not sufficient, a parallel incision will
afford through-and-through escape of the fluid, but no irrigation
should be made unless there is a free vent. Drainage should be free
and by rubber (gutta-percha) tissue or fenestrated rubber tubing.

176 TRAUMATIC SURGERY

K still the eflfusion has not' a free outlet, further incisions must be
made, and these are generally provided by enlarging the original
incisions or by additional incisions to drain pus-pockets or hidden
parts of the joint. Despite these, it may be necessary occasionally
to lay the joint open and irrigate it with every part in full view and
then to drain with the joint held widely apart (Fig. 74 shows this
form of drainage in the knee-joint obtained by a semicircular incision
below the patella — Mayors method). Splitting the patella vertically
(Jones' method) also gives good access to the joint. Such procedures
may prevent excision or amputation. If the process does not yet
abate, excision or amputation must be entertained, and the wisdom
of either will depend in great part on the general condition of the
patient; it is a hazardous alternative, but often saves life when all
else has failed.. In some cases the method of aspirating the pus via
needle and the injection of some antiseptic is of value — the so-called
"aspiration and injection" method. In this procedure the available
pus is withdrawn, and then from a few drams to an ounce or more of
the chosen antiseptic is introduced via the same needle, and then the
needle is withdrawn and the part is encased in gauze and cotton
and an extension splint is applied. A serous effusion generally
follows, lasting a few days, and then the inflammation begins to
subside if the treatment is effective. Renewed aspiration and in-
jection may follow if indicated. Two per cent, formalin in glycerin
(prepared twenty-four hours in advance) is strongly recommended by
the late John B. Murphy and others. lodin 3 per cent, or carbolic
(i : 20) are also used. Ether is also useful.

Septic arthritis treated after the method of Willems (of Bel-
gium) gives excellent results in selected cases. In this procedure,
unilateral or bilateral incisons are made, the joint is washed with ether,
no drainage is used and immediate use of the part squirts the pus
out of the joint.

After the acute manifestations subside, adhesions, atrophy, and
disability are to be overcome by the methods named in the foregoing.
Joint damage is generally severe after purulent invasion and ankylosis
is apt to occur, especially if the joint surfaces are not kept apart by
extension. In such an event, relief by arthroplasty may be offered.

Arthroplasty,^ — The following series of illustrations (Figs. 1 13-120)
show the steps in the late Dr. John B. Murphy's method of arthro-
plasty of the elbow for complete bony ankylosis between the humerus
and ulna in a position of complete extension.

^The following illustrations (Figs. 1 13-136), with descriptive legends, were taken
from the Clinics of John B. Murphy, Vol. III., Nos. 4 and 5.

oi LJje humerus, radius, and ulnd aic Qd LJlxd by liulleil Lnis Nut the dui. tion m
which the curved chisel is apphed to separate the bones od the radiul side of the joint.
Note also that the curve of the chisel selected for the division corresponds exactly to the
oonnal curve of the articular surface of the elbow joint, thus reproducing in the arti-
liciAl joint the exact contour of the original (Murphy's Clinics).

178

TRAUMATIC SURGERY

Fig, iij. — Expo^i

Fig. iifi. — Ruooval of ulni

INJURIES OF THE JOINTS

Rg. 117. — Pedicled fat-aud-fasda flap prefiared from the outer side of the .
aertion into the joint from the radial side (Murphy's Clinics).

Fn, itS. — Fedicled fat-and-fascia Sap prepared from the inner surface of the forearm
for iosertioa into the joint from the ulnar side (Murphy's Clinics).

TRAUMATIC SURGERY

Fio, 119. — Ulnar Qap interpi

I II.. I.' . -iv.iiii.il il.L|i JulL-rpoacd and sutured n
and till, rjdius and uliw, Tlic dcup stitches which I.:_u.
flaps in the depths of the wound have not been shown ii
Clinics).

The following series of illustrations {Fig. 1 21-128) show the es-
sential steps in the late Dr. John B . Murphy's method of arthroplasty
of the left hip by the fascia-and-fat flap method.

INJUKiES OF THE JOINTS

Fio. iJi. — The esacntjal Steps in arthroplasty ti[ tlit kfl hip by Ur. Murphy's /ascia-
Kj-fat flap method. "Goblet" iDcisioD through the skin and lascia lata down to
c musdei and trochnntcr. The lower tip of the upper flap is placed just below the
schuiter. The downward prolongation of the incision lies along the outer surface of
« femur (Murphy's Clinlo).

si.^The liap of 5kiti, tat, and fascia lata, has been retr.itti;d upward; the an-
terior and posterior borders of the wound are retracted, thus exposing generously the
great trochanter and its attached muscles. The chain-saw is passed on the needle
underneath the superior muscle group, chiefly the gluteus mcdius, down to the capsule
of the joint, and the trochanter with muscles attached is being sawed off in the direction
indicated by the dotted line (Murphy's Clinical.

FlC. laj.— The trochanlcr wiili ils attached muscles is drawn upwani, the anterior

fibers of tlic gluteus mcdiua muscle lia^'ing beea cut. The capsule at the joint is being

incised at right angles to the direction of its fibere. In this operation it was not ncces-

it cither the pyrifornus or obturator cJtcrnus muscles (Murphy's Clinics).

INJURICS OF THE JOINTS

183

FtC, 11S-— Rt-sliaping and smoothing the head of the femur and the acetabular
avity with Dr. Murphy's end-mill and reamers. The head of the femur b dislocated
Udtwud from the acetabulum pr«i;inrr,- >hW <u-\. 1,! tIk- i^pi-rallon (Murphy's Clinics).

^G. ia6. — Preparation from the under surface of liie skin-iiap of the Murphy
NicJcd faada'and-fal flap for interposition between the freshened ends of the booea,
^' dotted lines indicate the extent of the flaps. The use of a pcdicled and, therefore,
Wte flap of [asda and fat, interposed between the raw bony surfaces of the newly
iimacd joint, is the characteristic feature of aii arthroplasty operations (Murphy's

i84

TRAUMATIC SURGERY

17. — The interposing pcdiclcd flap of (asiia am] lai has been passed at
the ^uteus mcdius muscle posterior to its attachment, and dropped down over th
acetabulum, to the rim of whidi it has been sutured with chromiciied catgut. Th
head of the femur, when replaced, will lie on this flap (Murphy's Clinics).

Fio. u8. — The trochanter has been nailed back in place and the cut ends of th
muscles sutured. Usually Dr. Murphy used a continuous suture of phosphor-bronz
wiic to Kunite the muscles. The skin is sutured with horsehair and two or thre
tcnBion sutures of silkwortn-gul are inserted, if necessary (Murphy's Ginics).

INJXTRIES OF THE JOINTS

t85

The following series of illustrations (Figs. 1 29-136) show the steps
in the late Dr. John B. Murphy's method of arthroplasty of the knee
for bony ankylosis.

'^ Z19. — Internal and external curved incisions, giving free access to the luiee-Jolnt
on both sides (Murphy's Clinics).

^ic, 130. — Freeing tibia from femur with curved chisel. Interposing flap prepared.
Sote that the curve of the chisel selected correspmnda with the curve of the lower end
ol ^ femur. Although the pedicled fat-and-tascia flap was prepared in this case with

'1^ Pedicle downward, it might as well have been prepared from the other direction

(Murphy's Clinics).

TRAUMATIC SURGERY

Fig. 131-— I'rtci.iK jjiujupsiu |...Li-i1j iiuin iti-.m "itl. .iii,iM,= lIumI. lnLcrposing
flip prepared. Irpcing tibia from femur with curved chisel il'u'p'iy's Clinics).

jiurnace~^

Fig. 131.— fVrticulai surfaces of femur and tibia ready for insertion of Enteipodqid^
Subpatellu flsp prepared (Murphy's Clinks).

,87

^P^C. 153- — Aitkulor surfaces of femur and tibia reu'! . n i ' < i iriu

fl*p3. Internal subpatellarflap prepared. Note the width of thr intLTarLioular i
in (Jae new joint-^enough to accommodate the flaps easily, tritla sometliing tr
(Murpiiy'i Clinics).

• I J4. — Shows extemAl tibiofemoral Sap inserted and outer edge of internal patellar
Bap sutured into place. External patellar flap prepared (Murphy's Clinics).

TKAUMATlf SURGERY

Pig. T3(S. — Schematic drawing slu.uinB Ihu lii.in jnd anterior flap relations at comple-
tion of the operation (Murphy's Clinics).

INJUMES OF THE JOINTS

189

SLIPPING CARTILAGE
This reftts to the displacements occurring in the semilunar car-
tilages of the kneej the condition is also called "loose cartilage" and
"Hey's internal derangement of the knee-joint" (Figs. 137, 138).

Fic. 137. — Semilunar cartilages of the knee.

In this country it seems a rare occurrence, but it is exceedingly com-
mon in England and Wales,

The internal cartilage enjoys some motion normally and is at-
tached to the internal lateral ligament; but the external cartilage has
no such arrangement.

Fig. 138. — Varieties of semili

til age injury.

Causes. — Generally it follows a sudden twist or wrench of the
partly bent knee, the leg being at the same time slightly rotated
outward. This causes strain on the inner side of the joint, and hence
the internal cartilage is usually affected. It is said that displacement
on the inner side is hfteen to twenty times more frequent than on the
outer side. Running, a false step or jolt, athletics (notably football,

ipo

TRAUMATIC SURGERY

tennis, and hurdling) are also provocative. Rarely is direct violence
at fault.

Symptoms. — At the time of receipt, severe sickening pain is often
felt, the patient usually falls, and the knee remains more or less bent
or locked, and cannot be readily straightened. If seen promptly a
marginal knob may be visible and palpable; it seen later, the accom-
panying syno\'itis and local tenderness may be the only evidence,

Fio. 139.— Oxygen injeclior

especially if extension or manipulation of the joint has reduced the
deformity. Localized tenderness generally persists some time. In
all cases, synovitis occurs and the primary treatment practically re-
solves itself into caring for this. A'-ray examination is usually
valueless, but Robert Jones has shown that the injection of oxygen
into the quadriceps bursa will throw into high relief many joint
structures otherwise hidden (Fig. 139),

The typical history is that of a knee injury followed by effusion
and subsequent attacks in which the joint becomes "locked" in a

INJURIES OF THE JOINTS I9I

7 1

FjG. 140. — Complete exposure of the joint by the median incision o( Jones, showing
division of tendons and fat pad with Ugamentum mucosum intact and attached to inter-
'"•"liylat notch. Floor ajid lower edge of quadriceps peiuch k seen above, {Brackelt.)

1. 141.— Muscular relations in thigh and knee, {5i> Robert Jona, in "Annals oj
Surgery.")

XgS TRAUMATIC SURGERV

bent position, manipulation being needed to straighten it. Each
attack of "locking" induces re-effusion, and thus a recurrent syno-
vitis pertains. Minor grades occur in which the term "pinching"

Fig. 14a. — Illustrating preparations ftir .jju'iiih- ilir Un
" Anruils oj Surgery.")

rather than "locking" is more applicable. In these, sudden, tempor-
ary severe pain occurs with or without subsequent slight effusion.

Treatment— jRcrfuc(i(M[ is generally easy by hyperflexion, pressure,
and extension ; in recurrent cases the patient will often volunteer to

made with leg flexed to a right angle.
"Aanals of Surgery,")

"shake the knee into place." In primary cases anesthesia is usually
needed. The synovitis is treated after the manner described for that
condition. Care must be exercised later in bending the knee, and

INJURIES OF THE JOINTS 193

after the fluid subsides an adhesive or other support should be worn
until tenderness and laxness subsides. In recurrent and chronic cases
various knee-supporters are needed and much help comes from
building up the inner side of the sole and heel of the shoes yi to J^^
inch, so that the weight is shifted more to the outer side. Massage is
very valuable. " Shaffer's splint " and other allied apparatus are too
cumbersome to be long used in comfort. If palliatives are inefficient,
operative removal of part or all of the cartilage is advisable. The
cartilage is exposed by a vertical incision (preferably after it has been
dislocated), and then all or part of it is removed depending upon the
extent to which it is fractured, fragmented, displaced, detached, or
separated. Generally complete removal is the best procedure. The
operation demands the maximum of asepsis and often considerable
dexterity. The incision for removal advocated by Robert Jones is
very efficient, and his method of hanging the leg over the end of the
table facilitates the operative exposure (Figs. 142, 143). Access
to the joint by the so-called "Patella splitting" operation of vertical
bisection of the knee-pan (Fig. 140), should be reserved for those
cases in which accurate diagnosis cannot be made as between a
damaged cartilage, loose bodies, fringes, fatty pads or other intra-
articular lesions. Later an immobilizing splint is advised for two
to four weeks, and thereafter massage and increasing motion is pro-
vided. The outcome is usually satisfactory. Personally, I no longer
splint the joint but place it only in a gauze dressing insisting on
active motion from the beginning, preferably while the patient is
coming out Of the anesthetic. This is the '^active mobilization''
technic advocated by the Belgian surgeon, Willems, for every kind
of joint drainage.

CHAPTER V

DISLOCATIONS

Definition. — The displacement from each other of the articular
ends of bones entering into the formation of a joint.

Varieties. — Simple or closed is the ordinary form, and in this there
is no communicating break in the skin.

Compound or open is the form that communicates with the exter-
nal air by means of a wound.

Complicated is one associated with a fracture of adjacent bones, or
one with damage to neighboring soft parts.

Complete is one in which the articular surfaces are altogether sepa-
rated or displaced so as to touch only at their edges; it is also called a
luxation.

Incomplete is one in which the articular surfaces are only in part
separated or displaced; it is also called a subluxation, .This is a very
rare condition and the best authorities doubt its occurrence.

Unreduced or ancient is one that has not been reduced or set.

Recurrent or Iiabitual is one that recurs on slight provocation.

The name of the dislocation is derived from the bone furthest
from the joint; as, for example, in hip- joint dislocation, we speak of
dislocation of the upper end of the femur, and not of dislocation of the
pelvis, or of dislocation of the upper end of the. humerus, and not of
the glenoid cavity of the scapula.

Frequency. — The shoulder is oftenest afifected, providing nearly
90 per cent, of all; next in order are the elbow, ankle, knee, and wrist
in so far as the main joints are concerned.

Causes. — Age. — Commonest in adult life, rare under ten years of
age.

Sex. — Males more than females, in the proportion of 4 to i ; in
dislocation of the lower jaw, however, the figures are reversed.
Injury may act by (a) direct violence, as by a fall or blow imposed
directly over the joint — a rare method; (b) indirect violence, as by a
fall or blow transmitted to the joint from a distance — the commonest
and ordinary method; (c) muscular actioft, as by a sudden muscular
contraction or overstretching of muscle — a rare method and limited
practically to the lower jaw, patella, and shoulder.

194

DISLOCATIONS I95

Certain so-called "loose jointed'' persons can voluntarily produce
some dislocations, notably at the thumb and other small joints.

There are certain so-called pathologic^ spontanecms, and congenital
dislocations that may also be mentioned for completeness only, in-
asmuch as they are non-traumatic in origin.

Pathology. — The chief damage is to the capsvle of the joint, and
this is always more or less stretched or torn. The ligaments and
muscles may also be stretched or torn, but to a lesser degree than the
capsule. The nerves and blood-vessels may also be involved either by
tearing or pressure, and may give respective manifestations at once
or later. The hone may be fractured and the cartilage may be sepa-
rated or displaced. Synovitis is a regular accompaniment to some
degree at least.

Symptoms. — These are [a) subjective and {b) objective, (a)

Subjective symptoms relate to the history of injury (direct, indirect,

or muscular violence) followed by pain and disability. Pain will

depend on the location of the lesion, the manner of its receipt, and

upon the individual. Disability will be complete and immediate in

certain dislocations and individuals and less marked in other cases

and persons. In many complete dislocations of main joints, pain

will be great enough to impair or prevent function, and the

disability will depend thereon and also upon the attendant de-

ionnity. Many patients will also recognize and complain of

deioraiity, either due to the swelling or the distortion, (b) Objective

symptoms are often so apparent and pathognomonic that the

diagnosis is made at once.

Inspection discloses:

(a) Deformity, as shown by swelling or the reverse, and by mal-
^gnment in the contour or axis of the joint or limb, (b) Discolora-
^iw in the form of ecchymosis, often extensive and at a distance from
^e jomt. This appears generally within an hour and may last
Dionths; in direct violence forms it comes on earlier and leaves sooner
^an in other forms.

Pdpatiofi discloses an abnormal prominence and the reverse
al>out the contour of the joint, and tenderness and tension of the
Diuscles and tendons adjacent. Crepitus may exist if effusion is
present.

Motion discloses limited action, both actively and passively, with
^licitation of pain and spasm of muscle and tension of tendons.

Measurement discloses shortening in the vertical and increase in
the transverse axis of the limb.

DISLOCATIONS 1 97

x-Rayj fluoroscope, or radiograph discloses the actual condition;
too much reliance cannot be placed on the former alone.

Main diagnostic reliance is to be placed on deformity (visible or
palpable) and lessened active and passive motion.

Treatment. — The indications are to (i) reduce or set; (2) immobi-
lize or retain.

(i) Reduction is to be done at once, bearing in mind that the articu-
lar end of the bone must be made to return in a reverse manner along
the route through which it has escaped from its normal habitat. This
makes manipulation the key to treatment^ and has resulted in the
abandonment of forcible methods with or without special complicated
apparatus. In muscular persons, in the timid or resistant, an anes-
thetic is given to the necessary degree of muscular relaxation. Chlo-
roform should never be used for this purpose, because a dislocated or
fractured bone seems to lessen resistance to this drug, even as preg-
nancy confers immunity upon it. As will be shown later, there are
several means aside from anesthesia of inducing muscular relaxation,
and these may be tried first if desired. Under no circumstances
must undue force be used, and the physician will do well to first
ascertain if any nerve damage exists, lest his manipulation is later
accused of causing some neural or circulatory damage; this applies
e9q>ecially to shoulder dislocations. When the part is set, audible
notice thereof is often apparent; proof positive is given by the in-
creased range of motion that approaches or equals the normal.
Under anesthesia the muscles will relax, but the tendons will remain
tense until reduction.

(2) Immobilization need not be as complete or prolonged as in
fractures, and all that is necessary is a sling, bandage, or light plaster-
of-Paris dressing, to be worn not longer than ten days or two weeks.
Thereafter it is removed, and massage twice daily for ten to thirty
minutes is given for a week. The following week passive motion is
added, and in the succeeding week active use is allowed. Under this
plan restrictive adhesions are not likely to form; if they do arise, they
are combated by the methods named in discussing synovitis and
arthritis. In compound dislocation the wound is disinfected by tinc-
ture of iodin, used plentifully on as dry a surface as possible, so that

Ftos. 144-158. — ^Whitman, "the joint thrower," assuming various dislocations of
the shoulder- and hip-joints. This man is well known as a clinical exhibit, and has
ippeared many times at the author's Post-Graduate Hospital fracture clinic. Radio-
gtaphs of some of these " dislocations'' indicate that there is, in reality, no true bony
iqnratioiu

TRAUM,\TIC SlTiGERY

the maximum of penetration may result. No husitancy need arise
about pouring or injecting the iodin into and about the wound and
actually flooding the part with this drug. In practice this method
has proved most satisfactory to me, and it is inlinitcly superior to
the usual scrubbing method. Oil or grease can be removed by tur-
pentine, kerosene, olive oil, or gasolene. It the skin is ragged or
midermined, or ii torn fascia, muscle, or other soH parts protrude, it
is wiser to enlarge the external opening and then to re-iodimze any
fresh areas thus exposed. Suturing of soft parts is unwise except in
very large openings; if done at all, the parts must be loosely coapted
only. Drainage should al-u-ays be employed, gutta-percha tissue
folded or twisted acts well, either plain or in the form of a "cigarette
drain. " Rubber tubing with a strand of gauze passed through the
lumen of the tube is also efficient. Gauze drains soon act as
plugs and fail of their purpose. Subsequent dressings after the
Carrel-Dakin type are very effective. During the reductive manipu-
lation of the dislocation, the wound is suitably protected by sterile
gauze and a bandage or adhesive straps, and later a final dressing is
reapplied. At the end of twenty-four to forty-eight hours the drain
may be shortened or wholly removed if the wound shows no sign of
infection and if the secretion is only serous in type. The wound
edges may then with safety be further coapted by straps of sterile
adhesive plaster; these can be readily improvised by heating "Z.
O." adhesive over an alcohol or other flame. If infection occurs,
treatment is given in accordance with that stated in discussing In-
fected Wounds. Complications arising demand appropriate treat-
ment depending upon their nature.

li /ratrlure-dislociilion exists it will often be impossible to correct
both conditions without open operation; even then reduction may
be very difficult. Trial should be made under anesthesia first, and
if this fails, actual inspection through an incision is called for at once.

Nerve involvement may be due to the initial dislocaUon, to the
manipulation leading to adjustment, or to pressure from the dressings
As previously stated, it is very important to recognize such a com-
plication to forestall unjust criticism. Treatment for neuritis is
accorded along the lines indicated in discussing Injuries to
Nerves,

Blood-vessel involvement likewise may be an incident of the dislo-
cation or of the reduction or treatment. Immediate recognition is
essential, so that prompt incision may be made to prevent extensive
bleeding that may prove disabling, if not fatal.

DISLOCATIONS

199

Prognosis. — With prompt recognition and treatment the outlook
is good and functional return is the rule. This is notably true if
early massage and use are insisted upon, as disability is directly pro-
portionate to the extent of peri- and intra-articular adhesions. If the
latter are kept from forming by joint activity, function is measurably
restored when the rent in the capsule is healed and the stretched liga-
ments return to the normal; even in large joints this ordinarily occurs
within a few weeks. The outcome is not dependent directly upon
the dislocation, but upon the intra- and extra-articular adhesions
that form after reduction; this means that success in treatment
depends upon early reduction and early use.

Special Dislocations

upper Extremity.
Lower jaw.
Clavicle.
Ribs.
Shoulder.
Elbow.
Wrist
Fingers.
Spine.

Lower Extremity,
Hip.

Sacro-iliac.
Coccyx.
Knee.
Ankle.
Toes.

Fig. 159. — Dislocation of lower jaw: a, External appearance; b, internal appearance.

LOWER JAW

Definition. — Separation of the condyle at the glenoid cavity (Fig.

159)-

Causes. — Blows or falls upon the chin are less common sources of

origin than laughing or yawning or attempts at chewing big morsels.

It is very rare in the young because of lack of development of the

TRAUMATIC SUKGERY

articular eminence in front of the condyle; it is more frequent i
women because the condyle is smaller and has greater mobility.

Varieties. — (i) Forward, generally unilateral^ the commonei
form; (a) backward, rare and associated nearly always with fractur

DISLOCATIONS 20I

(3) outward, cUnJcal omoaty and only 4 cases are recorded; {4)
upward, only i case on record. Bilateral forms are very rare (Figs.
160, 161).

Symptoms.^-/»w^/tow. — Jaws open; lower teeth and dun pro-
trude; depression where condyle should be, in front of the ear.

Palpation. — Condyle felt in abnormal position ; socket of glenoid
empty; muscles tense; pain. Foregoing verified by finger in mouth.

Motion lost; chewing action abolished.

Treatment. — For reduction: (i) Wrap thumb in gauze or handker-
chief and press down and back on rear molars of lower jaw to disen-
gage condyle, and at the same time use remaining fingers to lift up the

Fig. 163. — Three methods of reducing dislocation of loner jaw: a. Thumb piessure
downnud at molars, the other fingera lifting upward and forward; b, palm pressure
downward and backward; c, gauze-covered thumb acting as in the first method.

point of the jaw ; it goes back usually with a click or snap and the sur-
geon's fingers may be caught; (2) insert cork or cylinder of wood be-
tween molars and press point of jaw upward; (3) in old or resistant
cases anesthesia or cutting operation may be needed; latter may re-
quire removal of condyle (Fig. 162).

Immobilizing. — Apply Barton's or other restraining bandage for
two weeks and use liquid foods only. Stationers' or other wide rub-
ber bands often act splendidly. Insist on caution in opening or shut-
ting the jaw for several weeks. Pain will be felt at angles of jaw
for some time, but this and the local swelling gradually subside.
Many patients say they get along just as well without any dressing
whatever.

Results. — Recovery without deformity or disability is the rule.
Working disability period two to four weeks.

TRAUMATIC SURGERY

CLAVICLE DISLOCATIONS
Sq>aration may occur at the acromioclavicular (outer end) or ster-
noclavicular (inner end) joint (Figs. 163-166).

Fig. 163. — Dislocation of the outer end of the
clavicle (acioiiiiocla\icular form).

164.— Same as Fig, 163,
showing bony deformity.

Varieties. — The acromial or outer end is oftenest dislocated, this
can occur in three directions: (i) upward or supra-acromial (usual
form) ; (2) downward and forward, or subcoracoid (rare) j (3) down-
ward and backward, or subacromial (very rare).

Fig. 165.— Dislocation of the inner end of the
clavicle (sternoclavicular form).

Fic. 166.— Same as Fig. :
showing bony deformity.

The Sternal or inner end can be displaced in three directions also:
(i) Forward (usual form); (2) upward (rare); (3) backward (very
rare).

Causes. — Both varieties follow indirect violence almost without
exception, and generally a tall on the shoulder or outstretched hand or

DISLOCATIONS 203

elbow is at fault. A blow over the joint or a crushing of the upper
part of chest may rarely be productive. They also occur as an ac-
companiment of severe crushing injuries of the thorax or shoulder-
girdle, usually in association with fractures of adjacent bones.
Efiforts at manipulation of a stiff shoulder exceptionally are also
productive.

Symptoms. — I nspecliem. —SveUing over articulation (depression
in the rarer forms) ; change in contour of upper chest or shoulder, arm
held stiffly; ecchymosis usual.

Palpation. — ^Articular end abnormally prominent and movable,
and it can be replaced but not retained by manipulation. Pain on
pressure; joint crepitus rarely.

Fic. 167. — Adhesive strapping (or Fig. 168. — Double shoulder spica

sternoclavicular dislocation of the clavicle, for injury to sternal or acromial end

Dotted lines indicate strapping for aero- of clavicle,
mioclavicular dislocation of the clavicle.

Motion of shoulder and arm impaired; respiratory efforts cau-
tiously made.

Treatment. — Reduction is easily made by pressure over the joirtt
from in front; or by drawing shoulders sharply backward and upward,
practically the same maneuver as in setting a broken clavicle.

Immobilizing is more difficult, and it is rarely efficient enough to
wholly prevent some enlargement. It is maintained by (i) a small
pad of several folds of gauze over the joint, held there by criss-crossed
straps of adhesive, and the arm is then held back by a shoidder
spica bandage. (2) A modified Sayre's dressing is comfortable and
probably acts as well as anything. Figures 167 and 168 show ade-
quate dressings. A pad in the axilla may be an aid in the acromial
lonn. The dressing is worn for two to four weeks, some massage

204 TRAUMATIC SUBGERY

being given after few days to prevent adhesive ankylosis of shoulder.
Elevation of shoulder and similar motions should be interdicted for
two or three months to prevent recurrent or habitual dislocation,
which is not uncommon. In women, a prone position with a sand-
bag or other weight over the joint for ten days or a fortnight offers
the best prospect of freedom from deformity. Open operation
designed to suture or remove the offending articular end should
be reserved for that class of cases in which disability results from
pressure or loss of shouider-joint power, but this is a very rare
sequence. Some cases may well be treated by the "abduction
method " advised by the author for the treatment of some forms
of fractured clavicle.

Prognosis.— Some persisting deformity is the rule, with increase
of motion and partial redislocation of the joint. Disability, even in
the presence of a complete unreduced dislocation, is rare, owing to the
anchoring afforded the joint and the whole clavicle by opposing
muscles. Working disability period averages two to ten weeks, ^h

Sm DISLOCATION ^H

Separation of a rib may occur at the anterior (sternal) or posterfor
(vertebral) attachment.

Varieties. — At the sternal end the displacement can be: (i) For-
ward; usual form; (2) backward; rare; (3) vertical; very rare. In the
eighth, ninth, and tenth rib the foregoing varieties occur at the costo-
chondral junction. The fifth to the ninth ribs arc oftenest involved;
the sixth and seventh most commonly. At the vertebral end displace-
ment is exceedingly rare and generally occurs with a fracture of an
articular process of a vertebra.

Causes. — Ordinarily due to indirect violence, as by a fall, squeeze,
or blow on the side of the chest, so that the main strain is transmitted
tv the attached ends, and the sternal articulation, being less firm,
gives way. Direct violence, as by a blow, is scarcely ever at fault.

Symptoms. — Inspection: Knobbed swelling (or a depression) at
the articulation; local swelling and ecchjTnosis sometimes. Palpa~
tion: Irregularity and motility are found; crepitus sometimes; pain.
Motion: Free, and the deformity is generally reducible.

Treatment. — Reduction by pressure, deep breathing, straining, or
coughing can generally be accomplished. Immobilization maintained
by a 3-inch strap of adhesive passing over the dislocation from the
middle of the back to beyond the center of chest; a second strap may
overlap this i inch if needed. A pad of folded gauze over the articu-

DISLOCATIONS

205

lation will aflFord more direct pressure if required. This is replaced
after it gets loose (three to fourteen days) and some form of pressure
is maintained three to four weeks. In that t)T)e associated with
decided depression ("caving in''), open operation and elevation with
suture or pinning may be necessary, but only if respiration is embar-
rassed or contour is much aflFected. Complications: Pleurisy rare;
punctxire of lung never occurs unless fracture or associated injury
exists.

Results. — Deformity may persist; generally it tends to grow less
in time and is non-disabling. Pain on motion and weather changes
subside usually after a few months.

Working disability period averages three to six weeks.

SHOULDER DISLOCATION

This refers to the displacement of the head of the humerus from
the glenoid cavity. Over 50 per cent, of all dislocations occur in this
joint (Fig. 169).

Fig. 169. — Shoulder contours: a, Normal rounding; b, depression in fractures of the

upper arm; c, dislocation deformity.

Anatomic Landmarks. — (i) Acromion process, especially the tip, is
prominent enough to be ordinarily visible, and it can always be pal-
pated even in a fat subject; (2) coracoid process^ less likely to be felt
in the presence of swelling or eflFusion; (3) head of humerus, visible
often, and palpable either from summit of shoulder or by deep pres-
sure in the cavity of the axilla; (4) spur on clavicle is occasionally
enough developed to be apparent (Fig. 170).

206

TRAUMATIC SURGERY

Varieties. — Many are given, but the following six are rTtmVfll more
than academic: (i) Anterior or forward: (a) subcoracoid — commonest;
(6) subclavicular — second in frequency; (2) downward: {a) subglen-
oid— uncommon; (3) posterior or backward: (a) subacromial; (6)
subspinous (both rare); (4) upward: (a) supraglenoid — clinical
curiosity.

Causes. — Direct violence, as by a fall or blow directly upon the
summit of the shoulder, is a common cause. Indirect violence,
transmitted from a fall or blow on the elbow or hand, the arm being ab-
ducted at the time of the injury. Muscular violence, as in wrestling,

70. — Structures about the shoulder-joint.

throwing weights or a bail, and in tests of strength, accompam'ed by
much tension of the upper arm and shoulder-girdle muscles. Of
all causes, the commonest is a fall on the arm, elbow, or outstretched
hand in an involuntary effort at protection.

Pathology. — The head of the bone is shifted from its normal place
through a tear in the joint capsule, this rent usually being in the
an tero- internal lower part of the ligament. Occasionally some of the
muscular fibers arc also torn, notably the tendon of the subscapularis.
Less often there may be some tearing of the infraspinatus, supra-
spinatus, teres minor, and long biceps tendon. The bony associated
occasional damage is to the rim of the glenoid and the greater or lesser
tuberosity of the humerus (Fig. 171), The vessels in the axilla,
vascular and neural, occasionally are also involved. The circumflex
nerve is most often affected, although the whole brachial plexus some-
times suffers from stretching and occasionally from tearing. It is

DISLOCATIONS

207

often questionable whether damage to vesseb occurred from the in-
jury or was due to efforts at reduction; frequently it is due to the lat-
ter or accompanies old or unreduced dislocations.

Symptoms. — The following general schema of signs is applicable
here and in all dislocations.

^^^

Fio. 171. — Subcoracoid dislocation of the
shoulder.

Tio 173 —Same as Fig. 171,
showing bony deformity.

inspection. — Deformity, disability, discoloration. Deformity: As
sceUm the attitude of patient and limb; swelling. Disability: Func-
uon limited or abolished. Discoloration: Depends on when the
patient is seen.

TRAUMATIC SURGERY

Palpation. — Head of bone out of place; pain on pressure and mo-
tion ; crepitation (sometimes unreliable) ; motion limited along normal

Measuremenl. — Length of limb and joint diameter increased (1
172. 173)-

The other signs depend on the variety of dislocation, but
subcoracoid tjpe only will be described in detail because this i;
the dislocation of the shoulder region and, indeed, of all other
artiiulatiiint;.

Fic. 174.— Bilntcral recurrent dJElocation of shoulder (left unreduced). Patient was
an epileptic who repeatedly dislocated the shoulders during his seizures.

Subcoracoid Symptoms. — Inspection. — (i) Deformity of patient's
attitude as indicated by the diagram. The arm is kept from the side,
and often is held upward by the patient's uninjured hand, the face
being tilted toward the damaged joint (Fig. 174). (2) Swelling or ful-
ness shows in the front of the joint, with a hollowness and flatness
over the region of the shoulder-cap at the deltoid area, and this
visible change in joint contour can often best be noted by standing
above and behind the seated patient and looking down upon the
shoulders. (3) Axis of arm slants in toward the middle line, so that
a line run along the lateral margins would strike well inside the joint.
(4) Axillary fold level is altered. (5) Discoloration from ecchymosis

DISLOCATIONS

209

uily does not occur within the first few days, and may be quite
extensive and take weeks to wholly disappear; but it is present to
some degree in all cases. Palpation: (i) Head of the bone is out of
I the axilla; it can be located in front of the joint close to the coracoid
I and is felt to move by rotating the arm. (2) Pain is manifest on
pressure and manipulation. (3) Elbow and inner arm cannot be
brought to the side of chest, and hence .the injured hand cannot be
placed on opposite shoulder with the arm touching the side (Dugas'
I test). (4) Crepitation is unreliable, and if present, comes from

(subconici)id) of the shoulder.
effusion. (5) Function is abolished by pain and the false position.
(6) The internal condyle lies in the same axis as the middle of the
head of the bone, and the external condyle in the axis of the greater
tuberosity; these relations are altered.

Measurement. — (i) Increase in length between the acromion and
the external condyle; this may be slight. (2) Diameter of joint
around the armpit is increased. The main diagnostic signs are prac-
tically visible, and chief reliance is to be placed upon (i) change in
posture of patient, the shoulder-summit, the axis of the arm, and the
axillary fold level; {2} inability to make elbow touch side; (3) feeling
I hole where a lump ought to be, and vice versa; (4) change in the
Tertical axis of the arm — this is the best single sign (Fig. 175).

212

TRAUMATIC SURGERY

Traction methods rely upon tiring out the muscles, thus preventing
their contractile action. Of these, Stimson^s method (Fig. i8o) is the
safest, and it is practised by making the patient place the side of the
head on one table and the rest of his body on another, the injured arm
hanging free between the tables. A hole cut in a cot answers the
same purpose. A weight of lo poimds is hung on the wrist or elbow,
and every few moments lo pounds more are added until 40 poxmds
are attached; usually within fifteen minutes enough relaxation occurs
to place the arm at the side, aided by a fist in the axilla to make
upward pressure.

Fig. 180. — Stimson's method of reduction in shoulder dislocation.

The heel in or over axilla method is mentioned only to be con-
demned, together with other forms of pressure-traction formerly
employed. If, however, any such maneuvers are used, the axilla
should be most carefully padded.

If reduction cannot be effected by the repeated trial of the Kocher
or Stimson methods, an anesthetic is far safer than resort to any
other procedure.

In old cases especially, it is important to determine the condition
of the nerves so that no blame may come to the physician in the event
of paralysis developing from the injury and not from the treatment.
Reference to the diagram will show the sensory distribution of the
nerves oftenest affected.

DISLOCATIONS 213

The Dressing. — ^An adhesive plaster ("Z. O.") strap 3 inches wide
is placed around the middle of the arm (so arranged as to permit two
fingers to be introduced between it and the skin) and then drawn
across the back and fastened just beyond the middle of the chest, a
small folded pad of gauze being loosely placed in the axilla. A broad
sling reaching from below the wrist to above the elbow completes the
dressing. This may be modified by adding a 2-inch adhesive strap
that begins at the middle of the clavicle, passes over the top of the
shoulder, and hence down to pass around the elbow to the place of
beginning; the sling is also used with this. In some instances the
typical Sayre's dressing (see Fracture of the Clavicle) is used. Dress- '
ings that completely encircle the shoulder are bulky and uncomfort-
able and have the added disadvantage of hiding the injured part.
The Velpeau bandage and allied shoulder-caps are of this class. No
initial dressing should remain on the part beyond two weeks; and from
the beginning, light daily massage over the joint (the adhesive dress-
ing being in place) will promote absorption of the eflfusion, prevent
adhesions, and restore muscle tone. Some passive motion after a
week is allowable, with active motion beginning ten days later.
After three weeks the adhesive or other dressing can be abandoned,
and in a month the sling also. One group of surgeons recommends
the use of a sling only, asserting that needed constriction will occur
involimtarily from the splintage aflForded by the contracting of
the muscles if they are overused. If there is an associated fracture
of a tuberosity, immobilization is maintained one week longer,
but otherwise treatment is the same.

Result, — In all cases this has a decided bearing on the period of
immobilization, and the longer and more complete this is, the more
certain will be the prolonged stiffness. The joint enveloped in an
immobile dressing for six weeks or longer scarcely ever regains full
functional capacity within three months. The average case properly
treated gets an excellent result and working power is restored in from
two to ten weeks, depending upon the occupation. Pain is felt in the
upper arm and in front of the joint for several weeks, and weather
changes and overuse may aggravate it; but in time it disappears.
The liability to recurrence is very rare and the "dislocation ten-
dency" generally precedes and does not follow the initial disloca-
tion. The motions last to be regained are circumduction and full
abduction, but fortimately time and real effort do much toward per-
fect restoration. The average case gets well completely and the arm
is ordinarily as good as ever.

TRAUMATIC SURGERY

Old or Unrbduced Dislocations

These are cases of mistaken diagnosis, or lack of. or imperfect
trealmcnt, and many of them are self-treated or wholly disregardeti.

Treatment. — If the head of the bone is not fixed, even though a
period of several days or even weeks has elapsed, cautious trial of the
Kocher or Stimson method may be successful. In cases of longer
duration an anesthetic must always be used and every care emploj'ed
to prevent damage to the vessels or fracture of the arm. Operation,
in which the parts are exposed through an incision between the del-

Fig. i8i. — Murphy's operation for rocurriuy luxation of tin- siiouldtr-joiiit. In-
trision anterior tt) bicipital groove, through deltcid muscle, e>:posiiig the joint: A, Cap-
sule split open; B, biceps tendon in bicipital groove; C, bead of humerus (Clinics uf
Dr. John B. Murphy, Vol. IV, No. 5, October, igis).

toid and the pectoral fibers, is in many cases the safest method. It
may be necessary to remove tlte head of the bone if dense adhesions
have formed and if the glenoid cavity is obliterated; excision should
be avoided if possible because of the abduction disability induced.
Proper postoperative treatment demands that massage and passive
motion begin after a few days of immobilization.

Habitital or Recurrent Dislocation
This often requires the operation of "reefing the capsule" so that ■
abnormal laxity of it is corrected (Figs. 181-183). Such patients

DISLOCATIONS

iSj. — <.>vtrl:iiiping ur imbrication o£ capsule so as to reduce capsular tissue to
destrd amount, thus increasing retentive power, so as to prevent luiation of humerus
(Oinics o£ Dr. John B. Murphy, Vol. IV, No. 5, October, 1915).

LjBj.— Capsule aiHured, to be followed by usual closure o{ wound (Clinics of Dr.
John B. Murphy, Vol. IV, No. 5, October, 1915).

ai6

TRAUMATIC SURGERY

should be cautioned against motions that unduly abduct the arm, and
some apparatus may be devised and worn with this in view.

In any complicated case, as of suspected associated fracture, pre-
liminary a:-ray examination will be prudent.

ELBOW DISLOCATION

This means the displacement of the bones of the forearm on the
lower end of the arm bone (Fig. 184).

Varieties. — Backward; the cumnioncsl by far. Lateral; usually
external and rather rare. Forward; very uncommon. A fracture is
quite likely to be associated, especially with the backward variety.

Fic. 185. — Backward dislocation of the elbow.

Either bone alone of the forearm, especially the head of radius,
may be dislocated (Figs. 185, 186).

Landmarks. — There are five about this joint; namely, the ole-
cranon, (wo epicottdyles, head of radius, and jront oj shaft 0/ humerus.

DISLOCATIONS

217

With the elbow straight, the tip of the olecranon and the tip of the inter-
nal and external condyle are on the same straight line; with the elbow
at a right angle, these three landmarks form a triangle. The head of
radius can be felt to revolve just beneath the back part of the external
condyle. The shaft of the humerus is readily apparent. In the
presence of even much swelling at least three of these landmarks can
be identified, and massage will often render them still further

—Backward dislocation of the elbow. Note avulscd Sake of bone at under
surface of humerus.

In examining an elbow (especially in children) most information
will be gained by inspecting and palpating it from behind.

Causes. — Generally a fall on the band or elbow with the latter
joint partly flexed. Rarely a direct blow is causative.

Symptoms. — Those of any dislocation, notably the changed atti-
tude and axis of the joint, and the fixed semiflexion and the promi-
nence on the back part of the elbow.

The diagnosis is ordinarily apparent and if seen early there is
often little swelling. A supracondyloid fracture is the only other con-
dition presenting similar signs, but attention to the bony landmarks
will differentiate promptly.

Treatment. — Reduction can be accomplished by (i) The exten-
sion and traction method; the forearm is extended and pulled down
while the arm is steadied, and then the joint is flexed after the ten-
sion is felt to relax. (2) Pressure on olecranon method: Standing
back of the patient, two thumbs are pressed against the olecranon and

2l8

TRAUMATIC SURGERY

the forearm forced down; especially good in recent cases and in
children. (3) Sir Astley Cooper method: Pressure against lower
forward end of humerus by surgeon's knee and slow forcible flexing
of the forearm. The safest and surest method is to give primary
anesthesia and then resort to one of the foregoing procedures.

Fig. 187, — Disbcation oi elbovv (1) nek ward) with /ratturi' at tip of olecranon; also
fracture of lower third of radius and ulna. Patient (aged twelve) fell in a gymnosiunii
trealment instituted: reduction of dislocation under ancsthtsia; anteroposterior molded
plastcr-of- Paris splints from middle of arm to web of finecrs, after reduction of fracture.
Later, open ojieration and kangaroo tendon suture of radius for irremediable deformity;
excellent result.

Afkr-lrealment. — The elbow is kept quiet for two weeks in a light
posterior right-angled splint, the parts not being wholly encircled or
hidden; massage is then commenced and the splint discarded after
three weeks and caution enjoined as to ovcraction, but use of the
part is insisted upon. Very rarely there is some involvement of the
ulnar, musculospiral, or median nerves.

Resulls. —XJsuaWy full restoration occurs, although for some weeks

DISLOCAnONS 219

there may be pain and inability to put the joint through the full limits
of motion. Genuine ankylosis is exceedingly rare (Fig. 187).

The other forms of elbow dislocation are of academic rather than
practical interest and no further mention will, therefore, be made of
them.

WHIST DISLOCATION

This means the dbplacement of the carpus upon the bones of the
forearm; an exceedingly rare injury, and it is quite questionable if it
ever occurs without frsicture.

Landmarks of importance are: (i) Tip of styloid process of radius,
about H to % inch beneath (2) tip of the styloid of ulna, which also is
broader than the preceding; (3) depression between base of the
thumb metacarpal and the radius — "the snuff-box:" (4) base of the
fifth metacarpal.

Varieties, — Backward, the usual fonii;f6rward, a dinical curiosity.

Causes. — Falls on the outstretched palm; rarely a direct blow.

Symptoms. — Those common to all dislocations, together with the
attitude of the bent wrist and its changed axis. Where the deformity
is not diagnostic, the altered position of the bony landmarks will be
determinative. The great majority of cases first diagnosed as dis-
locations prove to be CoUes' fractures (Fig. 188).

Fic, 1S8, — Backward dislocati&n of the wrist.

Treatment. — Reduction is made by flexion and traction; anesthesia
is a valuable and often necessary aid. An anterior light splint is then
applied, reaching from below the elbow to the web of the fingers, and
the patient instructed to move the digits. This is removed after a
week, and then for two weeks an adhesive plaster or leather cuff can
be used. Daily massage from the first is valuable. After three
weeks, use of the part should be insisted upon.

Results. — An excellent outcome is assured if splintage is not pro-
longed; otherwise it may take some time to overcome adhesions.

220

TRAUMATIC SURGERY

CARPUS, METACARPUS, AND FINGER DISLOCATION

Carpal dislocation is exceedingly rare unaccompanied by fracture;
the semilunar or os magnum are of tenest involved, usually from direct
violence. Diagnosis from fracture often requires x-ray corrobo-
ration. Treatment is by pressure-reduction and the application of a
palmar splint, as in wrist dislocations.. Operative removal may
rarely be necessary; but persisting deformity does not always entail
disability.

Fig. 189. — ^Three degrees of metacarpophalangeal dislocation of thumb: a, First

degree; 6, second degree; c, third degree.

Metacarpal dislocation is very rare except when the thumb is
involved. This last occurs usually from a blow upon the thumb-
knuckle, ordinarily received in fisticuffs.

The symptoms are obvious from the attitude of the wrist, the de-
formity of the thumb, and the ease with which the head of the bone
slips about.

Treatment. — This consists of pressure-reduction and the use of an
angled or gutter splint that keeps the thumb strongly abducted for
three weeks at least. Flexion movements must be interdicted for
some time thereafter to prevent recurrence.

DISLOCATIONS

221

Fig. xgo. — Steps in reduction of metacarpophalangeal dislocation of thumb: a,
xluction or hyperextension; b, dorsal flexion and downward pressure; c, traction
\d adduction.

TRAUUATIC SURGERY

Metacarpophalangeal Dislocation. — Thi^ typically occurs in the

thumb, and in many instances is produced at will — the so-called
"loose-jointed" person. The phalanx is dislocated backward on the
metacarpus, usually from a fall, twist, or blow that produces hj'per-
extension of the thumb. It may appear in three degrees:_^f.i/ , where
the phalanx is at an acute angle; sccojid, where the phalanx remains
hyperextendedatidstandsoutat right angles to the palm; third, where
the phalanx has been partly reduced so that it lies parallel to the
pabn (Fig. 189),

Treatment.— Tids is manipulative, so that the joint is relaxed and
the interposed torn capsule, flexors, and tendons are released (Fig.
190). This is accomplished by seeking to (i) hyperextend the
thumb so that it is bent far backward; (2) push the base of the thumb

downward toward its socket — pulling motions defeat this; ■
traction and adduction. A gliding or rotatory rocking motion helps
in these maneuvers; many attempts may be needed, and sometimes
open operation is required. After-treatment is light splintage for two
or three weeks, followed by moderate but increasing use. Consider-
able thickening and some limited motion is not unlikely to persist.
Finger dislocation is commonest in the distal joint and occurs from
a blow, fall, or twist, a backward dislocation being usual (Figs. 191, 192).

DISLOCATIONS

223

Symptoms are obvious; care must be taken to exclude fracture.
Treatment, — Reduction is by traction, pressure, or manipulation

Fig. 192. — Dislocation of phalanx: a, Incomplete dislocation (cross-section); b, com-
plete dislocation (cross-section); c, complete dislocation (cross-section).

F^G. 193. — ^Extension gnp tor reauction of a dislocation or fracture of a phalanx.

(Fig. 193). A light palmar finger splint (like a wooden tongue de-
pressor) is used for a few days, and then increasing use is advisable.

SPINE DISLOCATION

Definition. — ^The displacement of one vertebra upon another, the
superior slipping over the inferior. It is very commonly an associate
of fractiure, the so-called fracture-dislocation of the spine. Injury
above the fourth cervical vertebra is generally immediately fatal and,
therefore little will be stated about these unfortxmate forms.

Landmarks, — Spinous processes are visible and palpable almost
constantly, although their vertical and lateral axes are rarely uniform
or symmetric. The seventh cervical spine (vertebra prominens) is
the most visible landmark in the upper segment; but the first dorsal
spine is not infrequently a "prominens" instead. The spines of the
atlas and axis are frequently palpable. The body of the fourth lum-
bar vertebra is on a level with the crest of the iliimi. Transverse
processes are palpable in certain areas, notably near central part of
the stemomastoid muscle. Intervertebral bodies are palpable as far
as the fourth disk.

It is not to be forgotten that the spine presents many normal ir-
regularities, and too great reliance is not to be placed on the presence
of these unless the deviation is marked or accompanied by commen-
surate symptoms. See also p. 575, "Spinal Injuries."

334

TRAUMATIC SURGERY

VarietieB. — (i) Forward, either of (a) the entire vertebra or ^)
a lateral process; (2) backit-ard, the above reversed — rare; (3) lalcral
and rotatory— \sry rare; (4) diastasis or distortion, where there is
little if any displacement and the damage is to the soft parts and
to the stretched cord; this form occurs only in the cervical region
and is limited almost always to the fifth or sixth vertebra, and is
associated with hematomyelia and symptoms of root or ner\-e
pressure.

Pathology. — Hard parts: The bodies or arches (or both) are out
of place. There may be a slipping of ihe cartilaginous or bony parts.
Soft parts: The interspinous ligaments are stretched or torn; the
muscles may similarly suffer. The blood-vessels may be more or
less torn, resulting in extra- or intraspinal bleeding. The nerve-roots
or fibers may be bruised, crushed, or torn. The dura may be
bruised or torn, leading to escape of cerebrospinal fluid. The cord
may be bruised, crushed, or torn, and the laceration may even
involve the white matter. The lesions thus may vary from ordinar;-
sprain to complete cord destruction, depending upon (o) the location
and (6) the extent of the damage.

Causes. — Direct violence rarely originates, as from a blow, fall
or twist. Indirect violence commonly is at fault, like severe forward
or backward bending motions; thus any severe trauma imposing the
so-called "Jack-knife" position may be causative. Of these, may be
mentioned such incidents as diving, jamming betweenmovingobjects
(as an elevator and flooring), or objects striking the back while the
patient is stooping. Muscular violence very occasionally may cause
some of the minor forms.

Symptoms-^These depend upon the (a) site and (6) extent of the
trauma.

Region of the Four Upper Cervical Sjunes. — With any consider-
able dislocation in this area death is usually instantaneous (Figs. 194,
19s)' Where the displacement is only partial the signs are: (i) Dc-
jormity — the head is lilted forward and downward, or laterally; the
neck muscles are tense and prominent and their outline is changed.
There maybe ecchymosis or some local visible injury. {2) Palpation
shows rigidity of the neck muscles or local tenderness. Bony
irregularity may be palpable in the upper neck or in the pharynx.
The head often hangs loosely and "flops" about, seeking to rest on
the chin. Sensory tests may elicit agns of injury to the occipitalis
major or minor, the auriculo-temporal, the superfidalis colli, or
auricularis magnus ner\-es. (3) Cord damage of varying extent may

DISLOCATIONS

225

exist, pving appropriate trophic, motor, and sensory signs (Figs.
196, 197).

Treatment. — This depends upon the extent of the apparent dam-
age; all the factors must be carefully considered, as attempts at

Fic. igs. — Dislocation of

Fic. 196. — Typical deformity in dislocation
of cervical spine.

Fic ig7. — DetormityiD forward dislc
cationoftheupper cervical vertebiz.

reduction occasionally have caused death. Open operation (for
visible reduction or laminectomy) is generally contra-indicated.
The minor degree cases are best treated by a supine position with a
sand-bag under the shoulder and traction of the head from a support

TRAUMATIC SUKGESY

FIG. iq8. — Dislocation of cervical vertebra, sliawins s metbod of "'!'»" nl tnctlon.

DISLOCATIONS 227

under the chin, reaching thence over the head and ears. Later a
leather, plaster-of-Paris, or Thomas collar is worn. Severer cases
require traction and bending back of head, the surgeon directing the
extent of this by palpating the part through the neck and the pharynx.
This sort of manipulation must be slow, steady, and well planned,
with capable assistance. Later a neck support is worn, and is often
needed for a long time.

It is generally safer to attempt reduction rather than to rxm the
risk of an immediate fatality from spontaneous sudden increase of
deformity inducing cord pressure. No anesthetic should be used if
possible (Figs. 198, 199). Preliminary a;-ray examination is extremely
valuable, but unfortimately in the highest levels the plates may
not be very clear. Any treatment should be prompt to be effective;
but even after a lapse of two months successful reduction has been
accomplished.

Much attention should be given the patient's general condition •
to prevent bed-sores, ascending urinary infections, pneumonia, and
similar later liabilities. The water-bed is a valuable adjunct and a
skilled nurse an essential.

2f.

Fig. 200. — Deformity in fracture-dislocation of the lower cervical vertebrse: a.
Injury of the fifth and sixth segments; 6, injury of the sixth and seventh segments
(after Thorbum).

Region of the Lower Cervical Spine. — Typical uncomplicated
dislocations occur in the cervical segment below the fourth cervical
level of tener than in any other part of the spine because of the normal
mobility, the .absence of rib articulations, and the shape of the bony
processes. The fifth, sixth, and seventh vertebrae are oftenest
affected.

Varieties are similar to those iiamed hitherto; the forward com-
plete or incomplete types are the commonest.

Symptoms. — These depend on the site and extent of the damage,
as hitherto indicated. The tilting of the head is quite marked; if
the luxation is on the right, the head is turned toward the left, and
vice versa (Fig. 200). Bony irregularity, spasm of muscle, and local
tenderness may be marked. Pressure signs of brachial plexus
involvement may be present, especially in the unilateral forms.

azS

TRAUMATIC SURGERY

Treatment. — Reduction by traction and manipulation is fortu-
nately usually easy of accomplishment. An anesthetic is advisable.
The surgeon should not undertake the procedure without informing
the patient or his relatives of the possibility of an immediate fatal
outcome. Traction is best made by placing the left hand over the
mouth so that the fingers hook under the chin, the right hand mak-
ing traction and supporting the head from beneath the occiput.
Direct traction may also be made by pressure upward against the
angle of the jaw. If reduction is successful, the deformity is seen
and felt to disappear at once; oc-
casionally it is audible.

After-treatment requires the UsC
of sand-bags or a plaster -of-Paris col-
lar to prevent movements for several
weeks, and later a lighter similar
support is to be worn until pain on
motion disappears.

Region of the Dorsal Spines.^
Dislocation here rarely occurs with-
out fracture; the last three vertebrae
are oftenest affected, the twelfth
especially. It is said that, experi-
I.— Dislocation pI spine mentally, dislocation carmot be pro-
■„,„ duced below the fifth dorsal spine
(Keen's Surgery, Vol. II, p. 875).
Varieties.- — The forward unilateral, or bilateral type is usual, in-
asmuch as the producing cause is generally a "jack-knifing" force
, causing a sharp bending forward of the body (Fig. 201).

Symptoms. — These depend on the site and extent of the injury.
Deformity is generally obvious in the bent or arched condition of the
back, with or without kyphos or abnormal lateral deviation. There
may be a hematoma or other local signs of injury, and the late occur-
rence of circumscribed ecchj-mosis is very suggestive in the absence
of contusion signs. Pain on pressure is marked, and disability b
usually complete, either from pain alone or paralysis. Nerve dam-
age may vary from complete paralysis below the lesion to localized
areas of altered sensation. The initial extent of the paralysis is no
positive measure of the amount or degree of the cord damage. Pres-
sure from effused blood may be great enough to abolish all cord
sensation even though the latter is intact; for this reason a very
guarded outlook must be given, especially when the patient is seen early.

(forward variety) Hith anffulalion
and constriction of the spinal curd.

DISLOCATIONS 229

The signs corresponding to cord injury at various levels will be
discussed under Fracture of the Dorsal Spine, because the symptoms
are practically indentical as fracture and dislocation generally
coexist.

Treatment. — RMuction by traction and pressure with the patient
anesthetized has been successful, but the usual treatment in the non-
paralyzed cases is to apply a plaster-of-Paris jacket after full exten-
sion has been obtained. If, however, there is pain from pressure
and apparent danger of increase of deformity, the patient is to be
placed on a Bradford frame or similar device, and gradual pressure
made on the spine just lateral to the site of the deformity. Gradu-
ally increasing pressure of this sort sometimes removes the kyphos,
and then a plaster-of-Paris jacket can be worn. Open reduction,
by laminectomy or otherwise, is reserved for those cases that fail
to respond to other measures.

Region of the Lumbar and Sacral Spines. — These dislocations do
not occur as entities.

Sacro-Iliac Dislocation. — This is a very rare dislocation and I
have never seen a case unassociated with a fracture of the pelvis or
some other lesion arising from a considerable degree of violence.

Anatomy. — This joint is very firmly bound in place by numerous
strong, interlaced bands of muscle, tendon and fascia. The articula-
tion surface is shaped like a huge oyster, having a wide sacral
concavity above and a less wide concavity below to fit into corres-
ponding iliac convexities, each height and hollow being suitably
protected by a bony rim. This formation implies rigidity and thus
there is normally but little motion in the articulation, the lateral
play being most marked, the vertical practically nil.

Frequency and Types. — As an entity, true dislocation is so rare
that it is a clinical curiosity and for that reason atypical, incomplete,
partial dislocations are said to occur and these are then known as
"relaxations," "saggings,'' "separations." There is no surgical
warrant for regarding any of these as dislocations and no reason, why
this joint should receive any appelations denied to other joints of
greater clinical importance. Many anatomists and surgeons
believe that a true traumatic dislocation is practically impossible
without fracture. This lesion came into prominence largely be-
cause of the writings of some orthopedic surgeons who came to re-
gard it as a cause of back-pain; of late, less attention is given to an
isolated injury as the producing cause because most cases prove to
have developed from long standing, gradually increasing sources.

TRAUMATIC SURGERY

Osteopaths frequently assert that this joint (like many in the same
region) has "slipped out of place. "

Fic. 30S. — Sacro-iiiac disloc;

(l)y courtesy of Dr. Lewis G, (

Fio. 203. — Saero-ilkc dialoi

ifw (by courtesy of Dr. Lewis G. Cow]

Causes. — Severe falb, blows, crushes and injuries of a wrenching
type are the only possible sources in aculc cases; as staled, fracture
of the pelvis, spine (sacrum notably) or femur are usually associated,
with or without intra-abdominal injury.

DISLOCATIONS 23 1

Chronic cases may occur as the result of stretching of the joint
from a variety of causes; of these may be mentioned pregnancy,
intra-abdominal tumors, spinal curvature, rickets or debilitating
disease in which the musculature is quite generally affected.

Symptoms. — Pain is severe, sudden in onset, quite suflSdent to

cause disability; it may radiate, especially along the thigh or into

the lumbar region. Visibly there is swelling and discoloration;

often the ilium is tilted. Tenderness on pressure is marked and this

outlines the joint; the adjacent muscles assume a protective rigidity.

False motion, crepitus or bony signs are usually absent. Motion

transmitted to the ilium is very painful, notably abduction of the

thigh, pressure into the acetabulum, or rocking one side of the pelvis

against the other.

-X-ray examination must be made with care, and if possible the

plate should include both joints, taking precautions to have the pelvis

flat, the limbs equally placed and the anterior iliac spines even. A

siLfl5.cnent number of vertebrae should be shown to rule out spinal

as3rxximetry or postural static defects of old origin. Finally the

the rr-ray examination should be regarded as corroborative or deter-

miri^tive only if the violence has been of sufficient adequacy and the

sym^ptoms are appropriate , for a lesion of this type. The mere

finding of a "sagged," "relaxed," or "separated" sacro-iliac joint

in a^xi a;-ray plate does not make the diagnosis of "dislocation" unless

^^x"^ has been a resonably severe injury with typical physical evi-

den.c2:es. Inspection of a large number of a;-ray plates showing this

^^Si<:^n (for example, kidney and gastro-intestinal plates) convinced

^c ^that the ic-ray appearance of this joint was exceedingly variable

^^ that diagnosis from the radiogram alone should not be made.

^^^ this same connection it is pertinent to say that many radiol-

^P^ ts of very great experience have never seen an acute lesion of this

-^^DifferenHal Diagnosis. — Sacro-iliac, lumbar and hip-joint sprain
^1^^^ t be excluded by the absence of local and bony signs. Lumbago,
^^^- '^ica, arthritis, neuritis, the neuroses, and spinal asymmetry
^at^^-pj^j vertebrae; accessory vertebrae; fused or sacralized lumbar
'^^^ t^brae) must be excluded, especially in old cases. Intra-abdomi-
^^^ and intrapelvic sources of pain in this region must not be
t^^^otten. See also "Sprain of the Back," p. 146.

Treatment. — True cases should be capable of reduction by
to^xiipulation.

Atypical or chronic cases are often benefited by wearing some

332

TRAUMATIC SURGERY

form of support or girdle that crowds the wings of the iliac bones
toward each other; this may vary from adhesive plaster strapping,
to an elaborate brace.

Massage, baking, vibration or electricity are effective in some
cases. Very violent manipulation is said to do good when other
means fail. Internally, an ti- rheumatic, anti-gout and anti-syphilitic
remedies must not be forgotten. Postural defects are to be corrected
if they exist; likewise search is to be made for any focus capable of
causing an arthritis.

Region of the Coccyx.- — This dislocation is very rarely heard of in
civil practice, but is a common allegation in personal injur>' claims
and suits. The writer has had butone genuine
case in his own personal experience but h;is
examined scores of cases in which it was
claimed but never found.

Anatomy. — This rudimentary triangular

F(c. J04. — a, Sncro-iliac joint and sacrumand oxcyx, lateral view; b, cnccyit, posterior
view; c, coccyi, anterior view.

bone is made up of four segments, the distal three generally uniting
to form one. The total length is about 2 inches, the upper width
is about I inch (Fig. 204). The normal direction at the sacro-
coccygeal joint is forward, making an angle of about i2o
degrees, blit this may actually reach to almost a right angle
or tilt sharply backward and yet be a normal variant. The
sacrococcygeal ligament is strong but elastic, and allows con-
siderable motion within functional limits, and that this must be so is
apparent from the proximity of the rectum, which constantly exerts
varying pressure. In women the normal position and mobility is

DISLOCATIONS

»33

more marked because of the difference in the shape of the pelvis for
obstetric purposes. The levator ani (in front), the sphincter ani (at
apex), the gluteus maximum (in back), and the coccygeus (laterally)
are the attached important muscles of this region, and in real injury
to the bone their action should be limited or abolished. Until about
the twentieth year there is inore or less motion between the segments
composing the bone, the second and third being the last to fully
ossify and unite. At about the age of fifty, union or complete
ossification at the sacrococcygeal joint usually occurs; it may be
earlier or later and is one of the articular and other senile changes
noted at this period.

Fig. 105. — Coccyx and alterations in ils axis by pressure from within: a, Displacement
due to a full rectum; b, displacement due to a tumor.

Inasmuch as the spinal canal does not extend beyond the first
lumbar vertebra, the nerves about the coccyx are only filaments of
the Cauda equina, which latter begins at the lower border of the first
lumbar vertebra, and this is distant some 6 or 8 inches from the
beginning of the coccyx.

Causes. — Direct violence is obviously the only traumatic produc-
ing factor, and this may occur from a fall so that the parts between
the folds of the buttocks impinge upon a raised object. For that
reason falls astride chairs, fences, or pointed objects may be causative;
kicks or severe blows occasionally are the injuring force. No fall
on the buttocks or back nor any form of indirect violence is likely to
cause damage because of the intervening protection. From pressure
within the pelvis (as in parturition) dislocation has also occurred
(Fig. 205). Likewise, consequent to pelvic, rheumatic, or other
inflammation, an abnormally fixed position may be produced, but

234

TRAUMATIC SURGERY

this may not be discovered until rectal or vaginal exantinatio'
made, as in this tj-pe of case lesions are more prominent.

Varieties. — Foru-ard, the commonest sort (Fig. 206); backw
from pressure within, as in pregnancy; lateral, exceedingly rare; t
one genuine reported case is on record (Stimson).

Symptoms. — Pain is the most prominent, and it is espedi
marked at the time the violence is sustained and is usually se\
enough to completely disable. Later it is induced by motions t
drag on Ihc attached muscles; hence, sitting standing, and wait
are carried on with effort. Defecation is especially painful and tl:
is often frequent desire to urinate, with dysuria. There may i
be some blood)' discharge from the vagina or rectum.

DISLOCATIONS 235

Examination shows an attitude assumed to relieve direct pressure
and muscle pull, and such patients sit on the edge of the chair or
use "a ring" or air cushion. Early there may be ecchymosis or con-
tusion signs directly over the coccyx. Pain on pressure is prominent
and crepitus and false motion may be elidted from without or within.
All movement, espedally abduction of the thigh, increases the pain.
RectcUly or vaginally there is local tenderness on pressure, and the
bone then is foimd in an exaggerated motile position, and when it is
returned to the normal (usually pushed backward) there is consider-
able relief from pain. There may l^e crepitus. If seen after reduc-
tion, the history of the case (i. e., manner of acddent, immediate and
subsequent symptoms, and treatment) must be carefully considered
before a diagnosis of contusion of soft parts or coccygodynia is- ex-
duded. If the history does not accord with that of dislocation, and
if there are other signs of pelvic, rectal, or neurotic disturbance, and
no verifiable physical evidences of injury, then the case is not one
primarily originating directly from an injured coccyx. Certainly
from a clindal standpoint the condition is one of great rarity.

Treatment, — Reduction should be made at once bidigitally, with
^e index-finger introduced into the rectum or vagina, the thumb
being in the intematal fold. This will be painful for an instant, but
relief from this procedure is prompt. A soft-rubber tube (i inch in
diameter) wrapped in a piece of oiled iodoform gauze is then to be
iiiserted 3 to 6 inches into the rectum and left there three or four
^^.ys. The gauze may then be removed, allowing the tube to remain

•

*^ situ, the bowels being moved on the fifth or sixth day by cathar-
^cs. Packing the vagina with gauze may prove an aid to the rectal
splint; this should be removed on the third day. A gauze plugging
^^ the rectimi may be preferred. A rubber ring or air cushion sup-
port is essential, and a broad strap of adhesive about the hips may
help to limit muscular action. The patient can walk about as soon
^ desired.

The mental effect produced in such a case by referring to it as a
spinal injury'' should induce the cautious physician to refrain from
such remarks in the patient 's presence, espedally as this phrase has
no real surgical or anatomic warrant.

HIP DISLOCATION

This is a very rare form of injury especially in those over forty-
five years of age, inasmuch as patients at that time of life generally
sustain fractures of the femoral neck by violence which in a younger
person might induce luxation.

ajfi TRAUMATIC SURGERY

Landmarks. — Spines: Anterior superior, palpable even in the

very fat. Posterior superior, sometimes hard to fix. Pubic, found
even in a Cat subject by straddling the pubii symphysis with the
thumb and forefinger. Tuberosity: Ischial, usually found by deep
pressure and everting the internatal groove. Great trochanter^ often
visible in outline and ordinarily palpable.

Causes. — Direct violence is rarely at fault, such as a blow or fall
squarely upon the joint. Indirect violence is the ordinary cause,
as from a fall upon the flexed lower limb during adduction and
internal rotation, or from an object falling while the patient is in
some such position as the above, or its equivalent, resulting in the
usual backward dislocation through rotation of the pelvis. The
lesion almost always occurs in adults, but the writer once reduced a
case in an ii-year-old girl.

Fig. ao7. — Dislocation of hip (posterior). Treatment instituted; full anesthesia;
patient placed on Soor; reduction by flexion and rotation; application of long padded
wooden side splint from axilla to below heel; passive motion in two weeks; active motion
one week later.

Varieties.^ — Many are described, but practically they consbt of:
Anterior; the rarer form, includes pubic, suprapubic, injraspinous,
supraspinous, obturator, and perineal. Posterior: the usual form is
the dcrsal (iliac and ischiatic included) ; everted dorsal is a rare type

DISLOCATIONS

of this group. According to ALUs all forms are either inward or
outward. He thus classifies them:

All show abduction and outward rotatioD.

Symptoms. — The prevalent backward form will be described, as
more than one-half the cases are of this variety (Fig. 207). Disabil-
ity is immediate and complete from pain and deformity, and the
patient cannot stand or walk on the injured limb.

338 TRAmunC SDSGESY

Inspection shows deformity of attitude with the limb shortened
and adducted; the knee is bent and rests on the opposite knee; the
foot points downward and the sole rests on the opposite instep.
Trochanter outline lessened; muscles tense; gluteal fold higher;
ecchymosis or signs of contusion or external damage may also appear
(Fig. 208).

Palpation. — Pain on pressure and manipulation. Great tro-
chanter palpable, and it rotates in an abnormal position. Motion
is limited, but the deformity can be slightly increased. No crepitus

Fig. 909. — RelatioD of head of femur to condyles; a. Head and internal condyle in
same vertical axis; b, great trochanter and external condyle in same axis.

or false motion exists and the entire bone can be made to rotate.
The fascia tends to become relaxed. The head of the bone points
practically in the same direction as the internal condyle at the knee,
and this is the best single indication as to the type of dislocation;
the great trochanter is in the same axis as the external condyle (Fig.
209).

Measurement. — This is hard to estimate in the vertical direction
because the limbs are not parallel, but there will be a shortening of
less than an inch generally. The trochanter lies above the line from
the anterior spine to the top of the ischial tuberosity (Nfelaton's
line).

Differential Points. — Fractured neck of the femur (impacted) is
the most likely to be confusing; from a practical standpoint it is

DISLOCATIONS

239

wise to suspect and exclude this before diagnosing dislocation. In
JracluTe the manner of accident is usually less severe; the limb is
usually everted or straight and there is not so much flexion at the
knee or muscle tension; the trochanter is not displaced, and with
fracture there is visible and palpable fulness below Poupart's liga-
ment at the upper part of Scarpa's triangle; measurements are
different. Any disabling injury of the hip- joint in a person over forty-
five is most likely to be a fracture of neck of femur; in this joint,
fracture should be the first and dislocation the last thought

Fig, 3IO. — Reduction of dislocation of hip (donal) a, Thigh fiexed and daaUd; b,
thi^ txUmaUy rotated and abducted c, thigh tnternaUy rotated and addueled. Dotted
lines indicate use of the stockinged foot instead of a band to fix pelvis.

Treatment. — Reduction is carried out by manipulative methods
only, preferably under anesthesia. The patient lies supine on a low
table or, better, on the floor, and whatever the method, it is essential
to fix the pelvis firmly.

BigeUrw's Method {Circumduction). — (i) Flex thigh on the abdo-
men and lift, adduct, and rotate it inward; (2) evert and rotate out-
ward; (3) extend the limb (Fig. 210),

240

TRAUMATIC SURGERY

The foregoing manipulation is thus one of circumduction, the
reduction usually occurring just before extension begins.

Allis' Method. — (i) Flex thigh on abdomen to or beyond a right
angle; (2) lift up; this may accomplish reduction, but if not, some
internal rotation is needed; (3) extension, a step that may be imneces-
sary if the foregoing is successful. The hand or fist in the groin may
help by fulcrum action (Fig. 211).

The pelvis can be fixed by straps or other device, or a stockinged
foot can be used for this purpose.

Fig. 211. — Reduction of dislocation of hip (Allis' metliod): a, Flexion; b, lifting up or

elevation; c, extension and lowering.

Stimson^s Method. — Patient lies face downward on a table, with
both thighs dangling over the edge. An assistant holds the sound
limb horizontal. First, flex knee to right angle and make steady,
gradual forward pressure over the popliteal region. Second, trac-
tion-gravity produces the reduction when the muscles tire; slight
rocking or rotation may assist This is the safest and simplest
method of all. With the patient in the Stimson position, a test of
reduction is thus made (according to Allis) : Flex the leg backward
so that the heel almost hits the buttocks, and then let it drop; if
then it rebounds half-way, the reduction has been effective, other-
wise it is not, as the ham-strings are thus demonstrated to
be acting improperly.

Anterior Dislocation. — Outward Rotation Method. — (i) Thigh
flexed, with original deformity preserved; (2) adduction and internal
rotation; (3) external rotation and extension.

Allis^ Method. — (i) Abduct the sharply flexed limb; (2) pressure
out and back by the assistant's fists held against the head of the
bone; (3) adduct the limb against resistance of the assistant's fist.

DISLOCATIONS 241

After-treatment requires that the limb be held parallel and
immovable by sand-bags, a long side splint, or by tying the knees
together. Two weeks of this is enough, and after that gradually in-
creasing use is allowable. A month or six weeks should elapse be-
fore weight bearing is permitted.

Results. — Prompt reduction leads to early and complete recovery.

Old and Unreduced Dislocations. — Open operation is generally
necessary, because manipulative attempts are likely to cause frac-
ture. As in congenital dislocation, a new acetabulum will be formed,
and many of these patients get about surprisingly well considering
the conditions.

KNEE DISLOCATION

This is relatively rare and ordinarily is an associate of fracture.

Landmarks. — Condyles, internal and external, are readily palpa-
ble, the inner especially; tubercle //&/a, generally palpable and occasion-
ally visible; patella and tendons are located to determine synovial
limits; head of fibula easily palpable and often visible; top of tibia
especially well-marked on flexion of the joint.

'Varieties. — Forward, the usual form; backward, rarer; lateral,
quite rare, either internal or external, the latter being more common .

Causes. — Direct violence rarely is at fault, as by a blow or weight
falling upon the joint. Indirect violence, as in falling, or by a twist of
the knee, is the usual cause.

Symptoms. — Disability is immediate and complete from de-
formity and pain. Inspection shows a distorted, bent knee, with or
without effusion into the joint, and signs of contusion or other
external damage. Palpation demonstrates the tibia, fibula, and
patella abnormally placed, but there is no bony crepitus or fake
motion, thus excluding fracture. Lateral motion is much increased;
pain on manipulation is marked.

Some time ago I had at the Post-Graduate-Hospital an antero-
intemal dislocation without fracture. The symptoms simulated a
supracondyloid fracture of the femur and the patient was admitted to
the hospital with that diagnosis. This unusual condition was due to
a fall of about 20 feet, a mass of d6bris falling with and upon him.
Reduction imder anesthesia was easily accomplished. His recovery
was practically complete.

Treatment — Under anesthesia reduction is genetally easily
made by manipulation and traction; indeed, direct traction usually
succeeds, and should be tried first.

242

TRAUMATIC SUKGERY

After-treatment consists in the application of a posterolateral or
circular plaster-of-Paris cast reaching from the ankle to below the
groin. This is worn a month; massage should begin early, with the
cast split but not necessarily removed for that purpose. Some
passive motion begins when the cast is removed and a leather brace or
light splint should be worn for several weeks, and weight bearing and
overuse of joint enjoined for some time. Massage and increasing
bending of the joint must be a main part of the treatment if stiffness
and atrophy are to be prevented (Fig. 212).

Fig. 212. — Dislocation of knee forward: a, Two types of displacement; 6, c, arrows

show direction of traction for reduction.

Restdts, — Stiffness of the knee with weakness of the leg may last
several months; but if early massage and restricted use form part
of the treatment a successful outcome is reasonably assured. Most
cases get entirely well ; some are left with limited motion at the knee
and some deformity of the joint.

PATELLA DISLOCATION

This is rather rare except as a congenital affection, or as accom-
paniment of bow-legs, knock-knee, or fractures. It is stated that
only about 200 cases of the ordinary variety are on record (Keen's
Surgery, Vol. II, p. 426).

Varieties. — Outward, the usual form; rotatory, in which the articu-
lar surface is more or less reversed; inward, exceedingly rare.

DISLOCATIONS 243

Causes. — Direct violence rarely is productive; usually it follows
indirect violencCy as by a twist or fall, or from muscular action causing
sudden quadriceps contraction.

Symptoms. — The patient drops immediately from deformity and

pain, and disability is complete. Inspection shows a distorted knee;

the quadriceps stands out; signs of synovitis begin promptly; the

margins of knee (especially the inner) are unduly prominent. Palpa-

ium shows the firm patella between rigid bands, where it ought not to

be; parts of the joint generally hidden are seen or felt; some painful

extension but no flexion is possible; there is no crepitus or false

motion as in fracture.

Treatment. — Reduction is generally easy by straightening the

joint (extension), pressing on the knee-pan at the same time, the hip

being bent to relax the quadriceps. If this is unsuccessful after a

few trials, anesthesia should be used. Sometimes it is advisable to

bend the knee before trying to straighten it.

After-treatment is practically that of synovitis. A posterolateral
splint should be worn three weeks, some massage beginning in a week,
with the splint in place. Thereafter some form of knee support
should be used for several weeks.

Results. — Most cases get well completely; stiffness of the swollen
knee and atrophy of the thigh are the last to disappear.

Recurrent Dislocation. — This is due to some anatomic or patho-
logio condition, such as abnormal formation about the condyles,
'^^v'— legs, knock-knee, and laxity of the ligaments. Treatment is
<>pei"stive.

ANKLE DISLOCATION

iTiis very rarely occurs except as an accompaniment of fracture,
^ot^Hy Pott's fracture, and most of the reported alleged uncompli-
^^^'<d cases antedated the jc-rays.

S^andmarks. — Malleoli: the external is prominently visible and

P^t^^ble and reaches \i to i inch below and behind the internal; the

rela-tiipn here is analogous to the styloids at the wrist. The internal

is l^r^^ well marked, but can be made out; it is important to note the

norxxial ridges and spurs on the lateral and vertical surfaces. Astra-

gjl«^^, just in front of and below the external malleolus. Os calcis,

po^tierior margins sometimes visible and always palpable. Peroneal

\'\i)^Tcle, just below the external malleolus, is often visible and is

teadily felt. Scaphoid, the only prominent bony mark on the inner

^de of the foot. Fifth metatarsal, base can be felt.

244 TRAUMATIC SURGERY

Varieties. — Forward, rare; backward, the common form; lateral^
cannot occur without fracture.

Causes. — Direct violence from a blow or falling weight is a rare
cause. Indirect violence from a fall or trip on the twisted foot, or
by some crushing or jamming force, is the usual producing factor.

Symptoms. — Disability is generally complete from pain and de-
formity, and the joint will not bear weight unaided. Inspection
shows a distorted foot with abnormal prominences about the joint,
and the submalleolar tendons are tense. Palpation shows the joint
margins awry; there is no crepitus or false motion as in fracture;
motion abolished and painful.

Treatment. — Under anesthesia, manipulation and traction the
reverse of the deformity, produce reduction.

After-treatment requires a posterolateral plas'ter-of-Paris molded
splint made on the style of Stimson's splint (see Pott's Fracture).
This is worn three or four weeks, massage being given through it
after the first few days. A rubber bandage, strapping of adhesive, or
other support may be advisable for several weeks after the splint is
removed.

Results, — Most cases get entirely well; there may be pain, stiflF-
ness, and weakness for some months, especially if splintage is pro-
longed and massage and reasonable use deferred. Working dis-
ability period is from six to ten weeks; less in occupations where
standing and walking are not demanded.

FOOT DISLOCATION

These are rare and generally associates of fracture or other com-
plication. Astragalus is occasionally dislocated (ordinarily com-
pound) by the same sort of violence that produces ankle fracture or
dislocation.

Symptoms are those of distortion in front of the joint where the
rounded top of the bone can be felt. Subastragaloid dislocation and
fracture must he excluded.

Treatment. — This often has to be operative even where repeated
trials of manipulation under anesthesia have been adequately made.
Indeed, operative removal of the entire bone is regarded often as the
method of choice because, even if successfully reduced, nutrition so
suffers that necrosis is very common and may lead to infection and
amputation. After removal of the astragalus there is little or no
lasting disability, deformity, or discomfort. After-treatment is the
same as for ankle dislocation or fracture.

DISLOCATIONS

246 TRAUMATIC SURGERY

Results. — If reduced (with or without removal of the bone) func-
tion is ordinarily perfect. Working disability period six to twelve
weeks; less in non-laborious occupations.

SUBASTRAGALOm DISLOCATION

This refers to the luxation under the astragalus, including the os
calcis. It resembles the so-called "reversed Pott's fracture" as to
causation, symptoms, and treatment; x-ray examination generaUy
determines the exact diagnosis.

Results. — These are excellent and the disability period generally
does not exceed a month.

TOE DISLOCATION

Not uncommon, especially in the last joint of the big toe.

Causes. — Direct violence, like a blow or falling object; rather rare.
Indirect violence is the common cause, as in tripping, falling, twist-
ing, or jamming accidents.

Symptoms. — Pain and some disability. Deformity may be
slight and most marked in the soft parts. By massaging the
effusion the displaced joint ends can be felt, and fracture excluded by
lack of crepitus and false motion.

Treatment. — This is by traction and manipulation; afterward a
light splint is worn for a week and a circle of adhesive another week.

Results are usuallv excellent.

Fig. 216. — Dislocation of the dbtal phalanx of a toe: a, Posterior variety; 6, lateral

variety.

DISLOCATION OF THE TOES

These resemble those of the fingers and occur from the same set of
causes (Fig. 216). If direct violence is at fault, a fracture is usually
associated.

Treatment is the same as for the corresponding condition in the
fingers.

CHAPTER VI

FRACTURES

A fracture means a broken bone.

Varieties. — These depend upon a number of factors relating to
tlie bone itself and the parts contiguous to it; the following is a
convenient clinical classification :

Simple or closed Jracture, where the bone is broken, leaving the
skin intact.

Compound or open fraclurey where there is a wound in the overly-
ing skin communicating directly with the bony break.

T-ncomplelef bending, or greenstick fracture, where the bone is not

bfolccn completely across; this generally occurs before the age of

^^^cn, is commonest in the forearm and clavicle, and is a rarity in

^dtt.1 ts. Undetached cracks or splinters or depressions also fall into

this group.

'omplete fracture, where there is absolute separation of bony
fra^:B3ients in varying axes, as: (a) Transverse, straight across or
^^^"ly so, conmionest near the wrist and knee; (6) oblique, cleavage
^^ ^-^::i angle, the commonest form ; {c) spiral, oblique breaks with rota-
tiocft. of one or both fragments, next commonest form ; (d) comminuted,
^^i^ splintering or fragmenting; (e) impacted, with jamming or lock-
ing ^::%i the fragments, as seen typically in the neck of the femur; (/)
crus-^ifig or compression, with more or less pulpifying, as in the bones
^^ ^l:ie arch of the foot; (g) subperiosteal, rare, the periosteum being
^^^-^:rt over the break; (A) longitudinal, very rare, the long axis of
'^^^'^ being completely split; (i) T-shaped, a combination of trans-
ver^s^ and oblique or longitudinal, rather rare and oftenest seen at
^^ inee and elbow; (J) epiphyseal, separation of an end from the
^—^'t; they only occur before the twenty-first year and are prac-
tice. Ijy transverse joint fractures; {k) multiple, breakage at more
"^^^^>. one level in the same bone.

^Displacement Directions. — These depend upon the site and

ca^Se of the fracture, and the separation is greatest in long bones

itoxici severe forms of violence: (a) Lateral or transverse, this may be to

on^ side or forward or backward; overlapping or overriding of frag-

ix^^Xits of varying degrees is associated; (b) angulation, an exaggera-

tiotx of the above, one fragment being much displaced as a rule; (c)

247

248

TRAUMATIC SURGERY

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2 so TRAUMATIC SURGERY

longitudinal, an overlapping or overriding, usually of the lower
fragment upon the upper; (d) rotatory, a twisting of one or both
fragments, more or less overriding generally coexisting.

Causation. — The exciting or determining causes are: (i) Direct
violence, as from a blow squarely upon the part broken; (2) indirect
violence, the common cause due to force transmitted from a distance,
as from a fall, twist, or wrench; (3) muscular violence] from a strong
contraction of muscles. '

The predisposing or secondary causes may be said to consist of
the following (i) Local and (2) Systemic factors:

Local Causes of Fragility —

Pyogenic
Inflammatory! Osteomyelitis Tubercular

Syphilitic
Sarcoma — metastatic or primary
Carcinoma — metastatic
Tumors I Enchondroma

Cystoma (ecchinococcus of bone)
Hypernephroma
Aneurysms.
Systemic Causes of Fragility

Locomotor ataxia (Tabes)
Neural Syringomyelia

Mental(Paresb)
Senility

Chronic exhaustive diseases (Diabetes, Nephritis)
Atrophy of non-use
Scurvy

Rickets — osteomalacia
Osteoporosis — fragilitis ossium

Of the foregoing, the commonest are tumors, syphilis, tabes,
rickets, and local bone changes.

Healing Process. — The progress toward repair is similar to that
of damaged soft parts. In effect, a fracture is a lacerated wound of
bone. Essential elements for osseous repair are the periosteum and
cortical bone, as new bone cells are reproduced therefrom; these cells
are called osteoblasts. When any bone is broken the {a) bony edges
are more or less separated; (6) the periosteum is torn, separated, or
stripped up, a section of it remaining attached and forming the im-
portant so-called ''periosteal bridge;" {c) damage to the subcutane-
ous tissues occurs, resulting in hemorrhage more or less localized ;
(d) in joint fractures, there is synovitis, tenosynovitis and
arthritis. Repair starts promptly, and the hemorrhage is absorbed
and is replaced by connective-tissue cells in the form of a plastic

FRACTURES

251

exudate. The periosteum and cortical bone begins to form new
osteoblasts, and this and the foregoing unite to form a soft gluey-
mass called the temporary or provisional callus. The more perfect the
bony fragments are replaced, the sooner will this mass coalesce and the
smaller in amount trill it obviously become. If the fragments are
well coapted, we get, in effect, primary union (first intention) ; if not,
we get miion by secondary union (secondary intention), with the for-
marioD of much osseous granulation tissue or callus (Fig. 217).
The central part of the bone (medulla) helps also in the process by
plugging the canal of the bone and forming what might be termed
an "intramedullary splint." This soft callus gradually hardens

Fig. H7. — Callus formatioii following a fracture; o. Reduction complete; (, reduc-
tion nearly complete; c, reduction incomplete. In a there will be primary or first in-
tentioD utuon.' la b and c there will be secondary or second intention union.

and begins to be replaced by actual bone in from twelve to axteen
days, the ossification being chiefly due to cells derived from the peri-
osteum and adjacent cortex. All this time the bony fragments are
ensbeathed in an envelope of oval shape much like the joint made by
a plumber in joining a broken lead pipe ("plumber's wiped joint");
this is the so-called "ensheathing callus." This stage of bony or
permanent callus proceeds and the mass is gradually reduced in size
. by a process of rarefaction and condensation, and meanwhile the
plug in the medulla becomes traversed by the normal lamells, and
finaUy nothing remains to bridge over the break except a layer of
callus on each side of the fragments under the periosteum, and this
final result in repair is known as cortical callus.

It is thus seen that the whole process toward union is one of scar
formation analogous to that occurring in the skin or other soft parts.
The average time for the formaUon of bony callus naturally varies in
different bones, and is about as follows: three weeks, clavicle, ribs;
four to six weeks, arm, forearm, leg; six to eight weeks, thigh.

252 TRAUMATIC SURGERY

In children, union is somewhat more rapid; in the aged, a little
slower. The better the setting, the quicker the union. Simple
(closed) fractures unite somewhat sooner than clean compound
(open) fractures. Infected compound (open) fractures unite more
slowly, as do multiple or comminuted fractures.

Impaired Healing. — Where union is prolonged two or more weeks
beyond the average, we speak of it as delayed union. If the union
occurs with the interposition of fibrous tissue, we speak of it as
fibrous union (also called /a/se callus). This junction by a fibrous
band is common in the neck of the femur, patella, and olecranon.
If a joint-like function is eflfected we call it pseudarthrosis or false
joint; this is exceedingly rare. When there is little or no imion we
speak of it as non-union. Strictly speaking, it is rare for this to
occur, as in time some sort of union always ensues. When there is
much deformity or disability after union, we speak of it as ^' faulty ^^
or ^%icious union;^^ this is commonest in the clavicle, arm, forearm,
leg, and thigh.

Causes of Impaired Union. — These may be: (i) Local, due to the
bone; (2) general or systemic, due to constitutional disease.

(i) Local, — (a) Imperfect setting and immobilization, resulting in
separation of fragments. This is the main cause, (b) Intervention
between fragments, of bone, muscle, tendon, or other soft parts, (c)
Infection by pus-producing germs, (d) Deficient blood-supply from
original blood-vessel damage or subsequent treatment, {e) Tumors
of the bone, like sarcoma.

(2) General. — Acute infectious diseases, tuberculosis, syphilis,
rheumatism and gout, nephritis, diabetes, alcoholism, rickets, anemic
states, locomotor ataxia, syringomyelia, paralysis, and paresis. I
firmly believe that distant and perhaps relatively quiescent pus
foci are foes of early union and are often the source of infecting
blebs; oral and genito-urinary septic foci are the commonest
sources.

Practically speaking, the main cause is improper setting and im-
perfect splintage; the next commonest cause is interposition of soft
or hard parts. I do not believe syphilis to be a marked factor; if it
was, non-union would be exceedingly common.

Fracture Symptoms. — These are: (i) Subjective, related by the
patient; (2) objective, apparent to the examiner.

(i) Subjective. — The patient makes statements as to (a) pain^
usually considerable at the time of the injury; it may diminish for a
short period soon thereafter and recur when the "secondary swelling'^

FRACTURES 253

begins. After setting, it may completely cease, but always dimin-
islies. It may be located at the site of the break or radiate there-
from. Alcoholics and syphilitics feel it but little, and it is less marked
when there is wide separation of the fragments or when they are
impacted. Generally it is more severe near a joint or about parts
rich in nerve supply. Expressions of pain vary largely with the
indi^dual and the circumstances of the accident. Workmen,
soldiers, athletes, and others occasionally pay little heed to pain under
the excitement or interest of work or contest.

(i) Disability, — Usually loss of function is more or less complete
from pain or deformity, or both; this greatly depends upon the site
and nature of the fracture and the manner of its receipt. The dis-
ability becomes more manifest upon purposeful efforts to function-
ate, and it is greatest in those bones necessary to the work or object
irx h3.nd.

(c) Audible Sensations. — Frequently a patient will say '*I heard
Sonne thing crack;" in reality, any such sensation must be more
inaaginary than real.

(d) Deformity. — Usually spoken of in terms of distortion or swell-
ing ; this varies within wide limits.

(2) Objective. — Those are the most essential, and should be
searched for systematically. The pathognomonic signs of respective
fractures will be stated in detail later.

Cg) Inspection. — Deformity. — Indicated by the attitude of the pa-
tient and the outline or axis of the part aflfected.

Swelling. — This may not appear for an hour, and is greatest in
vascular areas and where the bone is close to the surface or main
joints.

JXscoloration.— Redness may appear within a few moments, to be
loUovred by more or less diffuse bluish discoloration within a few
l^ours. Localized and late, it is very suggestive of fracture; as, for
^'^ta.nce, the postmastoid ecchymosis of fractured base of skull, or of
^^ perineum in fracture of the pelvis. It may be very extensive
^^d extravasate a long distance, as in a fractured arm with ecchy-
^osis reaching to the elbow and midchest.

Slebs (serous or bloody) are typical of fracture and may occur

^ter the first few hours. They are most marked in simple fractures

^i the leg, but are rare in all forms of compound fracture because the

^ound of the latter appears to relieve subcutaneous tension by a

sort of spontaneous decompression.

[b) Palpation. — Deformity sometimes can be outlined. Pain

254 TRAUMATIC SURGERY

elicited by direct or transmitted pressure or motion of the part.
Even in the absence of other signs, the presence of localized or point
pain is very suggestive; this is notably so in the clavicle, forearm,
and fibula.

(c) False motion occurs in fractures and in no other condition, and
is the only pathognomonic sign of such lesion. It must be elicited care-
fully; it is least reliable in the presence of much eflfusion or near
joints, and most valuable in fracture of the shaft of long bones.

{d) Crepitus is the most unreliable sign, as it is inconstant, occurs
in other conditions, and to elict it often causes needless pain and
damage.

{e) Tension or spasm is often noted in adjacent muscles, especially
in upper thigh fractures.

(/) Motion, passive and active, is limited by pain, spasm of muscle,
and deformity. Certain abnormal motions may be increased, as in
Pott's fracture.

ig) Auscultation. — Combined with percussion, a change in the
note is apparent by use of the stethoscope or ear; most marked in
the skull, clavicle, and ribs, when little or no separation has occurred.

(A) Measurement. — Ordinarily shorter in the vertical and larger in
the transverse diameter.

(i) X-ray. — Usually not needed. Fluoroscopic examination is
exceedingly unreliable and deceptive. Radiographs should be made
in two axes of the limb, and the uninjured side should be shown on
the same plate if possible, and all the plates should be made with the
same focus and the same axis, so that false shadows will not mislead.
In a graphic manner the essential signs can be thus listed:

Inspection

Palpation

Motion

Mensuration

X-rav

eformity; in the bone, posture or attitude

isability; partial or complete

iscolo ration; pathognomonic in certain locations
Local pain; very suggestive in atypical cases
Irregularity; marked in cases with displacement
False motion; pathognomonic
Crepitus; very unreliable when near joints

j p . r limited by pain, deformity and muscle tension

Vertical; axis shortened
Transverse; axis increased
Fluoroscopic; unreliable in atypical cases
Radioscopic; both axes needed

Complications. — Those relating to the bone have been referred to
under Impaired Healing; the others may depend upon (i) local or
(2) general or systemic causes.

FRACTURES 255

•

(i) Local Causes. — Skin may be contused or otherwise damaged
by the inititating violence, or later from the swelling; either
occasionally leads to ulceration or gangrene. A bleb allowed to
become infected or pressure from a splint may act likewise. Teno-
synovitis, arthritis and myositis are often regular accompaniments.

Blood-vessels may be excessively torn, leading to hemorrhage; in-
flammation of vessels may cause arieritis or phlebitis. Embolism or
thrombosis occasionally occurs, most commonly of a pulmonary type
in the aged. Aneurysm is a very rare sequence.

Nerves may be contused^ lacerated, or severed. Some tropic changes
and disturbances of sensation may also occur, causing anesthesia or
hyperesthesia. Neuromata rarely occur.

(2) General Causes. — Shock of some degree is an incident of most
fractures; it rarely lasts more than a short time, and if profound,
generally indicates severe or associated injury, and frequently is a
symptom of hemorrhage.

Fat embolism is generally a late manifestation. Fat gets into the
circiilation in every fracture, and is generally found in the urine. If
emboli result, the lungs, and kidneys are oftenest affected; some-
times areas of infarction form that may lead to death.

Sepsis is limited practically to compound (open) fractures. The
pus-producing organisms, especially staphylococci and streptococci,
axe the common offenders. The germs of tetanus, malignant edema,
and the Bacillus aerogenes also occasionally gain entrance.

Delirium tremens is rather common and occurs usually in steady
drinkers who may be practically sober when hurt, and to them the
shock of the accident, the enforced idleness, and the withdrawal of
alcoholic stimulation is too much for a nervous organism that has
been more or less nourished by alcohol. This is a very serious com-
plication, and it is a good rule to administer prophylactic doses of
bromids and chloral (or other sedatives) at once to any patient of
known alcoholic type, or to one who shows tremor of the tongue,
fingers, or muscles, especially if insomnia coexists.

TraumcUic delirium is rare and is said to occur chiefly in the young
and aged, or in those who are total abstainers. The symptoms are
like alcoholic delirium. The writer has never seen an authentic
€ase.

Pneumonia is rather common, especially in the aged, debilitated,
and alcoholic. K it occurs early, frank lobar or lobular pneumonia
generally exists; later, hypostatic pneumonia is more usual, and then
the pulmonary symptoms are not marked, but the condition is usually

2s6

TRAUMATIC SURGERY

one of great prostration, dry tongue, somnolence or irritability, and
low delirium, with terminal edema and coma.

Fig. 2 1 8. — Coa4;-sleeve sling. Fig. 219. — Coat-sleeve sling.

Treatment. — There are " three R 's'* in fracture treatment, namely
Reduction (setting), Retentuni (splinting) 3,nd Restaralion (functioning),
and in a graphic manner these essentials may be thus stated:

Traction
Extension
Flexion
Manipulation .

Pillow

Board

Sand bags

Reduction

With or without } anesthesia

Retention

Tempo rar>'

Permanent

Bricks
Plaster Paris

Metallic

Operative

.^ I Moulded
i Circular
Army — Thomas
Hodgen-Jones
Calipers-Stirrup
, Steinmann
Wire — Nails — Screws
Clamps

Bone
Metal

Plates

Restoration

Massage — Motion

Hydro
Thermo
Mechanico
Occupational ,

Passive
Active

' Therapy

FRACTURES

257

Treatment may be divided into: (a) Primary or first aid; (i) re-
duction or setting; {c) immobilizing or splinting; {d) restoring func-
tion by massage, manipulation, or apparatus.

(a) Primary or first aid has to do with the transportation and
initial care up to the time of setting. Every effort should be made to
teep the part in as nearly a normal position as possible, free of all

Fio. 220, — Improvised splint made from a coat or blanket rolled on a pole or rail.

en.ciTcling pressure. If a patient is to be carried, one person should be
gi^^^en sole charge of the injured part and others should perform the
a-ctxaal lifting. A coat, two shirts, or a blanket rolled upon canes,
slats, or broomsticks (Figs. 218-221) makes an efficient splint that will
pre^vrent compounding a simple fracture. A pillow makes the best
of temporary splint for either extremity or for the pelvis. A

^10. ,„_

221. — Hyperflexion of the knee, acting as an improvised tourniquet for bleeding

from a fracture below the knee.

^^-•^ titer or cellar door makes an excellent litter. A bleeding compound

^P^^n) fracture may need a tourniquet occasionally; the wound is

^^t:er left exposed unless it can be covered by sterile material. With

*^^ patient in bed, the part can be kept motionless by sand-bags or

P^^ded bricks, or by some improvised loose splint made from a

^^^^ow, a pasteboard or wooden box, shingles, or fence-slat.

Blebs are opened only if they are likely to interfere with the dress-
^^gs; the later they are opened, the less the chances of infection.

258

TRAUMATIC SURGERY

Incomct

Correct

They should be iodin sterilized and transfixed at their base with a
sterile instrument (Fig. 222).

(6) Reduction or setting is the most important element and the key
to the outcome, as no splint or other device can promise a good result
if the setting is inadequate or faulty; conversely, the splint is rela-
tively unimportant if good setting has been accomplished. The bone
should be set as soon as possible.

However, it is to be appreciated that there are two general classes
of fractures, namely: (i) displaced and (2) non-displaced. The

former demand reduction and retention
as essentials of treatment; but the
latter require retention only. In other
words, some fractures must be set and
splinted, but others need only splintage.
Traction, pressure, and manipulation
are the maneuvers used, and where
anesthesia is declined or inadvisable,
some relief from muscular contraction
can be obtained if the limb is allowed to
dangle; or if pressure is made for a few
minutes over the main blood-vessel (as
the axillary or femoral); or if the limb
is placed in salt and ice until the
** freezing" effect is gained.

Anesthesia is a valuable aid, notably
in fractures about the wrist and ankle.
Nitrous oxid, ether, or ethyl chlorid
should be used in preference to chloro-
form, because the latter seems danger-
ous in this as in most injuries. Primary''
anesthesia only is needed, as a rule, but
care must be observed in keeping the
dressings intact when the patient is
regaining his senses.
Dr. T. Drysddlc Buchanan, Professor of Anesthesia at the Post-
Graduate, has at my request given the following directions for
anesthesia in fracture cases:

*^ln view of the fact that the safe administration of nitrous oxid
and oxygen requires a special knowledge and training, primary
ether, or ether analgesia as it is sometimes termed, offers the simplest
and safest means of anesthesia for the reduction of fractures or
dislocations.

Fig. 222. — Opening a bleb.
The correct method is to transfix,
incise, or aspirate at the junction
between the sound and unsound
skin. The incorrect method is to
make the opening at or near the
summit.

FRACTURES 259

With a little practice the following technic of administration will
be found to produce a very satisfactory anaesthesia and relaxation,
riace any frame mask, covered with several layers of gauze or
one layer of stockinette, over the patient's face, instruct the patient
to count aloud very slowly and begin dropping a few drops of ether
on the mask, increasing the rapidity of the drop as fast as the pa-
tient will tolerate it without a marked gulp, cough or other evidence
tlia.t the vapor is too strong for comfortable inhalation.

"WTien most patients have counted to fifteen or twenty you will
find that a steady stream of ether will be tolerated. Continue this
stream until the patient has lost the ability to count or where upon
skipping a niunber, the patient is unable to go back and pick up the
aiamber skipped.

-At this point the manipulations may be begun and the ether
discontinued. Given in this way the anesthesia is invariably fol-
lo-^^ed by immediate recovery without vomiting or nausea.

Should the reduction take longer than anticipated the anesthetic
can be renewed at the first sign of pain though in this event the
recovery is not always so immediate or free from nausea. ''

(^c) Immobilizing or splinting may be temporary or permanent.

The essentials of a splint are; (i) Safety and adequacy; (2) ease of

application and removal; (3) comfort, light weight, pressure freedom;

(4) ready inspection of the part; (5) cheapness; (6) capability of

beiixg used from start to finish.

The usual splint is of basswood or white wood or plaster-of-Paris.

Felt, tin, aluminum, and other materials are also used. The *^sets of

splints to fit any fracture" are usually about as valuable as the aver-

3-ge machined horseshoe before it has been shaped in the forge; it is

wisest to make the splint fit the fracture rather than the fracture fit

the splint.

Strips of freshly prepared plaster-of-Paris, so shaped or molded as
^ fit the part, make excellent splints for the arm, forearm, lower
^Sk, and leg fractures; these so-called "molded plaster-of-Paris
spLints" meet all the essentials nmaed above and they can be applied
^t ^^nce.

If swelling of the part is excessive, the limb should be shaved and

protected by layers of loosely applied gauze or cotton, and then placed

^ ^n elevated temporary splint made of a gutter-shaped box or tin

Itongh which extends far enough up and down to fix adjacent joints.

li a molded plaster-of-Paris splint is used, it is not necessary

to await the subsidence of the swelling. Splints of wood }^i to J'i

26o TRAUMATIC SURGERY

inch thick suitably padded can be placed laterally on a limb as a
temporary support; they should always be wider than the limb and
well protected to prevent pressure. In from one to ten days swell-
ing should dimmish enough to allow a permanent dressing to be
applied, and this is generally of plaster of Paris, either a circular
plaster or molded plaster cast.

Circular plaster casts are applied by first shaving the limb and
then washing it with soapy water and later with alcohol. After
being dried, it should be powdered with talciun or borax. Blebs are
painted with iodin and if punctured are covered with sterile gauze.
A flannel or sheet lint bandage is then applied, snugly, smoothly, and
circularly; any reserving will cause pressure and wrinkling. In lieu
of flannel or lint, sheet wadding, stockinette, or several thicknesses
of gauze or cotton may be used. The plaster-of-Paris bandage mean-
while has been soaking in hot water and is now applied, beginning at
the distal end of the limb. Depending on the fracture and the band-
age, from six to twelve layers of bandage will be needed. They are
best made from crinoline or wide meshed gauze with "dental
plaster." Any width less than 4 inches is hard to apply. Loose
plaster can be rubbed on to fill in the gaps and smooth rough spots.
Reinforcement can be made by strips of basswood, almninmn, wire,
or tin. The French do not use plaster in roller bandage form but
instead cut strips of crinoline of appropriate pattern, soak it in
plaster cream and then make the application in two or more strips.
This makes a very satisfactory splint. The limb must be carefully
held while the plaster is drying, and if any swelling occurs, the cast
must be immediately split, as pressure of a few hours may lead to
irreparable damage. The cast is best cut by an ordinary heavy jack-
knife; vinegar, or peroxid and hot water softens plaster. If a circular
cast is applied with the object of being immediately slit, this can
be best accomplished by burying a Gigli saw or piano wire just under
the first turn of plaster; such a dressing is called a "split circular
cast." With care and some reshaping it can be used from start to
finish in many cases, and the edges of it may be well protected by
adhesive plaster.

Molded plaster casts are fashioned by two methods. In one (as in
the shoulder or leg) a pattern is cut of the part to be enclosed, and
this is then covered by many overlappings (six to twelve) from a
moist plaster bandage, and while moist it is applied and held in place
by gauze bandages until drying is complete, and it is then suitably
held by adhesive or other means (Fig. 223). The usual method

FRACTURES 261

(especially in Pott's and Colles' fracture) is to determine the length
^nd 'Width needed, and then a piece of flannel, sheet wadding, or
Jint is selected an inch wider and longer than required. On this as a
1::>ase a moist plaster-of -Paris bandage is unrolled until from five to
^Jteen thicknesses are laid, and this makes one-half of the splint, and
X t is then put aside until the other half is similarly fashioned (Figs.
377-380). These are then applied (the flannel or wadding next the
skin) and molded to fit the part and kept in place until dry by a few
-txirns of a gauze bandage. When dry, this bandage is removed and
e splint is trimmed as needed, and then fixed by a few Spiral bands

Pig. 223. — Posterior molded plaster-of-Paris, metal, or felt splint for the lower ex-
tremity; this is commonly called a "slipper" or "trough" splint.

of a-dhesive, and still further reinforced by a gauze bandage. There
is always a gap at the margin of such splints sufficient to permit
circulation and inspection; likewise cutting one edge of the adhesive
allovrg either portion of the splint to hinge over like the lid of a box,
thvxs giving access enough for greater inspection, massage, or motion
wlien desired.

Other Splints. — Flour paste and paper make a fairly firm and light
folded splint. Yucca wood** and felt are useful in some cases.
Sheet aliuninum, tin, and wire netting also are used. The **Army
^yi>e" of splints arc especially useful for transport and temporary
^^ I>ermanent usage.

TVindaw Casts, — In a compound (open) fracture it is often neces-

^^^y to have a gap in a circular cast for dressings, and such a hole is

^1^ a "window.'' It is best to cut this while the cast is hardening,

^^^ required area having been previously determined. If an inverted

™- cup or small wooden block is placed over the site of the "window"

^t^T one layer of plaster is applied, the lump thus formed acts as a

P^cle for the cutting out of the plaster after it hardens. A strip of

^^e will answer the same purpose if the ends are left protruding

Itom the cast. The margins of such a window can be protected from

taveling and soiling by a lining of gutta-percha tissue, oil silk, or

adhesive. The former is purchasable in yard-square sheets and

262 TRAUMATIC SURGERY

is about as thick as paper. Mixed witli chlorofonn it forms a
rubber glue that can be brushed on the edges of the window if desired.
If the Conditions require, the cast may be applied in two drcular
segments, the intervening part being bridged over by rods of curved
iron or other metal (Fig. 224).

(d) Restoring Function. — This step in treatment occurs generally
of its own accord if the preceding essentials have been successful.
No rigid splint should be used after firm union occurs. GenUe massage
can be given after the first day in practically all fractures, notably

Fig. 224. — Plaster-of-Paria cast for compound fracture of leg with window and angle-

those near joints. Each massage period is gradually increased
from once daily for five minutes to twice daily for twenty minutes or
oftener. Camphorated oil, olive oil, or cocoa-butter are good
emollients. If a molded splint is used, the massage is given at first
with one-half the cast in situ. If massaging causes undue pain, swell-
ing, or redness, it is being given too vigorously, doing harm, and
should be modified; ordinarily it causes a sense of warmth, tingling,
and satisfaction. The parts above and below the actual fracture
should be first massaged, gradually getting nearer to the broken area.
Adjacent joints should get the most vigorous attention. The
"Scotch douche" is excellent for stiff joints and consists of five
minutes, forcible spraying or douching of cold water, five minutes of
hot water and then five minutes of rubbing with warm camphorated
oil. The whole object is to (i) reduce swelling, (2) promote cir-
culation, and {3) restore muscle tone during the period of enforced
inactivity.

Passive motion can be given in some cases in a few days, and in
nearly all in two weeks. The range of motion is at first very slight
and at a distance from the break, and ordinarily is given at the
end of a massage seance. The increase of motion keeps pace with
the massage increase; and when it has proceeded a week or more with-

FRACTURES

263

out undue reaction, then the patient can be allowed to make active
motion unaided and within narrow limits. In all cases the patient

Fig. 225.

Fig. 226.

Fig. 227.

Fig. 228.

Figs. 225-228. — Rubber-band exerciser for a stiff wrist or elbow. Thb arrangement

or modification promotes flexion or extension.

must be cautioned to move the unsplinted parts rather vigorously;
This is especially necessary in fractures of the forearm, where the

264 TRAUMATIC SURGESY

iiagers must be kept moving to forestall tenosynovitis. The vigorous
use, in or out of bed, of dumb-bells, weight pulls, and forced breathing
do much to prevent hypostatic complications, especially in'the aged

F^O. 3>9. — Rubber-band exerciser for a stiff ankle. This arrangement or modification
promotes flexion o

Fig, 331, — Rubber-band

or debilitated. The methods suggested in Figs. 225-231 are self-
explanatory and are of service in those cases associated with joint
stiffness. The further treatment is given under Complications.

FRACTURES 265

COMPOUND OR Open Fractures

Special attention is given these to prevent sepsis, leading to de-
layed healing, necrosis, amputation, or even death. We are dealing
with a presumably infected lacerated woimd and a broken bone in
every instance, and to that degree we begin with an infection.

One of the great surgical lessons of the war is the recognition of
the value of early complete mechanical or chemical sterilization
of broken bones. See "Woimd Treatment," p. 3i-

Primary Treatment. — The first essential is sterilization; the second,
cottservation.

Give tetanus antitoxin, especially if there has been any chance of
inf eotion from soil or street dirt. Pour tincture of iodin freely into
and about the wound and then cover it with a clean dressing. If the
part is dirty or much lacerated, or if the fracture seems severe, insist
on ether or nitrous oxid being used; then shave the adjacent parts,
k^^ping the wound itself covered by a sterile pad until the last. Gret rid
^^ grease with gasolene, benzin, ether, kerosene or oil, but do not
scrub or roughly handle the parts. Sop with alcohol and dry, and
then paint with one-half, strength (33^^ per cent.) tincture of iodin,
^Uing the wound to overflowing with it. The wound and the parts
a.bout it are now a relatively sterile field, and surface infection will
be cared for by the iodin.

Skin at the edges of the wound especially if badly crushed (already
dark, blue or brown) had better be clipped oflf (debridement process).
It is generally wisest for inspection to extend the original wound by
^ scissors-cut unless there is a mere puncture; comminution and skin
stripping m&e this incision imperative for the purpose of introducing
iodin.

Muscle or tendon pulpified or frayed so that it is brown or black

^nd soft can be cut away; otherwise it is safest left alone.

-Blood-vessels torn and bleeding are tied with plain or iodinized cat-
gut.

Serves, if important and recognizable, are anastomosed by fine
^^ sutures.

-Periosteum is saved to the last degree unless wholly detached or
discolored.

Bane fragments, if attached, are kept, especially if only a small por-
tion of periosteum adheres. Loose, detached, and denuded fragments
Me better out than in, unless they can be refitted; this is especially
true of the medullary part of long bones. If the medulla is exposed,
bmised or discolored, it should be curetted to a healthy level. All

266 TRAUMATIC SURGERY

soft parts preventing bony coaptation must be lifted or cut away in an
effort to make reduction as perfect as possible; however, continued
traction obviates much of this. Metallic aids to maintain the
corrected position (wire, plates, or pins) do not act well when applied
at an early stage; hence kangaroo or chromic gut should be employed
imless there is an obliquity or fragmentation requiring .unusual
force to maintain the position. In such an event, some metallic
device (wire, screw, nail, band, plate) is applied temporarily.

Instead of this immediate or "primary suture" method of con-
verting a compound (open) into a simple (closed) fracture, the pro-
cedure of intermediate or "primo-secondary" suturing may be
adopted. This means that the closure is made after the third day,
clinical and bacteriologic evidences having determined the sterility
of the wound. If closure is attempted after the sixth day, the pro-
cedure is known as late or secondary suture, and at this stage granu-
lations are so developed that the wound surface can be covered by
exsecting a thin slice of the skin and superficial fascia, undermining
at the edges if necessary but not interfering with the central part of
the wound.

Closure should begin by bringing periosteum over the line of break
so far as possible; interrupted plain or iodized catgut sutures are used
for this, without imdue tension. Loosely suture muscles and tendons
after the same manner. Drain down to the fracture site with gutta-
percha (rubber) tissue, a cigarette drain, or rubber tubing; make an
opening at the opposite side or lower down for counterdrainage if
needed. Two small drains are four times as good as one big drain.

Skin is loosely stitched with silk, horsehair, or silkw<trm-gut, this
stitch being interrupted and including the subcutaneous fascia.
Squeeze the wound dry and cover it by eight or more thicknesses of
gauze moist from immersion in iodin water (3 j : Oj). Do not en-
circle the limb until several more layers of dry gauze are applied, and
then use a gauze bandage to cover all. Place the part in a Thomas,
box, gutter or other loose, well-padded temporary splint. See that
reduction is well maintained and that the part is elevated when the
patient is returned to bed. If there is much separation, bruising, or
crushing of the part, it is a safer plan to do little if any suturing ; in such
a case the wound, after iodin cleansing, is loosely packed with moist
iodin water gauze.

No wound of compounding is too small to drain; none too large to
leave unsutured. Treat the constitutional signs in the ordinary man-
ner, as necessary.

FRACTURES 267

In certain cases (notably fractures of the arm, forearm and leg)
the war practice of exsecting the skin, the damaged soft parts and
the loose bone, flooding with ether and suturing of soft parts in two
or more layers may be the method of choice.

After-treatment. — In the absence of much local pain, soaking of
the dressings, temperature over ioi° F., or pulse over loo, it is un-
necessary to change the dressings until the third or fourth day; the
seventh day may be early enough in some instances. At this first re-
dressing the splint preferably remains in situ. If there is not much
discharge, if the woimd looks healthy and if signs of inflammation are
lacking, then it is prudent to remove one drain completely if two were
inserted. If only one was used, it can be removed or shortened an
inch and twisted in the wound to prevent adhesions fastening it.
A dry sterile gauze dressing is then applied. If, however, signs of
trouble are manifested by pain, fever, high pulse, and local evidences
of beginning infection, then some of the stitches must be removed, the
wound irrigated with hot iodin water (3 j : Oj), and the gaping open-
ing loosely packed with moist iodin water gauze. Support such a
patient well with food, whisky (especially if a drinker), strychnin, and
quinin. Regard this patient as a septic case. Bacteriological ex-
amination of the wound secretion should be made when possible to
determine the type of organisms present. Dress the part again that
same day if necessary. If there is any foul-smelling discharge
(generally it is brownish yellow), then irrigate with a deep pink-
colored solution of permanganate of potash and use a wet dressing of
the same. Do not use peroxid in any deep or hidden cavity. Cut
away sparingly any black or deeply discolored, sloughing, soft, or
gangrenous areas, for many of these later delimit themselves. A thick-
ish yellow or whitish pus means usually a staphylococcus infection a
great deal less virulent than a streptococcus infection, with but little
or no thin pus. Green pus is usually a pyocyaneus infection of low
grade. Foul, odorous discharge is probably colon infection. If
there is any crepitation, bubbling, or gaseous formation in the wound
the condition is dangerous, as the infection is then of the type of
malignant edema or Bacillus aerogenes capsulatus (gas gangrene).
Multiple incisions and counterdrainage are then needed, with flooding
of the part in peroxid of hydrogen and a plentiful gauze dressing wet
in the same material, or any other oxygen carrier, such as permanga-
nate of potash.

If the local or general conditions still seem uncontrolled, then an
anesthetic should be given, the splint removed, and the woimd laid

TRAUMATIC SURGEBY

PREFERABLE SITES oT AMPUTATION from
ARTIFICIAL LIMB STANDPOINT

(UPPER EXTREMrTY)

e Humeral Head.if posjiUtai'ituof
dJvartla^ in rilling Glenoid CWly

^ Upper Bonp Limtf of funcMonal
Value in Arm Ampul'ation.

iich?s of bon* shorfvsl ilump of valu*
in aclivaling appliance

Bon^ LeH of Greatest Funchonat Valu?
in Arm Amputation

Upper Bone Limit oF functional Value
in forearm Amputation

3 inchtt oF bone shortest of value

.Bonp Level oF Greatest runcliondl Vafu?
in Forearm Amputation Because of
PfpservaKon of Power of Pronation
and Supination.

Save Every Portion of Hand Possible

(ort anterior and pojierror flaps Ihe rule
:^pt a' nrist ivh«re long palmar Flap Is used.

Ro. 33*. — iProm "Remrw oj War Surgery and Medicinr," August, igi8.)

FRACTURES

269

PREFERABLE SITES ^AMPUTATION /«"»
ARTIFICIAL LIMB STANDPOINT.

{LOWER EXTREMITY)

itbovp this uppvr limit disartkulal*.-
Ti>D'Sl»pop«rdtion vSMWy prehrabtp

_Upppr Bone Limit of FuncHonal
~ Valup in Thigh Amputation

Two Mich slump measured from
pubvs shortest evrr of valo*.

n<? L?v9l of Greatest Functional
Value in Ttiigh AmpuJalion.

Upp^r Bortp Limit of Functional
Vdlu^ in Le^ Amputation.

inches of tibi» ibotitil twr of nlu9.

Bon^ LpvcI of ^rfdtest Functional ValuP .

Lt^ Amputation. At or Jusl Below the Middle.

e '\Khti oFbon? bKt from arlifkial limb standpoint.

e Level of Good Functional Value But
Unsatisfactory for Fitting.

6one Limit of functional Vdlue
in Foot Amputation.

AMfiUn^TfiW^Sonf OiKJs,on)f// S/M01D AffC/l (fit-
SmSfACTORy fROMAPTfrfC/AL UMB STANDPOINT.

—{FroM "Retieic of War Surgery and Medicine," August, igiS.)

270 TRAUMATIC SURGERY

widely open and redisinfected by iodin. If there are pockets or
sinuses, each must be drained and counterdrainage liberally provided
where needed, as the condition now is a deep-seated cellulitis with
perhaps osteomyelitis. The splint is reapplied with the wide open
wound loosely packed with gauze soaked in iodin (i dram to a pint of
water) or permanganate (deep pink color). If at this or subsequent
dressings the bone edges are wholly denuded, smooth, or sloughing,
they may be sawed off (resection procedure). If this reveals an
extensively invaded medulla, then the osteomyelitis will probably go
on to amputation and possibly death. If, at the same time, the
general state is showing deterioration, amputation should be done
before it is too late. When possible, be conservative in seeking to
preserve the adjacent joint, but select healthy tissue, lest reinfection
occurs in a new focus. When, however , the discharge is more rebellious
than serious, the pouring into the wound of pure balsam of Peru some-
times acts well, and daily exposure to air and simlight is of the greatest
value. The use of bismuth paste is sometimes effective. Many of
these wounds keep discharging until a sequestnun is absorbed
or cast off , for in effect the process is one of osteomyelitis, ^\^len the
infection is under control some sort of permanent cast may be applied,
usually a circular "window" or "molded" plaster-of-Paris splint is
used.

General Treatment. — This is most important, and every attention
must be given to the diet and general nutrition of the patient.
Whenever possible abundance of fresh air and sunshine should be pro-
vided, and the septic cases, especially, will do better if kept out-of-
doors the entire day and even at night under protected conditions.
As stated, when the wound can be exposed to the air and sunlight,
healing will be greatly hastened and discharge much diminished.
Alcoholics are provided with a reasonable amount of stimulants, and
bromids and chloral are given until tremor, restlessness, or insomnia
are controlled. Aged patients are frequently turned in an effort to
prevent hypostatic complications, and the head of the bed is elevated
or a back-rest is provided to aid in this. Tonics^ like strychnin and
quinin, are ordered when needed. 1 have never known sera to be of
any great value.

BULLET Fractures

Speaking generally, the same primary treatment should be given
as for compound fracture. The bullet should not be searched for un-
less it gives trouble, and it should first be located with reasonable cer-
tainty; enthusiastic and early probing is of left more dangerous than the

FRACTURES 271

missile. Most of these cases get along best by being tampered with
as little as possible, because most bullet wounds are fairly aseptic, and
interference widens the bullet track and is liable to open up channels
for reinfection.

Clinically, there are two general classes of cases corresponding very
closely to other forms of compound fracture; namely, those with
minor and major degrees of damage to the soft and bony parts.

Minor cases are those in which there is a punctured wound of en-
trance or exit (or both) with little or no bony comminution.

Major cases show more extensive tearing of the soft parts with
bony comminution enough to deserve the term "splintering."

The bullet wound ordinarily met with is inflicted by a revolver of
•32, .38, or .44 caliber. Less often a rifle or shot-gun is at fault.

Obviously the bony effect is dependent upon (i) site of the wound;
(2) size of bullet; (3) distance between weapon and target.

Treatment. — The primary attention is alike in both classes, and
the initial effort is to sterilize the wound in an attempt to prevent
greater infection. Antitetanic serum should be given at once in
every instance.

Minor Cases. — First pour in or inject iodin and then cover the
woimd with a small piece of gauze and paint iodin about the margins
for several inches; this gives a relatively sterile field to work in. If
the edges of the wound are already black or gangrenous, clip them
(debridement process) and then spread the wound apart and make
the iodin again penetrate every recess of it. Remove any wholly
detached bony fragments and then reduce the fracture with as little
manipulation as possible. If there is merely a hole or tunnel through
the bone (seton wound), do not curet or otherwise disturb this
channel but flood it with ether or iodin, if possible passing gauze
soaked in either of these antiseptics through the bony crevice.

Drain by a twisted or folded piece of rubber tissue or tubing to the
bottom of the cavity; do not make this a plug or dam by ramming it
in too hard. Use no sutures unless gaping or bleeding demands.
Cover with a moist iodin water (3 j : Oj) or 50 per cent, alcohol gauze
dressing and cotton and a bandage, and then apply a temporary
splint. Unless needed, do not disturb this dressing for twenty-four
to forty-eight hours, then apply a dry sterile gauze dressing, short-
ening the drain unless there is great secretion. Dress again in two
to four days, and if the wound is granulating, pour in pure balsam of
Peru solution, insert a few strands of silkworm for provisional drain-
age, and apply a permanent cast of molded or circular plaster-of-Paris,

272 TRAUMATIC SURGERY

with a "window*' in the latter. If infection proceeds despite the
above, the treatment is as indicated in infected compound fractures.
The bullet meanwhile has been definitely located and removed if
accessible; if embedded in bone and doing no harm, it may be left
undisturbed.

Major Cases, — The preliminary sterilization is carried on in the
same manner as in the preceding. Widely separated deep and super-
ficial parts should be loosely stitched, if at all. Plentiful drainage by
rubber or gauze in rubber is afforded, multiple openings being pro-
vided where needed. The fracture is adjusted and retained in a
temporary splint. Redressing is done every day until infection disap-
pears or is minimized, and then a removable permanent cast is applied;
ordinarily this cannot safely be done within ten days or a fortnight.
If infection gains, the treatment shifts to wider incision and drainage
and the other means advocated in advancing infection of compound
fractures.

In cases of greater severity, immediate amputation may be wisest;
this is especially true in the event of great transverse comminution
with damage to main blood-vessels, as the femoral or axillary, or
where the soft parts are extensively involved; but no limb should be
sacrificed unless the neuro-vascular supply is extensively damaged or
infection is far advanced.

Articular Fractures

A compound fracture entering a joint is a serious matter, not only
as to ultimate function, but also as to life.

Treatment. — This depends upon the extent of the original dam-
age, and, in general, is like that early given for bullet fracture. If,
after twenty-four hours, there is obvious increasing joint effusion, or
if originally the joint has been invaded, then drainage of the joint must
be adequately obtained at once (see p. 131 for incision sites). The
joint may be flushed through and through with salt solution at first;
later, if needed, with pure ether, iodin (i dram to a pint), or perman-
ganate (i : 200). The joint must be kept in extension.

A selected number of these cases can be treated after the method
described as debridement under *'Wounds" and ** Joint Injuries."

Early amputation or excision is advisable if the infection pro-
gresses rapidly or where the proc'ess causes practically a disarticu-
lation and irreparable primary damage, assuming that wide incbions
and free exposure of the joint are unavailing.

FRACTURES 273

Fracture results in general

These obviously depend upon three factors: (i) Patient; (2)
bone; (3) treatment.

(i) Patient. — Age, — The younger the better; after fifty years of
age repair and reconstruction are slower.

Sex plays little part.

Habits and Disease, — ^Alcoholics act badly. Those suffering
from constitutional troubles (syphilis, nephritis, diabetes, etc.) are
not likely to do ^ well as the healthly.

Occupation. — Where active use of the part is daily needed the
disability will be longer and more pronounced; a fracture about the
right wrist, for example, might totally disable a typist six weeks,
and yet permit a laborer to perform at least partial work in a few
hours.

(2) Bone. — Compound or infected forms do not knit as quickly
as others. Articular forms are more likely to take longer or result
in greater disability. Shortening due to impaction or overriding is
quite likely to some extent in fracture of the shafts of bone. This
may be considerable, however, without impairing function or caus-
ing marked deformity; it is a regular incident in a fractured shaft
or neck of the femur, and as much as 2 to 3 inches can be sometimes
compensated for by a tilt of the pelvis and spine without noticeable
limp. Flat bones (like the scapular and clavicle) quite regularly
throw out large amounts of callus which, however, later diminishes.

(3) Treatment. — The earlier and more accurate the reduction,
the qxiicker and more dependable the outcome. Early massage and
passive motion promote healing and diminish post-splintage stiffness.
Co-operation from the patient is a large factor. Splints allowed to
remain undisturbed over three or four weeks (femur excepted) are
almost certain to cause stiffness and atrophy inversely proportional
to the length of their application; in many such instances the treat-
ment is often worse than the injury. This is especially true in the
aged and in fractures about joints. 1 recall seeing an impacted
Colles' fracture in an old washerwoman, in whom splints reaching
from below the elbow to the finger-tips were allowed to remain
undisturbed nine weeks, and the resulting stiffness will be largely
permanent.

Baking, electricity, and apparatus designed to make forced,
gradual motion (like "Zander" machines or the " arthromotor ")
are of great value for the relief of adhesive stiffness or atrophy.

274

TRAUMATIC SURGERY

Operation to correct unreduced deformity or arthroplastic proce-
dures are final steps in regaining function.

The vast majority of cases are restored to full working capacity
even in the presence of obvious great deformity. In respect to the
latter, i»;-ray examination may disclose marked distortion and dis-
placement even though the functional outcome is excellent; hence it is
important for the physician and the patient to realize emphatically
that deformity does not necessarily mean disability.

Before predicting permanency (notably in litigated and compensa-
tion law cases) it is wise to ascertain if all the usual and ordinary
means of treatment have been faithfully attempted; and if less than
a year and a half has elapsed, whether or not a continuance of
accepted measures with ** reasonable certainty " will not bring about a
partial or complete cure. In this connection Stimson asserts, *'l
think it can properly be said that an uncomplicated fracture of the
shaft of the long bone of the arm, forearm, or leg will, in the great
majority of cases, heal without any diminution of the earning
capacity of the patient after six months, and that almost all the
remainder will have reached the same condition in a year. "

The average period in weeks of total and partial disability and the
deformity in the more common simple fractures is given below; the
former means inability to perform any regular work whatever, the
latter meaning capacity to do some or all work up to the time of
final recovery:

Bone. Total.

Jaw (lower) 3-6

Clavicle 4-6

Scapula 4-8

Humerus 6-10

Radius, ulna ... 4-6

Colles' 4- 6

Ribs 3-6

Femur (shaft, 1

neck). 1 '"^'^

Tibia 8-12

Fibula 4-10

Pott's 6-12

Partial.

2- 4

2-4l
2- 6

3-12

2- 6

3- 6
2- 4

20-50

10-20

5-10 J
4-16

Deformity.

Callus and stiffness usually disappear.

Marked callus at first; lessens in time.

May show rotation or other changes often.
Moderate grades likely to show rotation changes.
Wrist may show enlargement or tilting frequently.
Callus and displacement vary.
Often marked, with shortening or rotation; may
be permanent.

Varies; usually slight; sometimes permanent.

Marked often at first; later less, sometimes per-
manent.

Rating end-results. — In an effort to standardize my own results
1 have adopted an arbitrary rating based on the outcome as to the
function, union, and contour of the broken bone.

FRACTURES

275

Function if perfect is granted 60 per cent. ; union, 30 per cent. ;
contour, 10 per cent.; the summation is the percentage award or
rating.

Function refers to the involved

Union refers to the involved

Bone

Joints

,, , f Vascular
Vessels { ^^ 1
Neural

Quality

Quantity
Length

- of Callus

Long
Short

Contour refers to the involved y Circumference \ « n

[ Smaller

Displacement \ . ,,.
^ [ Angulation

of bone

Each of these elements is thus divided into components that accu-
rately determine in figures how the part acts (function) and looks
(union and contour).

An almost perfect functional result, for example, could be rated
2it 55; equally good union at 28; equally good contour at 9. The
sum of these three would give an end-res.ult percentage of 92.

OPERATIVE TREATMENT

Of late there has been a tendency to advise operation in many
simple fractures on the theory that better and more perfect anatomic
alignment is thus afforded. Some surgeons go so far as to counsel
o{>eration in all cases, in effect, to make a compound (open) fracture
of every simple (closed) fracture, arguing that modern asepsis is so
j)erfect that danger of infection is negligible. In this the writer does
not agree, because the usual and ordinary methods are generally
eflSdent, and perfect alignment is by no means necessary to a success-
ful outcome, either as to ultimate appearance or functional capacity.
There are selected cases in which a carefully performed operation
is of value, but the procedure needs experience and rigid asepsis,
and few general surgeons are sufficiently equipped to do as good
work on bones as on abdomens or brains.

Operative Indications. — (i) Where reduction cannot be obtained
or maintained. (2) In some spiral, very oblique, rotated, and mul-
tiple fractures. (3) Certain fractures near joints, notably when
small bony fragments are detached. (4) Fractures of the patella
quite often; some of the forearm, olecranon, lower }4 of leg.

TRAUMATIC SURGERY

i cakis. (5) Certain cases of non-union, or faulty

376

astragalus and (
or vicious union.

Compound (open) fractures do not respond well to operative in-
terference, especially if metallic foreign bodies (plates, screws,
wires) are introduced In the early stages.

Time of Operation.^ln simple fractures this is generally within
the first twelve days, or after reactive swelling and irritation cease,
usually between the first and second week; the tenth day is the time
of choice in the average case unless adequate faciUties are at hand
and then shock or other complications are the only deterrents to
immediate operation.

Material Used. — Suliires of chromic gut, kangaroo tendon, silk-
worm-gut, silk, or wire made of silver, bronze (or combination) are
often used. Of these, the chromic and kangaroo guts are the most
valuable, in that they are absorbable and least irritating. Wire is
the least satisfactory because it
breaks and irritates; aluminum
bronze is the best of this t>'pe.

Suture Methods. — (i) Uniting

f'l J W^ I periosteum and soft parts alone; (2)

!>\ /'\ Kh/I encircling the bone as by a band; (3)

holes drilled through the fragments.
Metal Pins and Plates.— The
method of "pinning a fracture" con-
sists in boring a hole through the
m ',!■ ¥^ fragments with a small augur or drill

' ' and allowing the latter to remain in

situ projecting through the skin open-
ing; this is especially valuable in
certain fractures of the neck of the
femur or where articular margins
have been avuised, as in the elbow. A small steel or silver tiail or pin
maybe substituted. All such devices usually become loose in a few
weeks and are then spontaneously extruded or are withdrawn.

Plates made of shaped steel, silver, aluminum, or vanadium steel
are screwed on the bone over the fracture line. This procedure has
been advocated mainly by the English surgeon, Lane, and the plates
are often known as "Lane's plates;" the operation is referred to as
"plating a fracture." Oblique fractures in long bones, as of the
arm, forearm, thigh and leg, are most often subjected to this treat-
ment (Fig. 234)- In a considerable number of cases the screws be-

Yw: 234. — a, Spiking ai
ftacttue; b, metal pUting a.
fracture.

oblique

FRACTURES 277

come loose, lead to irritation or infection, and require removal; this
may occur months after imion has eventuated. The author plated
a forearm (radius) foUowing vicious imion of the ulna and non-union
of the radius in which plate and screws required removal twenty
months later, when union had long been complete and function was
excellent.

Plating Methods. — A suitable plate and the special instruments
are selected; a special bone-holder (like the Lohman) will be found of
great aid. All instruments should be long handled and fingers are
rigidly kept out of the wound; indeed, the use of fingers at the
operating table is just aCs bad as their use at the dinner table. In all
of)erations involving uninfected bone the author rigidly practises and
advises this "fingers off" or "don't touch me" technic. All sutures
are tied by instruments, and the use of Reverdin needles and Michel
skin clips will aid in the closure. The fracture is exposed by an
incision that best conserves the adjacent structures and yet gives
adequate exposure. Reduction is affected by the use of tong-like in-
stnmients and by traction and manipulation; this can be much aided
by extension applied for several hours or days in advance in the
absence of an extension table. All intervening structures are re-
moved and the bone edges are made rough and fresh by cureting if
necessary. The periosteum is guarded carefully and carried or bridged
over the fracture line as completely as possible. While the bone is
properly held, the plate is applied; at least three screws are needed
to prevent subsequent slipping or tilting. All bleeding is stopped
and the parts are left as dry as possible.

The deeper parts are loosely sutured by catgut, and silk or silk-
worm-gut is used in the skin and no drainage is employed; if, however,
there has been much oozing, it is safer to insert a few strands of
twisted catgut or silkworm-gut in the lower end of the woimd.
Dressing consists of iodin water (5 j ^ Oj). A mild antiseptic on the
first dressing in bone cases is routine with me to prevent infection
by the skin coccus so prone to cause stitch or superficial infection.
A "window circular" or molded plaster-of-Paris splint is then
applied. If drainage has been used, it is removed on the second or
third day; if not, the dressing is undisturbed for ten days or longer.
Massage can commence on the tenth day and some passive motion
begins between the second and third week, and the splints can usually
be discarded earlier than in non-operative cases.

Clamps, like those of Parkhill and other allied devices, are some-
times used, but less often since plating has been in vogue.

278 TRAUMATIC SURGERY

Failure of or Non-union. — Ordinarily we wait 50 per cent,
longer than the average time for union before applying these terms,
meaning thereby that there is practically no cohesion between the
fragments when they are rubbed together. Delayed union may be
said to apply to those cases where knitting is slower than usual,
but yet actually there is some effort toward repair.

As already stated, actual failure to unite is exceedingly rare and
when it occurs is dependent upon :

(i) General causes related to the health or habits, notably syphilis,
alcoholism, nephritis, diabetes, and other alterative states.

(2) Local Causes. — (a) Imperfect splintage, so that movement
occurs between the fragments; very common.

(6) Fragments are not well coapted because of intervening soft
parts (muscle, fascia, or detached bone), or where much imcorrected
overlapping or rotation has occurred.

{c) Involvement of blood-vessels and nerves (rare).

{d) Infection, as in compound (open) fractures.

The essential common causes are imperfect reduction and too
tight or too loose splintage.

1 find more cases of non-union in the lower one-third of the tibia
than in all the other bones combined; next commonest is non-union
in the radius, ulna and humerus.

Treatment, — The cause must first be ascertained and here x-ray
examination is very helpful.

General causes are suitably cared for, and clinically it has been
found that iodid of potash is useful even where a frank luetic state
cannot be proved. Thyroid extract is valuable often, giving as
much as 2-5 grains three or four times daily. Calcium and phos-
phorus also have a place and general tonics are often indicated.
Open-air treatment and forced diet are quite effective adjuvants.

Local causes generally respond to one of the following:

(i) Massage is vigorously given and then the bone edges are rubbed
together and a firmer splint applied.

(2) Hyperemia is induced by Bier's bandage or other device
applied above the break; this is to be removed instantly if the ex-
tremity gets very blue, cold, or painful. Those accustomed to the
compression bandage wear it for hours daily. Sometimes the
bandage used above and below the break is more efficient.

(3) Injection of blood or serum between the fragments; from 10 to
50 c.c. can be used, and the fluid is preferably autogenous.

(4) Drilling the edges of the fragments to cause irritation.

FRACTURES ' 279

(5) Operation only is indicated if the foregoing are inefficient after
a reasonable trial (say two to four weeks), assuming that no soft or
bony parts are known to intervene between the fragments. Opera-
tive relief may consist of (a) open correction, so that the bone edges,
suitably roughened, are made to coapt; (b) bone grafting from the
fracture site or another bone, preferably the tibia; (c) metallic plating
or wiring.

The methods named under (i) and (2) usually suffice; in all, a
main essential is to reapply firm splints.

Vicious Union. — This means junction at an angle, or with much
deformity, and usually there is associated considerable disability.
This condition is frequently exaggerated in radiographs.

Causes are practically those of non-union.

Treatment is by ref racture, preferably by operation, and this is fol-
lowed by suture, pinning, plating, or some **stepping-down" form of
bone-graft operation. In the forearm, with both bones involved, it
is often only necessary to correct the radius; in the leg the ref racture
of the tibia alone may suffice. After purposeful refracture, union is
generally quicker than in the original fracture.

Excessive callus or an osseous projection can usually be removed
by the chisel or forceps without affecting the fracture line.

General Classification. — For descriptive and clinical purposes 1
divide all fractures into two classes, grades or varieties, either of
which may be simple (closed) or compound (open) :

1st Grade or Class A show displacement of fragments; the dis-
placed variety.

2d Grade or Class B show no displacement of fragments; the
non-displaced variety. The ist class require reduction (setting)
and retention (splinting) ; the 2d class require retention (splinting)
only.

CHAPTER VII

SPECIAL FRACTURES

Fractures of the skull

Injury suffident to cause skull fracture becomes important or
serious only if associated with damage to the cranial contents because
fracture per se often causes few symptoms and leaves little or no de-
formity. This fact is clinically so important that the discussion o£
the entire subject practically resolves itself into two groups of cases,
one with and the other without signs of brain or intracranial injury.

Under Injury of the Head (see p. 528) the topic is further discussed.

Anatomy and Landmarks. — The bony cranium is arbitrarily
divided into the vertex or vault, and the base or basin.

The vertex is that domed portion above a line passing from the
external margin of the orbit, through the orifice of the ear, and behind
to the occipital protuberance, and thence through the opposite ear
orifice and outer angle of eye to the place of beginning. This includes
mainly the frontal, the parietals, and part of the occipital and tem-
poral bones. The elastic vault is made up practically of five bones of
variable thickness, each of which has an outer and inner table sepa-
rated by a spongy diploe.

The base is that portion lying below the above line. It mainly in-
cludes the sphenoid, ethmoid, and part of the temporal and occipital
bones. This basal portion has three fossa, basins, or depressions,
called respectively anterior, middle, and posterior, and each has for-
amina for the passage of nerves and vessels; the middle fossa is quite
generally involved in basal fracture.

The vertex shows many normal heights and depressions, recogni-
tion of which is important in excluding certain sorts of fracture (Fig.
210). These phrenologic markings are chiefly the:

Superciliary ridges, above the eyebrow.

Frontal eminences, at upper margins of the forehead.

Frontal suture, between the preceding, and it is often visible and
palpable.

280

SPECIAL FRACTURES

Fic. 136. — Fraclure of the vault and base oi the gkuU (irontoparictal region k-
tending into orbit). Patient was a car conductor who hit his head against a trolley
pole while tcaning out of a moving car. Very few istncranial symptoms; perfect
recovery; no opcrnlion.

a82

TRAUMATIC SURGERY

Temporal ridges, above the ears and ^'ariably prominent.
Parietal eminences, above the preceding, and visible frequenti
Mastoid process, visible and prominent behind the ears.
Occipital protuberance, often \isible and always palpable.

Occipital ridges, leading laterally from the preceding.

Fontanels, anterior and posterior, are visible and palpable in ch^^
dren; in some adults they persist as depressions.

Fig. 337. — Comminuted fracture of skull, frooLopac
There were no intracerebral symptoms iifltT the initial
lateral views). TreutniEtit instituted: rest, ice-bag.

etal region, spreading into base.
( auteio pos terior

Frequency. — In my table of 7631 hospital fracture
were 698 fractured sliulls.

Of all fractures they constitute between 5 and 8 per cent, ac-
cording to most statistics. From 60 to 70 per cent, of vault fractures
also involve the base, or conversely; this means that a fracture in the
vault ordinarily radiates to the base, and conversely (Figs. 236, 237).
From 80 to 85 per cent, of basal fractures are said to originate in the
vault. The middle fossa in basal cases is oftenest affected; in the
vault the parietal and frontal fractures are commonest. For prac-
tical purposes we can say that most fractures of the skull (vault and
base) are included in a zone one inch in front or behind a line crossing

ior iw^^^l

SPECL4L FRACTURES 283

the vertex from one ear orifice to the other. I am m the habit of
; this the "two inch zone" for the sake of description.
Varieties.^ — There are various descriptive terms, but ijiasmuch as
the main sjinploms depend upon the effect produced within the skull,
it is wisest to base the classification upon this factor because of its
clinical and pathologic Importance. The older division of (i) vertex

tiaffanial injury. I'alicnt
Post-Gradiiale Hospital).

and (a) base fracture docs not usually pertain because the ordinary

case is a combinatioa of both.

All are divisible clinically and pathologically into those —
(i) Without intracranial injury; {3) with intracranial injury.
Either form may involve the vault or base (or both), or be simple

(closed) or compound (open).

TRAUMATIC SURGERY

SPECIAL FRvVCTURES sSj

(i) Without intracranial injury forms include thai group present-
ing in order of* frequency ;

{a) Linear, stellate, or radiating fracture lines with or without a
icalp wound or hematoma; commonly these occur from falls or blows
^Figs. 240, 241).

(b) Depression, usually localized, involving the external or both
tables; commonly this form occurs in children (indentations) or from
ion-penetrating missiles (as bullets) that gouge but do not penetrate.

(f) Linealion and depression combined. A crack leading from
a dent; this follows usually some direct impingement type of violence.

toparietal region).

[3) With Intracranial Injury. — (a) Linealion or fragmenting, as in
the preceding.

(6) Depression, usually localized, involving the external or both
tables; commonly from blows by a blunt weapon (small club, stones,
lammers) or falls on a raised object; or penetrations as by a bullet,
titling instrument, sharp-pointed tool or weapon (Figs. 242-246).

[c) Linealion atid Depression Cmnhined.—CommavAy from severe
alls, blows, or large-calibered weapons; this form is generally fatal.
Q either group, subdivisions (a) and (6) are the commonest.

TRAUMATIC SUSGERV

Fic. H2. — Linear fracture of skull with extradural cIoL

Fig. 343. — Depressed comminuted fracture of skull with henutoma of scalp udeitn
dural clot.

Fi3. 344. — Lineal fracture of skull with considMat>Ie involvement of internal tsU

Fig. 245. — Linear fracture of skull with slight involvement of internal t^>le.

Fig. 246. — Hematoma of scalp without depression or fracture of skuIL

SPECIAL FRACTURES 287

CAUSATION

This requires some statement as to the mechanism of skull fracture
and is not difficult if it is recalled that the skull is a spheric bony
box filled with a substance of somewhat elastic consistency which,
in turn, is surrounded by a layer of fluid, the whole being covered by a
membranous envelope. The bones are irregular in shape and thick-
ness and they are closely but not wholly immovably mortised, being
buttressed by numerous ridges which radiate generally toward the
base and which seem to direct impact thereto. The vault is quite
elastic and capable of changing in shape without fracture. The effect
of skull violence depends generally upon its (i) source and (2) site.

In the production of fracture without intracranial injury the source
is usually one acting upon a localized area of the skull which cracks or
splits (subdivision a) ; or becomes depressed or indented (subdivision
h) ; carried further this force may produce the added damage named
under fracture with intracranial injury. These are the injuries follow-
ing direct violence generally.

If, however, the source of violence acts over a more generalized
area, the skull then is impinged upon broadly and, being elastic, tends
to elongate or widen. If the violence is not too great, no break
occurs; it if is carried beyond the normal limits of elasticity, the
skull bends or bursts and thus we have the so-called "bending" and
"bursting" fractures. These are the injuries following indirect
violence generally.

The theory of origin of this "bursting" (of Messemer) is based on
the principle of the shortening of the diameter in the line of the vio-
lence, and a lengthening at right angles to it. Based on this, a blow
received on the center of the back of the head and transmitted
straight toward the middle of the forehead would shorten the distance
between the occipital and frontal bones and lengthen the distance be-
tween the lateral bones of skull (as the parietal and temporal) and
thus cause fracture of the latter. Conversely, if the violence was in-
flicted over a parietal or temporal region, the transverse diameter
would shorten and the vertical diameter lengthen and the vault or
base (or both) would be affected.

Under other conditions the foregoing mechanism does not prevail,
but instead the bone breaks at the edge of the widest part of the
depression at right angles to the line of violence; these are the bending
fractures, so named by von Wahl.

It is improbable that undissipated violence can often be trans-
mitted from the place of receipt to a distant site directly opposite;

388

TRAUMATIC SURGERY

hence so-called conlrecoup Jradure is not now given so much credence,
and at all events these are but variants of the foregoing "bursting" or
"bending" forms.

Fracture of Ike internal table without involvement of the external
table is generally a supposition only, and should not be credited
unless proved by exploration. Only one case is said to have been due
to a fall (Stimson). Most of these cases become infected and die.
However it is common to find the inner table more involved than the
outer when both are affected; this is notably true in bullet
or other punctured wounds.

General Cases. — Direct violence is the commonest source, such
as that following a blow or fall directly upon the part damaged or
fractured.

Indirect violence acts by transmitting the violence from a distance
to the place of impact, and this occurs commonly from a fall or a
blow from a broad object, as from a blow on the jaw or a fall on the
feet causing the ultimate impact on the base of the skull.

If the force is slight or localized, the fracture varieties named in
Group 1 (Extracranial) generally result; if it is severe or generalized,
Group 2 (Intracranial) effects generally prevail.

SYMPTOMS

ated^

These depend upon which variety exists, and, as already statt
they express themselves as (i) without or (2) with intracranial
injury.

Group I. Without Intracranial Injury, Extracranial Forms.
The history and subjective signs denote a fall or blow on the head
followed by little or no unconsciousness, some shock and nausea, but no
vomiting. Bleeding from the scalp may or may not have occurred.
There may be complaint of pain and headache more or less localized,
with stiffness and soreness of the neck and scalp muscles; swelling,
usually circumscribed; giddiness; some patients are apathetic or
may be restless or sleepless and troubled by dreams.

Objective 5ig«s.— Signs of shack may exist. The scalp may show
a circumscribed contusion or hematoma simulating a depressed frac-
ture; differentiation is made by noUng that the edges of the latter are
not hard or irregular and they can be rubbed away, and that pressure
made in the center shows normal skull beneath. Through a wound
the fracture may be visible or palpable; if the latter, the torn perios-
teum may be mistaken for a fracture unless the wound is widely
retracted. A normal suture line may also deceive; but it can be

SPECIAL FRACTURES 289

differentiated by the known position, the regularity, and by the fact
that bleeding over or from it can be wholly sponged away, while that
from a fracture line oozes despite sponging.

Ecchymosis may appear at a distance from the fracture site, espe-
cially if the case is seen from one to seven days after the accident; this
is typically seen in the eyelid or over the mastoid in basal affections.

Orifice bleeding denotive of basal involvement may appear in the:
(a) conjunctiva in a more or less crescentic form, usually on the
superior or internal margin; if due to direct contusion and not
fracture it is more diffuse, less geometric, earlier in onset, and associ-
ated with adjacent contusion signs.

(A) Nose, — Hemorrhage therefrom is variable in amount and usu-
ally unilateral.

(d) Ear. — This may show dry or fresh blood, and less often there
is escape of straw-colored cerebrospinal fluid. Blood escaping from
the ear, without fracture, may be due to a ruptured ear-drum,
wounds of the ear canal, a transmitted blow from the point of the
jaw, or it may drip into the external meatus from adjacent wounds.

Periosteum. — This may be torn, infolded, or undamaged.

Bone. — There may be a single linear crack, or these may be
steUate or numerous enough to resemble a "cracked egg shell."
Depression or indentation of varying degrees may be seen or felt.
Percussion may give an altered note over the broken bone. Tempera-
ture, pulse, and respiration are usually little if any affected.

Group 2 . With Intracranial Injury, Intracranial Forms. — History
and subjective signs indicate a blow or fall on the head suflBcient to
produce concussion (mild, moderate, or severe), as shown by
immediate unconsciousness and vomiting. On "coming to," there is
giddiness or dizziness.

There may have been involuntary passage of urine and feces.

Prostration is more or less complete.

Pain in the head may be local or general.

Bleeding from the woimd or orifices may appear.

Special sense disturbance is frequent, especially of hearing and sight.

Sensorium. — Confusion and perhaps irrationality are present
at times.

Memory is usually deficient from the instant of the accident until
unconsciousness disappears, and often the patient has no accurate
idea as to how the injury occurred.

290 TRAUMATIC SURGERY

Motor System, — Weakness or loss of power in a limb or limbs may
occur.

Sensory System. — Rarely there is tingling, burning, or altered sen-
sations in a limb or limbs.

In another group of cases there will be elicited a history of:

(i) Slight initial unconsciousness with an apparently normal
latent interval followed within hours or days by unconsciousness,
paralysis, and signs of intracranial pressure. All such cases show
some symptoms in the interval period, although these may be unob-
served by the patient or laity. This is the sort of case in Which
the patient may reach home unattended and later is found
comatose. Such patients are not infrequently alcoholic when hurt
and are regarded as drunk until the onset of some differentiating
signs.

The interval after an accident in which such a condition may
appear is variable; some of these are the so-called "traumatic late
apoplexy" cases of Bollinger and others about which heated contro-
versy has arisen. It is unreasonable to expect that the effect of an
injury to the head will be long delayed, and for that reason, even in
this rare and disputed class, the symptoms must not (a) be delayed
beyond a few weeks; (6) the interval must be filled by some connect-
ing and continuing symptoms; {c) there must be no other adequate
cause, like arteriosclerosis or its associates; (6) the injury must be
adequate.

(2) Another class of cases show continuing total or partial Un-
consciousness that deepens to complete coma, with usually a corre-
sponding advance in other symptoms.

Objective Signs. — There may be outward signs of shock; the
patient will be conscious or unconscious; rational or irrational;
and occasionally there may be visible tremor, or clonic or tonic
spasms of the face or limbs, or both.

Scalp. — Generally this shows a wound or hematoma.

Ecchymosis. — This may appear in the eyelid, mastoid, pharynx
or suboccipital region.

Orifices. — Bleeding from the ear occurs commonly; or it may be
nasal, pharyngeal, or conjunctival. Less often cerebrospinal fluid
or brain tissue exudes, usually from the ear. Infrequently, and some
days after the injury there may be a discharge of rather a large
amount of yellowish fluid from an orifice; usually this is presumed to
be serum or cerebrospinal fluid, and it often relieves headache or
fulness or deafness.

SPECIAL FHACXURES 39I

Periosteum. — This often is torn or otherwise damaged.

Bone. — It will be cracked, indented, or depressed more or less
regularly and extensively.

General State. — Shock signs exist. Vomitus may be mized with
swallowed blood.

Temperature. — Generally it is elevateci and may reach 105° ¥. in
unfavorable cases.

Pulse. — Usually it is normal or rapid at first; it slows and becomes
tense later as intracranial pressure proceeds, and usually then beats
below 70 and may reach to 40 or less.

RespiraUcn, — This is normal or rapid at first; later, breathing is
slowed (4 to 12) and often is stertorous, and as the medulla becomes
more and more involved the Cheyne-Stokes type appears.

Blood-pressure. — This is normal or slightly affected at first;
later it rises and is one of the best signs of advancing pressure.

292 TRAUMATIC SURGERY

Choked Disk. — It is present only in existing intracranial pressure
due to blood or edema; it is an important symptom.

Spinal Puncture. — This reveals blood in basal fractures, but it is
rather imreliable, because the needle in being introduced may be the
source of the so-called "bloody tap" (Figs. 247, 248).

Special Senses. — These may be blimted or abolished; hearing,
sight, and speech defects are the commonest.

Sensorium. — This shows more or less impairment.

Motor System. — There may be impaired or abolished functions of a
limb or muscles. This may come on at once in severe cases; usually
it is gradual and shows first as a localized twitching or spasm (affect-
ing one side of the face, the arm or the leg) and may proceed to
tonic or clonic convulsions of the same part and gradually extend to
the others on that side of the body, and may finally end in paralysis of
one-half the face, one limb (monoplegia), or an extremity (paraplegia).

Sensory System. — There may be diminished, absent, altered, or
normal sensation.

Reflexes. — These may be exaggerated at first, later diminished or
abolished. The most important are the patellar, Achilles, cremas-
teric, and pupillary. The latter early may be unaffected; later the
pupil on the affected side is generally dilated and the eyeball is turned
toward the lesion. A convergent or divergent strabismus may exist.

X-ray. — Radiating fractures, out of ordinary view or touch, are
sometimes shown.

Determining Symptoms. — Compoufid (open) fracture is usually
visible and always palpable.

Hematomas should be incised if at all confusing.

Basal fracture exists if the history and subjective symptoms are
rationally adequate and if examination discloses some of the follow-
ing in association:

Subconjunctival hemorrhage,
Ecchymosis of eyelid,
Eyeball tension increased,

Nasal hemorrhage

Nasal cerebrospinal oozing,

Olfactory involvement.

fractured anterior fossa,

via broken orbital plate of the frontal,

or bleeding along the sphenoidal fissure or optic tract.

fractured middle fossa,

via the cribriform plate of the ethmoid.

Ear hemorrhage,
Ear cerebrospinal oozing,
Pharyngeal hemorrhage,
Auditory involvement,
Postmastoid ecchymosis,

The ear shows signs oftenest; next, the nose.

f fractured posterior fossa,

I via the petrous portion of the temporal.

SPECIAL FRACTURES 293

About six out of ten fractures affect the base, and eight out of ten
of these begin as vault fracture.

INTRACRANIAL DAMAGE

This results from pressure due to (i) bone or foreign bodies; (2)
bloody serum, or inflammatory exudate; (3) laceration of meninges or
brain.

(i) Bone-pressure usually is not great enough to cause immediate
symptoms. If it is, a compound (open) depressed fracture is gener-
ally the easily recognizable cause. Missiles are usually removable,
but may do no harm if small or in a "silent" or non-fimctionating
area.

(2) Blood or serous pressure is the usual initial cause and the
pressure effects then depend upon the location and extent of the effu-
sion. It may appear promptly; later in onset it may indicate an in-
flammatory exudate.

SiUs of Pressure from Blood. — (a) Above Dura, — The so-called
extradural hemorrhage.

Here it is commonly from a torn meningeal vessel, usually the an-
terior branch of the middle meningeal.

This is the common form of "hemorrhage of the brain."

(6) Under Dura. — The so-called subdural or cortical hem4)rrhage.

It occurs from torn vessels on the brain surface generally, or from
smuses.

It is the second most frequent variety and is difficult to differen-
tiate often from the following form.

Generally this is ventricular or medullary in origin and it is an
associate of fatal injuries, and recovery practically never occurs when
injury is the cause. Ordinary non-traumatic apoplexy is the usual
producing factor.

(3) Laceration of the Meninges or Brain. — This is an accompani-
ment of severe compound depressed fractures, of tenest from perfora-
tions and bullets; or it occurs from localized extensive depressions or
"bursting" fractures. It shows itself mainly by coma or semicoma
and irritation with more or less delirium and rise of temperature.

A considerable amount of pressure or effusion may occur before
any local or general pressure-signs appear, and for that reason a sus-
pected case must be carefully watched for the first signs of localiza-
tion. In some patients the exact situation at the onset may be puz-

294 TRAUMATIC SURGERY

zling^ and yet within an hour local pressure may so manifest itself as
to almost mathematically determine the location of the lesion.

Diagnosis of Hemorrhage. — (a) Above Dura, Extradural Hetnor-
rkagf. — This exists if the history and subjective signs are rationally
adtfquate and if the following, in order of their significance, appear:
VO Latent period following initial concussion; (2) advancing uncon-
sciousness; (3) changed temperscture (rise to 100° F. or over); pulse
showing (below 70) ; respiration slowing (or approach to stertor) ; (4)
tocaUzed twitching, spasm or convulsive movements, especially sig-
luticant if it begins in a distal part and advances proximally, or the
rt?verse; (5) flaccidity, rigidity, or paralysis of a limb or other part of
known innervation; most important when the motor-cortical area is
involved; (6) rising blood-pressure as shown by the sphygmoman-
ometer or choked disk, or both.

{b) Under Dura, Subdural Hemorrliage. — This exists if the history
and subjective signs are rationally adequate and if the following, in
order of their significance, appear: (i) Persisting unconsciousness
that is stationary or deepening; (2) signs of fractured base; (3)
changes in temperature, pulse, and respiration, as in (3) of the preced-
ing variety; (4) paralysis of one side of the face or one limb; (5) in-
volvement of the reflexes; (6) signs of rising blood-pressure, as in (6)
of the preceding variety; (7) cerebral irritation as shown by restless-
ness ur delirium.

(c) Within Brain, Cerebral or Central Hemorrhage, — The signs are
exaggerations of the foregoing and the condition is grave from the
outset; hemiplegia is the common manifestation and ordinary" apo-
plexy is the existing cause in hemiplcgic cases that recover, as those
due to injury are promptly fatal.

DIAGNOSIS

Other conditions capable of causing unconsciousness or actual
iuina must be excluded, such as:

(i) Alcoholism. — Odor on breath and vomitus; pupils usually
equal and dilated; general and not local flaccidity or paralysis usually
i'xists; patient frequently can be aroused by slapping soles, supra-
tuhit al nerve pressure, or the ** grid-iron '* (rubbing chest vertically with
knui kles to irritate the intercostal nerves); pulse generally boimding
and rapid. It must be remembered that the conditions may and
ollen do loexist.

[j) A poplexy. — Coma and paralysis usually earlier in onset and
mole profound; hemiplegia and aphasia common; age and adequate

SPECIAL FRACTURES 295

causes of hemorrhage usually present. Often a fractured skull occurs
from the fall incident to a "stroke," and death is due to the latter
and not to the former.

(3) Uremia. — Coma not usually profound; appearance often
suggests nephritis; pupils even, sluggish, and dilated; urine albumin-
ous, with casts.

(4) Opium. — Habitu6 signs; patient is arousable; pupils small
and fixed; respirations low; reflexes slow or absent.

TREATMENT OF FRACTURED SKULL

This depends obviously on the extent of the injury, notably as to
the extent of intracranial involvement.

All suspected cases should be kept exceedingly quiet during the
early stages particularly, and the period of convalescence should be
prolonged xmtil objective and verifiable subjective symptoms abate.
Unconscious patients should be catheterized every eight hours during
the first day and every twelve hours thereafter.

(i) Cases Without Intracranial Injury. — General Measures.
Patient is abed; diet is restricted; an ice-bag is given for headache;
sedatives are sparingly used when necessary, the bromids preferably,
XJrotropin (5 to 10 grains) every four hours is advisable.

Local Measures. — Cold compresses (saline solution, boric add,
alcohol) may be used over contused areas of the scalp; hematomas
ordinarily subside on pressure, or later are carefully aspirated or in-
cised only if necessary.

Wounds have iodin poured into and about them and a consider-
a.ble surrounding area is shaved and every effort made to prevent in-
fection. Suturing of the periosteum is usually unnecessary and iur
a.dvisable. Scalp wounds are loosely stitched or left open, and drain-
a.ge by twisted strands of catgut or silkworm-gut is provided; rubber
"tissue or tubing or thin gauze may also be used. If the wound edges
axe bruised, irregularly torn, or otherwise lacking in \dtality, no
suturing is advisable; the cavity is then loosely packed with gauze.
Suitable cases can be subjected to the process of debridement (see
Wounds, p. 33). If the skull is much indented, cracked, and de-
pressed, it is elevated by the edge of an instrument, and in so doing it
may often be found that the inner table is more involved than the
outer. Detached fragments causing pressure are removed; they may
be safely left if they remain elevated and have even only a slight
attachment by periosteum or jamming. Bleeding from the bone is

298 TRAUMATIC SDRGERY

of symptoms, and changes in the temperature, pulse, respiration,
reflexes, and muscle power. Blood-pressure and eye-ground exami-
nations are here of greatest value. Spinal puncture may prove to be
the one best sign of basal involvement Local signs from the begin-
ning may be marked enough to make treatment unavailing; but if
the symptoms are focal and within reach, operation is advisable
(Fig. 250).

In all forms a;-ray examination may prove of great value in accu-
rately locatmg the lines of fracture.

Operative Indications and Methods. — The essential element is
pressure, and the main sources of this are; (i) bone or foreign bodies
and (2) elusion (blood, serum, or pus).

Fig. 351.— Rubber tubing passed through safety-pins previously introduced through
all Ihc layers of the scalp. This acts as a hemostat in bone-flap skull operations.

(i) Bone or foreign body pressure usually accompanies obvious
compound (open) depressed fracture. Where possible, no fragments
of bone should be removed, as most of them are viable unless wholly
detached. No anesthetic is needed unless the patient is conscious;
ether is the best.

TecbnJc. — Preliminary iodin cleansing of the entire shaved scalp.
Head raised. Ears plugged by sterile cotton; tourniquet in place
^llg. 351). Wound enlarged if necessary; it is needless and unwise
to mcise the Intact scalp to trace the limits of fracture throughout.
It is unnccessar)' to trephine if the bone can be elevated by the edge
\)i a chisel or similar instrument; if trephining is needed to elevate the
fragmvuts, let the hole be small and at the margin of the depression in

SPECIAX FRACTURES

Fig. 351. — Haidenhain hemostatic stitch used to eocircle the soft parts preparatoiy
to bone-flap skull operations: a. Properly introduced, reaching under periosteumi b, im-
properly introduced, reaching oiuie periosteum.

Fig. JS3 — Compound depressed fracture of skull 0 Pa««ing Gigli saw through
multiple trephine openings 6 prelimmar> Gigli sa« cut to fashion bone-flap; c, eleva-
tion of a depressed fragment by mstrument passed through a trephine opening.

TRAUMATIC SITRCEBY

Fig. 154- — Compound depressed fracture of Che skull: a, Rubber tubing tourniquet
placed, wound enlarged; b, skin-flap and periosteum retracted; c, depressed bone being
elevated.

SPECIAL FRACTURES 3OI

sound bone. Small amounts of depression do no harm and perfect
restoration of contour is not required (Figs. 253, 254). If the frac-
ture lines are numerous and if external bleeding has occurred from
the fracture-site or the orifices, spontaneous decompression has
occurred and there is less need for operation having this object in
view.

Bleeding may be free from the bone, but punching or nipping the
diploe usually stops it; packing with gauze or wax may be needed
rarely. A piece of freshly cut muscle pushed into the bone is a very
effective hemostat. Clotted blood under the skull should be gently
scooped out enough to bring the dura and pulsating brain to the sur-
face; it is imwise and imnecessary to try to get all the hidden clot
out. Some of it can be floated out by gentle saline irrigation. Visi-
ble sources of bleeding (meningeal vessels) are caught by forceps or
controlled by gauze wicks. If blood wells up from beneath, it cannot
be reached directly, but can be drained in part by gauze; this usually
signifies basal involvement of bone or brain. Nothing should be
done to a torn or otherwise damaged cortex.

Dura, if torn, is loosely sutured by catgut or fine silk; if untorn, it
is undisturbed, and it should not be incised if of a normal pearly color
and if the brain pulsates. If there is a large loss of dural substance,
a graft of fat or fascia may be inserted as every effort should be made
to so cover the dura that adhesions will not form.

Closure is made with drainage and loose suturing of the scalp by
silk, silkworm-gut, or horsehair. Rubber tissue or catgut or silk-
worm drains are used where little drainage is required; gauze is
employed otherwise to stop oozing. The drains reach to, but not
through, the dura. They ordinarily should be removed within 48
hours. Secondary or post-operative hematoma formation must be
guarded against to prevent re-infection.

Dressing is firm, and in the restless or alcoholic is-of ten reinforced
by starch bandages.

Assuming that intracranial pressure from blood or other effusion
exists, operative interference may be necessary, and becomes indi-
cated in the presence of (a) focal or localization evidences, (6) ad-
vancing intracranial pressure. Lumbar puncture, repeated if
necessary, often makes operation unnecessary.

(a) Focal or Localization Cases, — In the absence of a compound
(open) fracture, shaving the entire scalp may disclose some external
evidence of hematoma or ecchymosis to corroborate those symptoms
already manifest.

3<M

TRAUWATIC SURGERY

The commonest sites of clot-pressure are near meningeal vessels,
notably the anterior branch, and these are reached by incisions

planned as indicated in Figs. 249-255.

through the scalp may be vertical or i

FlO. 356. — Subtemporal decompressioD of skull (flap method). Fibets of temporal
muscle have been separated and the original trephine opening has been enUrged to
expose the meningeal vessels, A vertical incision can also be used.

The approach can be made through the ordinary circular trephine
opening enlarged by the rongeur; preferably it is by the bone-flap
method shown in Fig. 256 and 257.

SPECIAL FBACTURES

303

This latter has the advantage of providing wide exposure with-
out loss of bone. Conditions are then met with as indicated pre-
viously in speaking of pressure by bone or foreign bodies..

(6) Advancing Intracranial Pressure Cases. — ^Localization evi-
dence in these is undefinable, as the pressure is wide-spread and the
idea is to afford relief by providing a drainage opening in the skull;'
such a procedure is known as "decompression. "

Subtemporal decompression is the method popularized by Gush-
ing, and it is quite commonly employed because it is easily done and
the trephine hole is later covered by the temporal muscle (Fig, 255).

^c, 357. — Occipital osteoplasty: a, Single flap; b, unilateral flap; c, bilateral fiap.

Tecknic. — The semidrctilar or vertical incision is made (Figs.
^55, 256) midway between the orbital edge and the ear top, and it
^*poses the temporal muscle, the uncut fibers of which are then sepa-
■^ated and a trephine button removed. The opening is then enlarged
'^y the rongeur to the size of half a dollar or a dollar; the dura is
^l; a gauze or rubber drain is placed down to the dura; the muscle-
fibers are allowed to fall into place or are loosely stitched; the skin
is sutured. Drainage is maintained forty-eight hours; longer if the

304 TRAUMATIC SURGERY

discharge seems to so warrant. See also p. 538. Occasionally
decompression is made bilaterally.

In other cases (as in some basal fractures) the suboccipital decom-
pression method is advisable, and it is similarly performed (Fig. 257).

Some surgeons advise either of the foregoing as routine measures
in every case showing compression evidences; others more properly
reserve it for that class of cases seemingly unbenefited by ordinary
means. Gushing reports 13 recoveries in 15 cases. Such good
results as this are seemingly not attained by other surgeons, and in
my experience 1 have not observed that it is markedly beneficial in
comparison with other methods. Many cases would get well with-
out operation, and 1 do not believe that those operated upon are
less likely to develop early or later complications. Spinal puncture
as stated is of great value and is often an efficient substitute for
decompression.

COMPLICATIONS AND RESULTS

Cases that early recover from objective signs generally get well;
the majority of fatalities occur within the first forty-eight hours.
Cases in Group i (Extracranial forms) practically recover completely.
Fifty per cent, at least of basal fractures live; many of those surviv-
ing recover in every respect (Figs. 258, 259).

Sepsis and Meningitis. — These usually occur in compoimd
(open) cases or fracture of the base with infection through the ori-
fices. Prehminary sterilization is the best prophylactic.

Abscess of Brain. — This is rare and is usually seen in cases of
localized depression or follows compound infected forms; 1 have
known such a complication to follow a fracture of the middle fossa
in a patient with an old and partly quiescent otitis media.

Delirium Tremens. — This is very common, and may itself lead
to edema of the brain (alcoholic wet brain), making diflferentiation
from traumatic intracranial pressure difficult or impossible.

Pneumonia. — An early lobar form is occasionally seen, especially
in alcoholics. A later hypostatic form is common in the aged or de-
pleted.

Neural Involvement. — The sevet^th or facial is most often affected,
giving total or partial unilateral paralysis of the face; it generally is
due to pressure from effusion and commonly disappears, although
months may elapse.

The eighth or auditory may likewise suffer, causing unilateral deaf-
ness; this also is generally recovered from wholly or in part.

SPECIAL FRACTURES

Fic. 358.— Harvard

Note wuund through a
Patient lived many years after (he accident.

Fig. i5g, — The Harvard "crow-bar case,' with subsfceiL-h ahoning relative size of
cull and ciow'liar; in a blasting accident, the latter penetrated palate, orbit, and
iu]t, entering by way of the mouth.

3o6 TRAUICATIC SUKGEKV

The third or motor oculi occasioaaily is affected , producing internal
squint, imilateral ptosis, and a dilated and inactive pupil; it may in
part be permanent.

The sixth or abducetts, if involved, gives internal strabismus that
may pevsist.

The olfactory and glosso-pharyngeal are rarely involved.

Speech defects are generally overcome.

Paralysis in a limb rarely lasts.

Fig. 160. — Aspiration of lateral ventricles: a. Vertical approach; b, lateral approach.

Memory may be defective for a time, but usually is wholly or
partly regained; defects are most common respecting recent events,
especially as to figures. Amnesic Impairment is more likely if the
left inferior frontal part of the brain has been involved in right-
handed persons; the reverse obtains in left-handed persons.

Instability in the muscular system may be indicated by unsteadi-
ness, incoordination, some staggering and inability to maintain equih-
brium when off the ground or in the dark. This is commonest in
alcoholics and the aged. A good deal or all of it may eventually
disappear. It is most likely in basal cases, especially if the middle
or posterior fossa has been involved.

Menially there may be irritability ; a tendency to tears or laughter;
strange likes and dislikes; incapacity for alcohol or tobacco, or the
reverse. Like the foregoing sequela:, most of these abate in time.

SPECIAL FRACTURES 307

Insanity. — This is a very rare sequel, even in the presence of
marked original damage; less than 2 per cent, of known insanity fol-
lows head injury. Even in extensive war wounds with gross loss
of substance, mental complications have been relatively imcommon.

Neurasthenia and hysteria are generally most marked in the liti-
gated cases and in those in which the objective signs of injury are
least marked. Many of these do not subjectively recover until
financial or other expectancy is realized.

Cysts as remnants of blood absorption occasionally form, and
later may give rise to signs of tumor.

Epilepsy as a pressure or irritative sequel of head injury is not now
regarded as so frequent a complication, doubtless owing to :

(i) Wider knowledge as to the origin of the disease.

(2) Experience gained through the large number of so-called
"traumatic cases" operated upon, in which none of the expected
local damage was foimd.

(3) Because of the very great number of head injuries and the
relatively few cases of epilepsy arising therefrom.

(4) Because the brain can readily accommodate itself to changes
in pressure; according to Stimson this pressure must amount to
about 2 cubic inches of sudden depression in the adult skull before
permanent symptoms of general compression arise.

If epilepsy is to be regarded as traumatic in origin, it is most
likely to occur if the motor area has been affected by the injury;
then the symptoms begin with local irritation of the affected part
(Jacksonian epilepsy), followed by general spasms and imconscious-
ness, the**fit," in other words. It is said also to arise from adhesions
due to a scar in the cortex or dura, or between the same; or between the
dura and the skull or scalp. This seems less probable than the former
named source. Children are prone to epilepsy from so many causes
that its orgin from injury is more doubtful than in adults, especially
as a child's skull can more readily adapt itself to enforced changes.
War experience has shown that epilepsy is a rare sequel even
after extensive involvement of the motor-cortical zone.

Post-traumatic epilepsy is now regarded by many as an indica-
tion of pituitary injury.

Bony defects from depression or operation are generally replaced
by fibrous tissue over the central part, the edges being smoothed
and hardened by a more osseous material. After a lapse of years
this fibrous covering apparently hardens, and may even become
bony in consistency over a space as large as 2 inches square. In

3o8 TRAUMATIC SURCESY

children such gaps are more likely to be filled in earlier and more
uniformly-

Pulsations can often be seen and usually are felt; they may be
marked and annoying at first, but later
grow less.

Hernia of the brain is rare (Fig. 261).
Lumbar pimcture may prevent or cure it.
LOWER JAW FRACTDSE
The inferior maxilla is more commonly
broken than any other bone of the face.
In my statistics 228 cases occurred; a
percentage of 7.1.

Anatomy and Landmarks. — Practically
the entire bone is palpable.

Ramus. — The perpendicular portion

Fio. j6i.— Hernia cerebri ending above in the condyles articulating

following exsection of stull ^j^ ^^^ glenoid cavity; in front of this

for compound depressed ..... .ni -i

fracture. ^ "^^ sigmoid notch capped by the coronota

process.
Angle. — ^Lower back part of the ramus, often prominently visible.
Body. — Transverse horseshoe-shaped part, with the upper alveolar
border for sixteen teeth.

In children and the aged the ramus and body form an acute
angle; in adults, a right angle.

Causes. — Direct violence is the common origin, and this is usually
from a blow or fall received on the chin, or less often on the side of
the jaw.

Indirect violetice is a very rare source; the condyle occasionally is
broken by transmitted force from blows upon the chin.

Muscular Violence. — Coronoid process fractures alone may thus
occur; this, however, is a clinical freak.

Sites and Varieties. — (i) Region of incisor teeth commonest; (2)
condyles next most frequent; (3) ramus least frequent (Fig. 262).
The break may be multiple, usually on either side of the middle
border, as from heavy blows, falls, or bullets.

Partial fracture of an alveolar border from teeth extraction is not
infrequent.

The vast majority of fractures are in the teeth-bearing area and
are vertical or oblique in direction.

Compound (open) forms are not uncommon, and the wound may
be in the skin or gums.

SPECIAL FRACTURES

309

Symptoms. — (i) Visible deformity and disability, showing either
ia the face, mouth, or teeth. (2) Crepitus and false motion, best
elicited by bidigital palpation inside and outside the mouth. (3)

Fracture of the lower jaw in front of the angle.

S-ter, swelling of face, gums, and glands; salivation, stomatitis.
^osteomyelitis and abscess are common in neglected and severe cases.
Treatment. — Reduction is by pressure manipulation that aligns
t^e teeth.

^r Immobilizali

Fig. 363. — Interdental splint for fracture of the lower jaw.

Immobilization is by (i) bandages {four-tailed or others), binding
the jaws together. Two broad rubber bands act well instead.

{3) Splints. — Wire, thread, plaster-of-Paris, leather, or metal so

3IO TRAUMATIC SURGERY

devised as to lock the teeth or embrace the chin and pull it back and
up. Wire or thread twisted about the intervening teeth answers in
ordinary cases (Fig. 264).

C3) Special splints, interdental in type like those of Matas, Kings-
ley, or Moriarty; or those specially molded by an oral surgeon (Figs.
263, 265).

(4) 0/>ero/tiw.— Exposing the fracture through skin incision and
suturing it by gut or wire, or plating it.

Fic. 265. — Matas' splint ip fracture of the lower jaw.

In all forms, one or more teeth may need extraction for reduction
or feeding. Loosened teeth generally tighten. Particular attention
must be gi\-en to keeping the mouth clean. Nasal bleeding may be
v.n accompaniment.

SPECIAL FRACTURES 31I

Union is complete in four to six weeks, and before this part or all
of the splintage may be removed.

Results. — Usually these are good; and even in the presence of
considerable oral deformity the outward appearance and fimction is
excellent Dental treatment may be required later if the teeth are
da.zaaged. In patients with pyorrhea, osteomyelitis and sinus forma-
tion sometimes occur. An excellent mouth wash can be made of ten
drops of tincture of fluid extract of ipecac to a glass of water.

Disability. — Total, four to six weeks; partial, two to four weeks.

UPPER JAW Fracture '

The superior maxilla is infrequently broken except when it is
associated with other fractures, as of the nasal or malar bones.

Causes.~Direct violence is at fault always; commonly this is from
blo^w^s, falls, kicks; automobile, bicycle, and vehicular accidents.

The alveolar border or one of the .processes is usually involved.

Sjrmptoms. — ^Visible deformity and disability vary; usually there
is a good deal in the region of the cheek and nose, and often bleeding
from the mouth and nose occurs. Ecchymosis of the hard or soft
pa,l3.te is a corroborative sign. Facial emphysema is common.
Crepitus and false motion are variable. Teeth are often loose,
broken, or missing.

Treatment — Like that of lower jaw, this is by a bandage or
^I>eoial splint; reduction may* be difficult in complicated cases.
Union is complete in four to six weeks.

Results. — Practically perfect as to function. Deformity of the
^^^tili or nose may persist.

XHsability. — Total, four to six weeks; partial, two to four weeks.

Nose fracture

This description includes that of the two nasal bones proper; the
^^pizwiy cartilageSy and \he.nasal process of the superior maxillary, and
f^o^Mridl (perpendicular plate), vomer, and lacrimals.

Anatomy and Landmarks. — Nasal hones triangular, and located
^^ the upper and lateral fixed portions of the nostrils (Fig. 266).

Septum the dividing cartilaginous partition, with a more or less
"Marked normal lateral deviation, almost always.

Cartilages. The quadrilateral join the nasal and ethmoid bones
^•bove, the vomer behind, and the lower lateral cartilage at the tip
(Fig. 242).

3jTlUnC SURGERY
— Cffrv: Tutatce practically the sole origin, as

, MiE^pUMi* stcucturcs of and about the r
nc* Jhlicate usual fracture sites.

Flo. J67. — Anatomy of the nose,

•„»- ■■ytum: 1, Septal cartilafic; 2, lower lateral cartilage; 3, vomer

tf.wAi LmKtss; S, ethmoid (jierticndicular plate); 6, vomer; 7, frontal

■J, jMt ft> Nasal bime anil carlilaKc. front view: u, Upper lalcral

.,y ^.-tftilage; 10. lower lateral cartilage; 13, tip of cartilase; 16,

,^ulan»; 1, lower lateral cartilafie (mesial crus). c, Nasal carti-

^ >'^>>ji.-«rtilaRe ; 10, lower lalcral cartilage; 11, small alai cartilage;

'.. '»iHtf lateral cartilage.

fWtMlrK.

-A rare source in connection with other

X'lAL FRACTUHJ

Very frequently the fracture is compound (open) because of
wounds in the skin or nasal mucous membrane.

Nasal bottes alone may be broken, especially at the lower part
where the cartilage joins, and hence the latter are frequently involved
at the same time.

Septum cartilages may be broken or separated at their (a) nasal
attachments; (6) from the superior maxilla: (c) from the inferior
cartilage at the tip.

Lines of fracture may so radiate as to involve small portions
of the frontal, superior maxillary, lacrimal, ethmoid, and vomer
bones.

The commonest form is a combination of one broken nasal bone
with some separation of an attached cartilage, thus deviating the

Symptoms. — Deformity is common from swollen soft parts and a
tilted or flattened "bridge." Bloody nose. Ecchyniosts of eyelids.
Occasionally local emphysema occurs from the frontal sinus, especially
if nose blowing is done. Plugged nostril, causing difficult breathing.
Lacritnal duct plugging rare; when it occurs tears flow over face

314

TRAUMATIC SURGERY

(epiphora). Crepitus, motility , and pain on manipulation; finger or
instnunent in nose may verify these foregoing (Fig. 268).

Hematoma septum usually seen later; may occur without fracture.

Via speculum the distorted swollen septum is best apparent ; this

is the most reliable means of determining the exact extent of injury.

When seen after a few hours, the swelling and pain may prevent any

accurate opinion.

Treatment. — Reduction cannot be properly made in many cases
without some anesthesia, local or general; this is especially so in cases
seen after twenty-four hours.

In cases with great swelling or bleeding, cold applications and pre-
liminary gauze plugging may well be the primary measures. Speak-
ing generally, immediate reduction is indicated.

After a week it will be impossible to adjust the fragments on ac-
count of firm union. A speculum and intranasal light are very help-
ful. Setting once properly made usually
persists.

Manipulation, bidigital or instrumental,
to restore the fragments is usually necessary,
and this should be done promptly except
where epistaxis or great swelling prevents.
A blunt conical bullet probe, urinary sound,
artery clamp, or similar instnunent can be
used where the finger is inefficient for eleva-
tion or other procedures. High fractures
need . a flat instrument like a periosteal
elevator.

Immobilization is well maintained by
perforated metal or hard rubber Asck splints, formerly used in
septum deviation operations; one on each side of the same size
should be used.

Adhesive plaster strapped over the pressed upon bridge is effective
only if minor displacement exists.

Rubber tubing (wrapped in gauze) or gauze packing of iodoform
carefully introduced on the injured side is most valuable in the lower
septum injuries. Special splints, fastened by head-bands with lateral
prongs to press upon the nostrils, are usually needed in fractures
high up or those tending toward redisplacement (Fig. 269). Of these,
the Cobb and Coolidge may be recommended. Wounds are treated
like those elsewhere.

WTiatever method is used, much attention is given to keeping the

Fig. 269. — Metal splint for
fracture of the nose.

SPECIAL FRACTURES

31S

nostrils clean by antiseptic irrigations, the head being held forward
while they are being introduced to prevent sinus extension. The
patient is to be cautioned against efforts similar to those of blowing
the nose or snuffing.

Union is complete in two to three weeks and splintage is rarely
needed beyond a fortnight

Complications. — Erysipelas and cellulitis are not uncommon, es-
pecially in neglected, compoimd (open), and assault cases.

Chondritis and perichondritis and periostitis occur occasionally,
especially in badly contused and infected cases; permanent thickening
usually ensues from these.

Abscess of septum with subsequent
deformity is most likely where re-
peated intranasal examination is
neglected; pain, swelling, occlusion,
and discharge are the usual signs.

Hematoma of septum is rare with
fracture and common without it; if
present and irreducible by pressure,
it should be incised to prevent abscess .

Necrosis is sequential to the fore-
going; a rare sequel.

Epistaxis occasionally is recurrent,
but prompt and proper treatment is
generally preventive; it is commonest
in alcoholic, cardiovascular, and
anemic patients (Fig. 270).

Results. — Deformity to some ex-
tent is exceedingly common, and for
that reason a perfect restoration of

profile should be guardedly promised; the common remnants are
tilting or depression. Some of these arc capable of plastic correction.
Deviation of the septum can be marked without serious inconvenience.

Disability, — ^Total, two to four weeks; partial, one to three weeks.

Fig. 270. — Epistaxis controlled by
water or air inflation of a rubber
finger-cot, condom, or glove-finger.

MALAR FRACTUR£

This occurs rarely as an isolated lesion, but may be an associate
of extensive adjacent injuries.

Causes. — Direct violence always, as by a severe blow, fall, or kick.

Sjrmptoms. — Deformity of the much swollen cheek and orbit usu-
ally obscures the bony signs. Epistaxis and ecchymosis of the lids

3l6 TRAUMATIC SURGERY

are common. Crepitus and mobility are rare. Local pain and a
depression are the usual signs, and these are best elicited by standing
behind the patient and passing the index and middle fingers outward
from each nasolabial fold toward the ear orifice. This maneuver
palpates the zygonia and body of bone, the parts usually involved.

Anesthesia or paresthesia of parts of the cheek, gums, or upper teeth
may exist if the infra-orbital nerve is involved. Motion of the lower
jaw may be diminished.

Treatment. — Reduction. — In the ordinary case this cannot be
done without operation to expose the fracture through the cheek or
mouth, and then traction by a hook or other device is employed. In
involvement of the zygoma alone, pressure is usually effectively
applied outside and inside the cheek, as by a pair of curved forceps,
one blade of which rests on the zygoma, the other within the mouth
against the upper teeth. Once reduced, the position tends to remain
without any dressing; adhesive straps over gauze pads may some-
times prove helpful.

Results. — Deformity may persist in unreduced cases as a dimp-
ling, depression, knobbing, or sagging. Impaired motions of the jaw
are usually regained.

Disability, — Total, two to six weeks; partial, one to three weeks.

FRACTURE OF THE CLAVICLE

This is exceedingly common, and of all fractxires of single bones
ranks third or fourth in frequency. It occurs often in children from
the sort of violence which in later life dislocates the shoulder.

In my series there were 236 cases, 4}^^ percentage of all.

Anatomy and Landmarks. — This S-shaped bone is about 6 inches
long and divided into thirds, and it is visible and palpable practically
throughout.

Inner or Sternal End. — Knobbed and has some motion.

Outer or Acromial End. — Flat and also somewhat motile.

Tubercle or Knob. — On upper part of outer third; this may be
misleading in some atypical fractures.

Causes. — Direct Violence. — Rare, as from a blow or fall or other
localized impact; breakage from this source is usually located about
the middle or outer third, and then generally it is compound (open).

Indirect Violence. — Usual origin, as by a fall on the shoulder,
elbow, or hand, the extremity being rigid.

Muscular Violence. — Exceptionally causative, as by lifting,
swinging, or contracting motions.

SPECIAL FRACTURES

317

Varieties. — Usually the cleavage is oblique, complete, and simple,
and about one-half of ail varieties are in the middle third, approxi-
mately within 2 or 3 inches of the outer end. About one-third of the
remainder are at the junction of the middle and outer thirds,

Greenslick or Bending.— These occur in children only.

Parlidi. — A rare form in which a border or edge is split, or the
lone is not broken completely across.

Multiple and Comminuted. — Very rare forms.

I Symptoms. — Deformity of attitude, so that the drooping shoulder
is lifted up and supported by the opposite hand; visible irregularity
in outline of the bone; swelhng and ecchymosis later appear.
Crepitus, false motion, irregularity, and local pain are confirm-
atory signs.
In cases showing little displacement, local pain ehcited by direct
"point" or finger pressure, or that produced by pushing against the
"bone from within out, will sometimes verify suspicions. In typical
cases the outer fragment is usually found drawn down and in; the
loner, drawn up and out by muscular contraction.
Adult fractures often show much obliquity and impaction (Figs.
272-274). In the young, the fracture line is generally transverse
or nearly so (Fig. 275).

linv,

Ion-
thruugiiniii

Inner or .1

Outer or

Tubercle c
misleading in

Causes. — j
localized impi
the middle or

Indirect Vi
elbow, or han(

Muscular \'io!
swinging, or contrj

SPECIAL FRACTURES

Fig. 274.— Fracture of Ihe clavicle (outer third).

320

TRAUMATIC SURGERY

Treatment.— The shoulder has dropped dou-n and in, and the
object is to push it up and out.

Reduction is accomplished by raising the shoulder and pulling
it backward. This occurs sometimes spontaneously if the patient is
placed on the back with a pillow between the shoulder-blades.
Standing behind the patient and placing the knee between the
shoulders and forcing them backward is also useful. With the
patient seated on a stool, abducting both arms to a right angle, and
pulling the scapulae toward each other is also an aid to setting
(Fig. 280).

Sayre's adliesive plaster dressing for fractured clavicle. Fig. 176, posterior piece
to retract shoulder. Fig. 377, anterior piece to dcealc sboulder. Note the padding iti
the axilla and under the palm; the olecranon pressure is relieved by an opening in the

With much overlapping or impaction, anesthesia or operation
may be necessary to overcome the deformity. Occasionally
osteotomy alone is efficient.

Immobilization is difficult, but is best maintained in the average
case by the Sayre dressing of zinc oxid adhesive plaster applied as
shown in Figs. 276, 277. Axillary vessel freedom is assured if space
enough is left to insert two fingers at the inner edge of the arm-piece
of the adhesive. A gauze bandage shoulder-cap may well be used

SPECUL FRACTURES

Fto. 978. — Mmyor's scarf sling for fracture of the clavicle or other injuries of the shoulder
girdle.

Fic. 379. — T-splint aad tbc method of applicatioD. It is made of K
wood broad enough to dots the shoulders and long enough to reach the waist
is soilftbly padded and the croespitce is first attached by bandages, the oule
<rf the q^int bang notched to prei'ent slipping. Then a felt or cotton pad
betwcra the shoulder blades so that the pressure of the long arm on this may
■boulder back. An adheave strap or bandage binds the lower end of the
tbc waist. OotMng may be worn with this device and the arms arc free.

by 3-m.
line. It
r margia

322

TRAl'MATIC SURGERY

with this for a time. In very fat people and in women the abcwe
dressing sometimes cannot be used; in these, a shoulder bandage
will answer usually. Whatever method is used, preliminary
removal of hair is advisable. The parts should be well dried and
the axilla dusted with talcum or other powder. Mayor's scarf
sling may also be used (Fig. 278).

The dressings are worn for two or three weeks by children; in
adults, two to four weeks.

Fig. 380.— Postui

In women, or in those who seek a cosmetic rather than immct
recovery, it may be advisable to reinforce the foregoing by insisting
upon a dorsal position with a pillow between the shoulders for a week
or ten days. Couteaud's posture treatment is allied to this (Fig, 281),
the position to be maintained two weeks.

Apparatus specially designed of wood or metal is rarely employed.

Of these one of the most efficient is the T-splint indicated in Fig.
279. Pads of felt or cotton are placed under the armpits so that
the figure-of-8 bandages passing around the armpits will not constrict
circulation. Another similar pad is placed between the shoulder
blades under the splint.

SPECIAL FHACTURES

Operation and direct coaptation by sutures (gut or wire) or
plating is reserved for great deformity, compounded, or ancient
I untreated cases.

The author advocates the use of his plaster-of-Paris "abduction
I method" in certain cases not well retained by the usual dressings*
CFig. 280-282; see also Fig. 312).

' Published in Tke Poil CtaduaU, Dec., 1Q14.

324 TRAUMATIC SURGERY

Results. — Union is complete by the end of three weeks (Fig. 282).
Deformity is shown by marked early irregularity or callus, but it
usually disappears wholly and is always lessened in time; but the
site of fracture is practically never free of some irregularity even
after a lapse of years. Despite marked deformity, with or without
bony union, the rule is for complete recovery; here, as in many
other fractures, deformity by no means implies disability.

Fibrous Union. — Not uncommon, and frequently it causes no loss
of function.

Impaired Motion and Ankylosis. — Shoulder stiffness for a time is
not unusual; if immobilized by treatment longer than a month the
extent and duration of stiffness is generally due to the treatment
more than the fracture. Massage and forced use eventually bring
about restoration even in marked cases.

Atrophy is commensurate with the above.

Nerves. — Those in the axilla are rarely affected; circumflex and
spinal accessory occasionally are involved, but Recovery in all forms is
the rule.

Disability. — Total, four to six weeks; partial, two to six weeks.

Scapula Fracture

This is rather rare and does not constitute more than i per cent,
of all.

Anatomy and Landmarks. — Body. — Palpable over the lower por-
tion.

Vertebral Border. — Brought best to view by elevation and abduc-
tion.

Spine. — Visible and palpable, wholly or in part.

Processes: acromion, at outer end of spine and jointed to the clav-
icle; coracoid, overhanging the axilla.

Glenoid Cavity. — Rim sometimes palpable (Fig. 283).

Causes. — Direct Viokftce. — Blows or falls, especially common in
fractures of the body and acromion.

Indirect Violence. — Blows or falls on the shoulder or elbow; not
infrequently an associate of humerus injuries.

Muscular Violence. — Rare, except as affecting the processes.

Varieties and Sites. — Commonest in the body, spine, acromion,
and coracoid; rare in the glenoid and neck. Fracture lines may be sin-
gle or multiple in the body varieties.

Symptoms. — Body. — Deformity and disability about the shoulder
varies; the commonest signs are crepitus, false motion, and pain on

SPECIAL FRACTURES

3^5

Ecchymosis

pressure against the ribs or when the arm is abducted,
and swelling may occur.

Spine. — Defonnity and disability variable; commonly crepitus,
false motion, and local pain are determinative.

Acromion and Coracoid. — Deformity slight, if any. Ecchymosis
and local swelling variable. Crepitus, false motion, and local pain
exist; abduction or elevation of the arm best elicit the foregoing signs.

In all, *-ray corroborations may be necessary.

Flo. 383. — a. Common sites of fracture of the scapula; b, normal scapula, posterior view.

Treatment.— Boii)' and Spine. — Reduction is by manipulation of
the fragments or arm, or both, and maintenance of same in the cor-
rected position by binding the elevated arm to the side with a shoul-
der-cap bandage, adhesive plaster (Sayre's dressing or modifications)
or plaster of Fans.

Acromion and Coracoid. — Reduction, and application of Sayre's
dressing or modihcation, with direct pressure by gauze or cotton
pads ; or by means of bandages to relax the muscle pull and keep
the shoulder at rest.

Results. — Body and spine: Union occurs with more or less callus
in four or five weeks and complete restoration is general; some pain
may for a time persist on elevation of the arm, deep breathing, or
actions bringing the ribs and the body of the bone in contact.

Processes. — Bony union generally does not occur (except in im-
pacted forms) and the length of the fibrous uniting bands may widely
separate the fragments without marked loss of function. Healing is
generally complete in three or four weeks.

Disability. — Body and spine: Total, four to six weeks; partial, one
to three weeks. Processes: Total, three to five weeks; partial, one
to two weeks.

326 TRAUMATIC SURGERY

STBRNUM FRACTDItE
A rare injury unless associated with fractured ribs or fatal chest
crushes (Fig, 284). •

Anatomy and Landmarks. — Manubrium: The interstemal notch
and junction for clavicles and first ribs are palpable and sometimes
visible. Gladiolus: Only anterior portion palpable usually. Ensi-
form (xiphoid) appendix: Variable in shape, position, and motility.

Fic. 284. — Lines of fracture of the

Up to the age of twenty-five, each of the foregoing are made up
of several segments. The ensiform joins the gladiolus about the
fortieth year; partial bony junction may rarely unite the manubrium
and gladiolus late in life, but usually they remain separated. This
explains the freedom from fracture before the twenty-fifth year,
dislocation consequently being more common.

Causes. — Direct Violence. — Commonest, as from blows, missiles,
falling or moving objects, or crushes.

Indirect Violence. — A rare and improbable source.

Muscular Violence. — Occasional, as from great straining or
exertion.

Sites and Varieties. — Usually breakage occurs at the junction of
the first and second segment, involving the lowest end of the manu-
brium; next commonest location is about the center of the gladiolus.
Simple, transverse, more or less complete fonns are usual; compound
or multiple forms are rare in non-fatal cases. Dislocation may be
hard to exclude in some instances.

SPECIAL FRACTURES 327

Symptoms. — Dyspnea, cyanosis, cough, and hemoptysis common.
Palpation elicits irregularity, local pain, and perhaps crepitus and
false motion. In a severe case there will be a good deal of shock or
prostriation.

Treatment. — Reduction by direct pressure, or manipulating the
arms and chest may be enough. Sometimes it may best be made by
bracing the patient's back against the edge of a box, or a dorsal pos-
ture over the edge of the table may be assumed, so that the shoulders
and upper chest will fall backward, pressure over the line of breakage
then being added. Respiratory efforts and coughing sometimes lend
additional help. Operative aid is rarely needed. Immobilization is
by a wide strap or straps of adhesive completely encircling the chest,
applied during expiration.

Results. — If shock is survived and pneumonia or local necrosis
does not complicate, healing is complete in from five to eight weeks.
Deformity may persist permanently, but generally this causes no
trouble; in appearance it may resemble the "rickety chest."

Disability. — Total, five to eight weeks; partial, two to four weeks.

RIB FRACTURE

These are exceedingly common and in my list of cases ranked
second in frequency, a percentage of 11.7.

Anatomy and Landmarks. — Of the twelve, seven are attached to
the sternum, forming the so-called true ribs; of the five remaining
false ribs, the eighth, ninth, and tenth are attached in front by carti-
lage, the eleventh and twelfth, being unattached in front (floating
ribs), are very movable and thus rarely broken. The first and second
are fairly well Overlapped by the clavicle and usually escape injury;
those forming the widest part of the barrel-shaped thorax are most
exposed to violence, and thus the fifth, sixth, and seventh are of tenest
broken (Fig. 285). Ribs do not completely ossify until the twenty-
fifth year, and they are quite elastic in children, thus accounting for
the great rarity of fractured ribs in the young.

Most ribs are palpable throughout and many of them are also visi-
ble. The intercostal and other muscles and ligaments are so strongly
interlaced and intimately attached that great displacement of frag-
ments is rare (Fig. 286).

Causes. — Direct Violence: Common, notably a localized blow or
fall on a projecting surface, or contact with a raised edge of a moving
or stationary object. Indirect violence: Rather more frequent, as in
accidents tending to narrow the anteroposterior diameter of the chest,

338 TRAUMATIC SURGERY

thus causing a bulging at the lateral margins and fracture at a ti
tance from the source of pressure; this is often aptly illustrated by

Fw, aSs.— Fracture of the first rib at

iitlachment; a very rare injury,

forcing together the ends of a barrel hoop and noting that the break
is at the center or nearly so — a sort of "bursting" fracture. Crush-

Fm. !86, — Lines at ffacture of the ribs.

t ilid jamming accidents are common causes. Musadar v
|Vt'a»ionally a source, as during violent sneezing, coughing, or power-

SPECIAL FRACTURES

329

fu! lifting or straining actions; if broken in tMs manner, the lowest
ribs are generally involveti, and it occurs from this source more often
on the left side of the chest.

Sites and Varieties.— Commonly breakage occurs a few inches
outside the sternal attaclunent; that is, at or near the line of the
nipple, and this is especially so if the source is direct injury. If
caused by an indirect or squeezing force, they may be broken further
back and on either or both sides.

Complete and incomplete fractures occur, the latter as Jndentings
without much change of contour or definite signs. Multiple Jraclure
is not uncommon, adjacent ribs being usually affected (Fig. 287).
Compauitd or comminuted types are rare and usually result from
bullet wounds or severe crushing accidents (Fig. 288).

Fracture at the attached ends (sternal or vertebral) is very
uncommon.

Symptoms. — Focal Signs. — Visible swelling, ecchymosis, and
changed contour sometimes. Local pain on direct pressure, or that
elicited by forcing the sternum backward may be the main sign; this

TRAUMATIC SI

thus causing a bulging at the later?
tance from the source of pressure;

I forcing together
, is at the center o

ventli ritisinachilddue tOBUtamoblle

Ktident.

jM- is usually characteristically affected

^shallow, quick, jerky, or cog-wheel, and

g £> chosen to relieve respiratory iavolve-

a is chosen, Uie injured side will be kept at

r the patient is resting upon. Speech is

^ agjciratory difficulty, and it is limited and

d or quickly sputtered, all in an effort to

^ and cough are frequent. Bloody expec-

^. 1 docs not of itself indicate gravity or exten-

- r,wn absent in serious and present in ordinary-

^ ilued about the fracture or even spreading

jbdomen is not very infrequent; it indicates

i* not usually a serious feature, as it disap-

^>^ treatment. Pneumothorax or hemothorax

,. vKcurs occasionaliy, the former more com-

the pleural cavity or lung has been entered.

SPECIAL PHACTURES

331

*;,i:. The average patient will be short of breath

ii'.iu'li .111(1 point to a small painful area of the chest

l.ugur liian a half-dollar), and this region will be

(■rcsjcd upon or when strain is brought on it by squeezing

It" the chest wall; there may be crepitus here or localized

L- outline of the ribs may be changed and there may

. frothy spittle.

Fig iSq. — Strapping chest (fro

w).

Fig. 390, — Strapping cheat (back view).

Treatment. — Reduction is usually not needed, but if it is, press-
ure and manipulation may produce it, but operative replacement is
only necessary ^ if urgent impingement exists. Immobilization is
provided by adhesive plaster strapping applied around the chest
during expiration; in whatever way applied, it should tightly include
more than half the chest to be of any value. In applying it the arms
should not be elevated, as that position of itself expands the chest.
It is first fastened behind just beyond the midspinc and brought
taut toward the injured side with a rapid swing to beyond the center
of the chest or further; it needs to be snug, but not painful. If
small V-shaped sections are cut from its upper margins considerable
space will be gained and perhaps make complete removal unnecessary
in the event of too great pressure. The adhesive need not con-

TRAUMATIC SURGERY

tact throughout with the skin, as it often unduly irritates; gauw
laid along the strap as shown in Fig. 291 makes the strapping quite
as efficient and much more comfortable.

Fio. iQi. — Single layer of gauze to ptotcct akin when large

DrcisiHgr.— (i) Broad Strapping. — A 4- to 8-inch wide strip of
zinc oxid adhesive is applied to the shaved chest.

{2) Narrow Strap ping. —j-inch overlapping strips are applied, be-
ginning above and covering an area several inches above and below
the fracture.

FiG. 292.— Relation of pleura (fed) tochestwall; a, Anterior Mtenl;6,posteriorwttoL

(3) Malgaignc's Dressing. — For a left-sided injury, a 3-inch
strap is started from the right end of the seventh rib, and passes to
the left across the chest and under the left arm, and across the hack

SPECIAL FRACTURES 333

and over the rigfU shoulder; thence again across the front of the chest
and around the left side and back, to end at the right iliac crest.
This leaves the right side free; it can be reversed for injury to the
opposite chest. The arms, if bound to the side, aid this form of
immobilization.

Plaster is worn three weeks, and its removal is facilitated by hot
water, gasolene, ether, wintergreen, or camphorated oil. The re-
maining plentiful crop of itchy pimples are benefited by alcohol and
dusting-powders; such acne-h'ke signs are fair indications that some
sort of plaster was recently used. A flannel or muslin bandage
sometimes is agreeable for a week or two longer. Plaster of Paris,
starch, and other bandages cannot be applied firmly enough to be
of supportive value.

Complications. — Pleurisy, localized to the fracture site, is quite
common. It practically never becomes serous or purulent and gener-
ally disappears before the fracture is finally knit (Fig. 292).

Pneumonia, — Rare; it begins within the first three days and is
generally lobar in type. The hypostatic form seems no more common
as a late manifestation of this than of other fractures; the aged and
alcoholic are rather prone to have it develop in this and many other
injuries.

Hemorrhage from the intercostal arteries or torn lung is rarely
prominent; exceptionally it requires removal by aspiration.

Intercostal neuralgia occasionally occurs; no special treatment is
needed. It may last for some weeks after imion occurs, but is never
permanent.

Traumatic asphyxia (also called *Hhe ecchymotic mask") is an
accompaniment of severe crushes of the chest and usually is due to
jamming between moving objects, as in coupling cars or squeezes
between a moving and stationary object. In addition to broken ribs,
and dislocated cartilages, there is great dyspnea and cyanosis, with
ecchyinoses and subconjunctival hemorrhages. It is said also to
occur from impingement of the abdomen. Most cases get well.

The one patient I have seen was rolled at the upper chest level
between the projecting edges of two trolley cars, and from his neck to
the top of the forehead he was dusky blue, his eyes protruded, and the
conjunctivae were deeply hemorrhagic. The unconsciousness lasted
several hours and there were numerous ecchymoses and petechial
hemorrhages on the upper chest and several broken ribs. A diag-
nosis of fractUted base of the skull was made before the exact mech-
anism of the accident was explained. He recovered despite a marked
old endocarditis.

334

TRAUllATIC SURGERY

Strangulation sometimes causes similar facial and nedt appear-
ances.

Results. — Complete and rapid recovery is the rule from nb
fractures. Callous formation is complete by the end of the third
week; it may be quite marked at first, but usually smooths away
(Fig. 293). Pleuritic adhesions occasionally result and may give
pain until gradual stretching releases them. Pulmonary remnants
are exceedingly rare.

Fig. 393. — Callous formation in overlapping fractuie of a rib.

Disability Period. — Total, two to four weeks; partial, one to
three weeks.

COSTAL CARTILAGE FRACTDRE

This is exceedingly rare and rather difficult to differentiate from
dislocation. Less than 100 cases have been recorded.

Causes.— Direct falls and blows.

Sites and Varieties. — At the junction with the rib (costochon-
dral), usually involving the seventh or eighth rib. It is generally
simple and complete, with some displacement,

Sjrmptoms and Treatment.— Similar to fractured ribs.

Humerus fractures
This bone is not uncommonly broken, forming 3 to 6 per cent, of

Fig. 294. — Relation of nerves to head of bumerus.

Anatomy and Landmarks. — Upper End. — Head can be felt to
rotate in the glenoid, especially on deep axillary pressure (Figs. 294,
295). Greater tuberosity forms the bony point or proniinence at the

SPECIAI. FRACTUILES

PiQ. 395- — Relation of blood-vessels to head of humerus.

flo. 197. — Curying angle of arm: a. Normal, 15' from a straight line, about 165";
b, cubitus varus or gunstock deformity; e, cubitus valgus.

336 TRAUMATIC SURGERY

shoulder and projects beyond the acromion process; aometimes pal-
pable. Shaft, palpable to some extent, especially in the central part
(Fig. 296).

Lower End. — Internal condyle prominently visible and palpable.
External condyle less marked than the above, and leading up from it
is the condyloid ridge.

Sites and Varieties. — Upper End: Head, anatomic neck, surgical
neck, tuberosities, and epiphysis. Shaft, lower end: Internal condyle,
external condyle, epiphysis, combinations.

on Upe).

Head. — This is broken so rarely as to be a curiosity.

Anatomic Neck. — This corresponds in great measure to the intra-
capsular fracture of the nec'k of the femur. Relatively it is a very
rare sort of injury and generally occurs in old people, and is usually
impacted or combined with dislocation or fracture of a tuberosity.

Causes.— Direct falls on the shoulder in the common source; less
often indirect violence transmitted from falls on the elbow or hand k
at fault.

Diagnosis. — The Joint is disabled, painful, and swollen; there
may be slight deltoid flattening; crepitus is variable; pain on pressure

SPECIAL FRACTURES 337

and motion exist; shortening is slight if present at all. Ecchymosis
occurs later; ac;-ray examination is often needed for confirmation and
differentiation (Fig. 298).

Treatment. — Impacted or non-displacement forms need practic-
ally nothing beyond a bandage and sling to keep the arm at the side
for three or four weeks.

Unimpacied or displacement forms may sometimes be helped by
traction and abduction, with the arm later fixed at the side of chest
with a pad in the axilla. Others do better with the arm held in right-
angled abduction, as indicated below. Operation may be needed
where dislocation is associated, and then the fragment is sometimes
removed if replacement cannot be otherwise accomplished. Occa-
sionally nailing may be necessary; but in old people all operative
procedures must be limited to selected cases.

Results. — Union occurs in three or four weeks if at all; the im-
pacted cases do better than the others, but in all there may be some
permanent shoulder disability.

TUBEROSITIES

These are rarely broken alone, but usually are accompaniments of
anatomic neck fracture, or dislocation of the shoulder. The lesser
tuberosity is rarely involved.

Causes. — Generally a direct fall or blow on the shoulder, or less
often a severe muscular contraction or abduction is at fault.

Diagnosis is made by exclusion plus the finding in the swollen,
tender joint such signs as local pain and perhaps crepitus on manipu-
lation, notably during abduction; a;-ray confirmation generally is
necessary.

Treatment. — Reduction usually is not needed; if much displace-
ment is present, oj>en operation and fixation by suture or pinning is
sometimes required. Immobilizationy as made in anatomic neck frac-
ture, usually suffices.

Results. — Deformity is very unlikely and disability is slight, if
any occurs; complicating injuries modify this outcome. Fibrous
union b common and does not interfere with function.

Disability, — Total, .four or six weeks; partial, two to four weeks.

EPIPHYSIS

This is the injury about the shoulder in children. It never occurs

after the twentieth, and is relatively commonest from the ninth to

seventeenth year. This is the most frequent of all epiphyseal

separations.
22

338 TRAUMATIC SURGERY

Causes.— Blows, falls, and pulls on the joint are the ordinary-
sources; occasionally the same factors act from a distance, but indirect
is far less productive than direct violence.

Sjrmptoms. — The arm is disabled and the deformity looks not
unlike that of an adult dislocation of the shoulder; there is distortion
and swelling of the shoulder and the axillary fold level is altered.
Palpation discloses the head in place and the upper end of the shaft
displaced forward and inward usually. Local pain, some false mo-
tion and a soft crepitus may exist. If there is little or no displace-
ment, x-ray confirmation or anesthesia will be needed for accurate
diagnosis.

Treatment. — Reduction may be exceedingly difficult to maintain
without operation. Setting is best accomplished by traction and
abduction, this being maintained by a triangidar pad in the axilla and
a shoulder-cap and cast, after the manner of some shaft fractures.
Some with little displacement do well enough by simply keeping the
arm at the side and using a sling. The position of right-angled ab-
duction is probably best for most cases. Operation may be necessary
for reduction, and x-ray examination should be made often before
successful replacement is assumed.

Results. — Functional . restoration is proportionate to the success
of reduction, and in those cases accurately set a perfect result ensues.
In those less well reduced there may be some permanent deformity
and inability to fully elevate or rotate the arm; however many of
these cases eventually do a great deal better than the early clinical
and x-ray signs indicate, and for all practical purposes complete
function is regained. If there is much maladjustment the subse-
quent growth of the humerus may be badly impaired.

Disability. — Total, four to six weeks; partial, two to four weeks,
but a child need be from a school a great deal less time than this.

SURGICAL NECK

This clinically comprises all fractures within the upper fourth of
the arm and the epiphyseal line; it is the common fracture of this
location in adult life and corresponds to the extracapsular fracture
of the neck of the femur.

Causes. — Falls or blows on the shoulder, twists of the arm, or
falls on the elbow are the usual sources. Muscular action is a rare
factor.

Varieties. — The ordinary form is complete and transverse with
variable degrees of displacement; it may be impacted orunimpacted

SPECIAL FRACTURES

(Fig- 299). Dislocation of the shoulder or tuberosity fracture are
often associated.

Fig. 195, — Fracture of the 5uri,'ic:il nerlc r)[ ilic IminiTUsi J. External appearance; I

Fio. 300. — Fracture of sur(,'ital neck oi humerus (impacted). Treatment indicated:
axillary pud; arm fastened to cbest bya broad swathe of adhesive or muslin; sling for
forearm; massage on third day; passive motion at end of second week; active motion
begun one week later.

Symptoms. — The disabled joint is swollen, painful, and held in a
position of hxation against the chest, supported by the opposite

338 in.

Causes.— Blows, fai)^
sources; occasionally thu
is far less productive l.ii,ii

Symptoms. — Thr Km
unlike that of an adult dK
and swelling of llu- siuv
Palpation discloses the l»i-
displaced forward and ini
tion and a soft cr<-|
ment, ar-ray confini
diagnosis.

Treatment.- R,
without operation
abduction, this Ln-in
a shoulder-cap and
Some with hltle di^
arm at the side .ini
ductionisprobalil;
for reduction, an. I
successful repUiceiii

Results. — Fuin
of reduction, and in
In those less well recluu
and inability to ftlUy
these cases eventi
and .f-ray signs
function is regaim
quent growth of

DisabUity. —TcA
but a child need

This clinically
the arm and the ept]
location in adult life
of the neck of the fenftjlf

Causes. — Falls or V
falls on the elbow are t
factor.

Varieties.— The onf
variable degrees of diq

,. lure of ihc surKkal neck of Ihe hunv
m by a plastcr-o (-Paris shoulder spjau J

as Hg. joi property reduced.

SPECIAL FRACTURES

Fig. 303.— Fracture of surgical neck and greater tuberosity of humerus (impacted).

FiAo. 304. — Fracture of the surgical necli of tiumcrus well reduced and held in abduction
by plaslcr-of- Paris shoulder spica.

FlO. jo8. — Fracture of the surgical neck af the humerus Kparating the greater
tuberosity. Treatmeot indicated: abduction of arm to right angle and fixalign by
plasler-cf-Paris or other splint in th3,t position.

^:,- marked and extend to the elbow

■:.. .: iBe bone is in placi- and the fraf;-

;: jolla. In impacted cases, crepitus

, r -iirv 10 rotate, constituting abnormal

■.^. Shortening may or ma\' n<it \w

-j>-±:ied irom the elbow elicits local

- - .;.-ji^. the axis of the arm points

_ - .T fold is changed (Fig. ,^00-308).

- •i«'*'* tf"^*'"" !<trap9. Useful ir
'~ oflhcwm.

^^, generally is possible by traction and

^^i-c; in some cases anesthesia is needed. In

Bttch displacement no effort should bi'

^^— flits; in fact, this is the aim of treatment,

ijfeplaccment is unlikely.

■""^j^-of the following: {1) Arm fixed at side by

* ; j^ng; this answers for the non-displaced

^^^lutcd by (a) axillary pad (Fig. 311); (ft)

j^« iQ the axilla like Micldledoqi's triangle,

.^^ *7»^jiallow's splint; Id ])laster-of-I'aris splints,

J*^^j!.i shown in Fig. .^i.;; (d) internal angular

Fic. 310.— Dressing for non-
displaced fracture of the upper part
of the humerus, including tuberosi-
ties, neck, and adjacent shaft. Note
sboulder-cap splint of plaster, felt,
or tin, Ihc broad bandage alxiut
chest, and a simple sling.

the shaft of the humerus, consisting of: i
padding for the axilla held by a strap pass-
ing over the opposite shoulder; 2, padded
splints over front and back of arm; 3,
gau^e bandage from finger to eli)ow to
prevent edema; 4, sTing.

31 J. — Apjuitation 01 an ainlijiluin sJiuukler-spiinl, sheet lint or flannel band-
lir^t applied from fingers along arm and about the injured shoulder as a foun-
dation for plasler-of -Paris spica. Cotton is carefully used to pad the a.iilta and elbow.
A bass-wood splint helps to support the arm in abduction as here shown.

346 TRAUUATIC SURGERY

splints with weights attached to the elbow (Fig. 313, d). (c) The

Jones or Thomas splint with or without weight or torsion traction.

Either of the foregoing will need readjustment as the swelling

subsides. None of them should be employed longer than three or

Fio. 313. — Drcssiag for fracture of the shaft of the humerus, consisting of: a. Pad
In axilla held by a strap over shoulder; b, molded padded plaster-of- Paris, metal, felt,
or wood splints applied with forearm pronated; c, body swathe (muslin or gauze) and
sling; d, weight attachment to be used if traction is needed.

four weeks, then being replaced by a sling or adhesive, with or without
a removable shoulder-cap, just as soon as union is iirm.

My personal preference is for an adhesive strap and sling for the
non-displaced cases, and a plaster-of-Paris abduction dressing for
the displaced cases (Fig. 312).

SPECIAL FILACTUKES

Results. — Union is complete in thirty or forty days; non-union is
not especially rare. The impacted cases usually recover perfectly.
The unimpacted cases do not do as well and there may be a good deal
of stiffness and disability even as long as six months after; but
continued use and active attempt to increase abduction, elevation,
and rotation of the arm generally brings about an excellent working
outcome even in seemingly unfavorable cases. In this respect the
general outlook is not unlike that of dislocation of the shoulder.

Disability. — Total, five to eight weeks; partial, two to twelve
weeks.

SHAFT

This includes the region from below the upper fourth to the supra-
condyloid ridge.

Causes. — Direct blows or falls sometimes are at fault; usually it
occurs from indirect violence, as from falls, blows, or twists on the ab-
ducted arm. Muscular contraction as an origin is more common in
this location than in any other bone; generally it is the outgrowth of
efforts at throwing an object, or in trials of gripping strength, where the

FlC 315.— Lines of displacement in fracture of the shaft of tije humerus: a. Fracture
at upper third; b, fracture at loner tliird; c, fracture of middle of shaft-

. elbows are on the table and the opponents grasp hands and push or
twist against each other. The lower third of the arm is so often the
site of a compound fracture due to the wliirling propellers of a
recently started aeroplane, that it is known as "aeroplane fracture."
The musculospiral or median nerve is very often involved in this
type.

Varieties and Sites. — Complete, simple, obUque, or spiral forms of.
the middle or lower third are commonest (Fig. 315). The amount of

348 TRAUMATIC SURCERV

Flo, 317.— Fnwture of Uie shall of ihi- hum
ably shuws the budy li

SPECIAL FRACTURES 349

overlapping b determined generally by the extent of the violence and
by the counter-pull of the pectoral (inward) and deltoid and teres
(up and outward) muscles; or the latter and the triceps in the lower
levels (Figs. 316).

Symptoms. — Deformity shows by the attitude of the patient and
the changed axis of the arm; swelling and ecckymosis later. occur, and
the latter may be very marked. False motion, local pain, and crepitus
are quite uniformly present. Shortening may amount to an inch or
more between the tip of the acromion and the external condyle; in
the middle third fractures there is usually not much displacement.

Fig. 318.— Thomas splint ("

pcDsion. Useful

Treatment — Reduction is made by traction and manipulation,
usually under anesthesia, until the acromion and external condyle arc
aligned, bony crepitus is elicited, and shortening is overcome (Fig.
320). Splintage need be little more than placing the arm at the side
and holding it there in cases with little displacement, thus using the
the chest for a side splint, supporting the bent elbow and shoulder by
a siing. In the average case some abduction by a triangular pad
in the axilla and a shoulder-cap will be needed; hence treatment is
practically that of surgical neck fracture, except that weight
extension is sometimes necessary. In many cases abduction of the
extended arm to a right angle and maintenance in this position by
plaster of Paris from the wrist to the shoulder and about the body

:^u treatment, and t

.;. j23). The Jones
m may also be used

r*.o.

■ nduclion and maintain it by suture, pinning,
^'"'^.^climcs necessary-

" ■ -^-^The musculospiral may be affected at

' * Icnce- w ***"" "'^''■'^ ^'^'^'" swelling or efforts at

,■■■■ '''T^a from pressure of callus or splints. Wrist-

Pig. 3>i. — Thomas splints, one of irhich is bent to act as a trestle so that abduction is
possible in treating certain humerus fractures. Tliis resembles "aeroplane splints."

TRAUMATIC SURGERY

Fill. 271, — Incnmplete reduction of a. Tig. J13. — Same case after reduction

fracture of the 5haft of the humerus. and retonlion in abduction plastcr-of-

Paris shoulder apiea.

SPECIAL FRACTURES

353

drop is the common sign of this condition with loss of thumb abduc-
tion and extension; there will also be numbness or tingling on the
outer side of the forearm and hand, and back and outer side of the
arm, atrophy appearing later. The ulnar and median are occasion-
ally affected.

Before setting the bone the surgeon will do well to exclude any
neural injury so that subsequent blame may be properly placed. It
is generally wisest to wait several weeks before operating on such a

Fic. 3:5. — Applying shoulder spies, patient on board bridge LeLwcen two tables.

case of nerve palsy so that effusion or pressure from anything but cal-
lus may be excluded.

Blood-vessels. — Thrombosis or severing of the brachial artery has
occasionally occurred; this shows itself by changes in the radial pulse,
pallor, and coldness of the extremity, with signs of gangrene later.

Nonunion. — This is more likely here than in nearly any other
bone, probably due to lack of complete fixation rather than to
interposition of soft parts or nutrient artery damage.

Results. — Union is generally complete and soHd in from four to six
weeks; in children it occurs in three or four weeks.

The outcome is generally satisfactory as to appearance and func-

354

TRAUMATIC SXJRGEEY

tion; stiffness of the shoulder or elbow, or both, usually are remedied
by time and forced motion. The original calliis may be large and
irregular, but in time it diminishes and becomes smooth.

Disability. — Total, four to eight weeks; partial, three to twelve
weeks.

Fig. 336. — a, Lines of fracture of the lower end of the humerus, t

i ?. \

Fig. 317. — The relation of the bony prominences of the elbow to each other: i.
Internal condyle; 2, olecranon summit; 3, external condyle; a, with the elbow cilended,
these form a straight line — or with the elbow straight, they are straight; b, with the
elbow fle;ied, these form a triangle — or with the elbow at an angle, they are at an ansle.

LOWER END

These forms vary greatly and may be associated with dislocation
• of the elbow. A great many confusing subdivisions are described and
the nomenclature is not uniform; clinically the following are impor-
tant and inclusive (Figs. 326, 327).

SPECIAL FRACTVRES

355

Sapracondyloid. — This is the most common variety. The line of
fracture is above the flaring surface of the condyles; it may be trans-
verse, oblique, or penetrate the joint, causing a so-called T or Y
fracture, often coi.iminuted.

Some of these fractures are at a lower level, and are then known
as "diacondylar" (Kocher), or "low supracondylar" (Stimson).

Fig. 31S.

Causes. — Falls on the outstretched hand or twists of the arm are
the common sources; less often falls on the elbow may be productive.
The former are called by Kocher the exlensio-n variety, and occur in
early life; the latter he calls iheJJeximi variety, commoner in the aged
(Figs. 328, 3,33). Direct violence is most likely to produce T- or Y-
shaped modifications, often compound (open).

Symptoms. — Deformity in the attitude of the patient and the
elbow, with disability and pain are usually marked. False motion.

356 TRAUMATIC SURGERY

crepitus, local pain, and irregularity are noted; elbow dislocation or
fracture below the elbow is excluded by locating the three bony diag-
nostic points mentioned in the illustrations. The hollow in front of
the elbow is often found filled by bone. Ecchymosis and blebs
may appear later.

Treatment. — Reduction is by combined hyperextension, traction,
and manipulation, and this is best done under anesthesia. Correc-
tion is purposely made so that the forearm tilts outward, in order that
the normal relation of abduction of the forearm to the arm may be
preserved. Normally the angle between the arm and forearm is
about 165 degrees.

Forms 0] Splintage, — (i) The elbow is placed at a right angk and a
molded plaster-of -Paris splint is applied to the front and back of each
half of the arm, beginning just below the axilla, reaching to the wrist
in front and beyond it behind. The forearm is then abducted and
placed in the position of mid-pronation and supination (thumb up).
This antero-posterior splint is held by straps of adhesive and loosely
bandaged, if at all. A sling is the final support.

(2) The elbow is flexed acutely beyond a right angle and main-
tained there by a gauze bandage or strap of adhesive with a pad in the
fold of the elbow; this is the so-called "hyperflexion position" so
much advocated by Jones, of Liverpool. The rationale of this
position is explained by the internal splintage afforded by the spread-
ing out of the triceps tendon (Fig. 337). The degree of flexion is up
to a point beyond which radial pulsation ceases. The forearm is to
be abducted to preserve the normal carrying angle (165°) between it
and the arm. Redressing is done in the same way on the third or
fourth day, and twice weekly thereafter for over two weeks, the
degree of flexion gradually being decreased, until at the end of three
weeks the joint is at a right angle and a broad sling is then substi-
tuted for a week. Thus at the end of four weeks no dressing at all is
used and free motion is encouraged. No passive motion or massage
is ever given early if pain, swelling, or heat are induced. In selected
cases, active motion (the surgeon holding the elbow) can begin as
early as the tenth day, massage and passive motion having preceded
this.

Plaster-of'Paris and rubber bands are also used to maintain this
hyperflexed position.

(3) Extension is made and, with the limb straight, wooden or
plaster-of-Paris anterior and posterior padded splints are applied.
These are worn three weeks and then some flexion motions gradually

SPECLAL FRACTURES

F[C. 33a. — Hand.-i^c splint for elbow fractures.

TRAUMATIC SUBGFRY

Via. 331. — Bandage splint for elbow fracture.

SPECIAL FRACTURES

Fig. 334. — Supracondyloid fracture of I'ig. 335. — Supratondyloid fracture o£
the humerus showing partial union and tlie humerus.

imperfect coaptation

360

TRAUMATIC SURGERY

begin and are steadily increased. This method is hard on the pa-
tients; it is most valuable in fractures quite close to the joint.

My own preference is for the hyperflexion position, bending the el-
bow as far as possible and in such a manner that the bent forearm on
the ulnar side will touch the outer margin of the shoulder as this folds
the forearm so that it is parallel with the arm.

It is maintained in this posture by a gauze bandage about the
elbow, a pad of gauze being placed in the elbow-crease Cmodified
Ashhurst's dressing). Figs. 329, 330 and 331.

Fig. 337. — Action of triceps tendon in supracondylar fracture: a, Tendon on stretch,
causing disjunction of fragments; 6, tendon relaxed acting as an internal coaptation
splint by hyperflexion of elbow. It is thus seen that hyperflexion causes the triceps
to act virtually as an internal splint.

External Condyle. — This is the second commonest form. The
line of fracture may involve the entire condyle from the center of the
joint or only split a portion of it. It is most often seen in the young.

Causes. — Falls on the palm of the hand with the elbow bent or
stiff is the source of origin; it may also occur from falls on the elbow,
or inward twists of the forearm.

Syynptoms. — Deformity is variable; disability is nearly complete
from pain and swelling, which are manifest chiefly on the outer mar-
gin of the joint, where ecchjTnosis later appears. Crepitus or false
motion exist; intercondyloid pressure is painful; the fragment may be
felt if much displaced ; pronation of the forearm is painful.

Treatment, — Reduction by manipulation may be quite difficult and
occasionally impossible without incision, if much rotation of the frag-
ment has occurred. Splintage is by one of the flexion methods de-

SPECIAL FRACTURES 361

scribed. Operative means may consist of (a) removal of the fragment;
(i) suturing, pinning, or plating it.

Internal Condyle.— This form is not especially common. The
fracture line is more or less straight and enters the trochlear surface of
the joint at or near the center; avulsion forms chip oil fragments of
various si^i - i

Causes. — Falls upon or twists of the elbow are the common

Symptoms. — Deformity varies; the elbow is usually held partially
bent and is locally painful and swollen enough to produce disability. '
Crepitus, local pain, and mobility exist; intercondyloid pressure or
that transmitted from the forearm is painful over the fractured area.
The ulna may also be broken; the ulnar nerve may give signs of
involvement.

3^4

TRAUMATIC SURGERY

Fic. 34t.^To show the arrangement of die Lrolley. In A c
bar serving as a track and right angled at one end while the other ends passed through
a small piece of iron (S) screwed to a longitudiniU bar. The wooden biock wilh 2
pulleys above and three below hangs from this bar. C and D show the lead wci^ts
used, each weighing a half kiln. (Bluke and Butkh

Tig. 342. — .1 shows the shape of the bands used to support the limb it
or Blake splint or in a forearm cradle. They are made of a layers of unbleached muslin
and in two sizes. The smaller measures 40 by 11 centimeters and the larger 60 hy 10
centimeters. With wet dressings, bands of similar sites but made of double faced
rubberized linen can be used.

B shows the bands used with glue for traction. They are made of canton Bannel
ia a small sixe for the farearm and the sole of the foot and a large size for the leg. They
measure without the tape 15 by 8 centimeters and 40 by tj ci
(Blake and Bulkley.)

SPECIAL FRACTURES 365

External epicondyk fracture is even rarer than the foregoing, and
.he diagnosis is extremely difBcult and is generally academic more
han clinical, and depends on a;-ray or operative demonstration; in
general, the signs and treatment resemble external condyle forms,

Capitellum fractures are clinical curiosities.

SUMMARY OF HUMERUS FRACTDKES
Upper end involvement is commonly of the surgical neck, and
lere associated dislocation or fracture must be excluded.

366 TRAUMATIC SURGERY

Oukome depends on the success of reduction; reasonably early
massage and passive motion are helpful, and even with considerable
restricted motion at first, a good end-result is obtainable if active
motion is persisted in.

Shajl involvement generally causes no diagnostic difficulties, and
proper treatment brings about excellent results in the majority of cases,
even though rielayed or non-union prolongs the eventual outcome.

Fig. 344. — To illusltnli' Ihe mi^lliod of suspension in Iractuic of the humerus,
is to be noted thai three longitudinal bars arc employed, the outermost serving to sup-
port the forearm and maintain outward rotation of the lower fragment. (Blake and
Bulklcy.)

Lower md involvement is generally the supracondylar or exlcmal
condyle forms in adults; before twelve, an epiphyseal form is most
likely, and this in children under four years consists of the entire
epiphysis (corresponding to supracondylar forms), and at other ages is
most liable to show separation on the outer side of the joint. In all,

Piffuna 33s to 348 inclusive sad Pigi, ^ofi, 411, and 45D. Ebowing suspension and traction uppk-
nlUE arc taken from the article 00 '■The Treatment c* Fractures of the Eitrraiitics by meaos ot
Smpenjion and Tractton'' by Major Joseph A. Blake. M.R.C.. and Lieuleniint Kinneiii Bulkier.
}i.tL.C.. m Suriiry.CynieolQtyaad (Shiltlrici. March. iqiS-

36?

dislocaUon and associated involvement of the head of the radius or
olecranon region must be differentiated, and usually this demands
proper x-ray interpretation. Early massage or graduated passive or
active motion is generally advisable. Splints are removed after three
or four weeks in all patients, union permitting.

PlO. 345- — To illiiBtiale a simple method of obtaining abduction and traction
by meoiu of a rougli board slipped between mattress and bedspring and holding by
friction. (Blake and BulUey.)

The early results are liable to be bad, especially in children; but
after six months most joints recover as to appearance and function,
De/ormity, especially an inward tilting of the axis of the forearm, pro-
ducing cubitus varus ("gun-stock deformity), occurs practically only in
supracondylar forms due to ascent of the condyle; it is best prevented
by maintenance of proper reduction and a position of overabduction
of the forearm.

Examinations of tlie elbow are much facilitated by sitting behind
(the seated patient whose elbows are held in a right-angled position

the examiner's knees.

Practically speaking, my practice is to treat fractures of the lower
ticular end of the arm in the position of hyperflexion ("Jones' posi-

368 TRAUMATIC SURGERY

tion''); fractures above this level that require correction aretreat«d
in a position of right-angled abduction. In this group, as in aU other
fractures, operation is not resorted to until two unsuccessful attempts
have been made to attain reduction by the closed method. In all
forms, the key to stKCess is proper reduction. Compound forms are
often best treated by the overhead frame as shown in Figs. ssg~M

Fig. 346.— Suspension o( the forearm in a compound wound of Ihe elbow-joint.
The arrangement of the hand spreader and the lack of support of the upper arm are to
be particularly noted. (Blake and Bulkley.)

Fractures of the foreakm

These are very common injuries, comprising 331 cases in my
a percentage of 6.6- Either the radius or the ulna may be separately
involved at the upper or lower end; but in the shaft both are likely to
be broken together.

Anatomy and Landmarks. — The ulna enters into the formation
of the elbow-, but not of the wrist-joint. The radius enters into the
formation of the wrist-, but not of the elbow-joint; hence elbow frac-
turing violence is liable to involve the ulna, and wrist violence the
radius. Upper end landmarks have already been spoken of. J9j

370

TRAUMATIC SURGERY

of renins can be felt behind and below the external condyle, and some-
times rotation is visible. Shaft of renins and idna are palpable in the
lower two-thirds especially, notably laterally and posteriorally.

Lower End, — Styloid of radius is palpable and is larger, lower, and
more posterior than that of ulna; the tip of the radial is from \i, to ^
inch lower than the opposite styloid. Styloid of ulna is also palpable
and is quite easily seen as a knob on the back of the wrist. Wrist
wrinkles are seen on the front of the slightly flexed joint and changes
in their appearance and location are often suggestive.

Upper-end Fractures, — Ulna: Olecranon or coronoid process.
Radius: Head or neck.

Fig. 349. — Fracture of the olecranon: a, Cleavage at the base (common form); b,
avulsion form at summit; c, cleavage at the center; (/, cleavage at the tip and of the
coronoid process.

OLECRANON FRACTURE

This is the commonest fracture hereabouts, and the line of break-
age is usually at the base, but cleavage may be higher up with frag-
ments of various sizes (Figs. 349-351).

Causes. — Direct falls on the elbow is the common source; less
often a transmitted fall from the hand is at fault. Very rarely triceps
muscular action pulls away a segment from the top, as in throwing or
straining efforts. Sometimes it is of the compound (open) variety
from a direct impact.

Symptoms. — Deformity indicated by the attitude of the patient
and the changed contour of the back of the joint, with much disability

372 TBAUMATIC SURGERY

from pain and swelling, are usual. Crepitus and false motion exist,
especially in the separated forms; there is usually not more than
J-^ inch separation even in marked cases because the pull of the
triceps upward is limited by the ligamentous and other soft part
attachments.

Treatment. — Redaction is generally easy, either by straightening
or overbending the joint. Spintage can be done in several ways:
(i) The joint b flexed beyond a right angle and kept so by anterior
and posterior molded plaster-of-Paris or metal splints reaching from
the upper third of the arm to the wrist (like that for supracondylar
fractures). If the fragments are not brought together by flexion

Fic. 352. — Extension splinl for fracture of the olecranon.

of the Joint, they can be coapted bj- straps of adhesive plaster which,
however, must not encircle the limb. (2) The elbow is held straight
or nearly so, and posterior or anterior and posterior molded plaster
or padded wooden splints are applied, covering the same area as tlie
foregoing (Fig. 352). Adhesive plaster may be used if needed to aid
coaptation. This splintage is useful mainly where there is much
separation and when any other position increases rather than dim-
inishes it. (3) Hyperfiexion in "Jones' position." {/[) Operation, hy
which the fragments are joined by kangaroo tendon, wire, nails, or
plates. Splints are worn three or four weeks and then some gradual
use begins.

SPECIAL FRACTURES 373

My personal perference is for operation in selected cases, a strand
of kangaroo tendon encircling the torn soft parts; drilling the bone
is usually unnecessary. Operation is much facilitated by fastening
the hand to a leg stirrup of the operating table so that the extended
arm faces the operator.

Results. — Union is very rarely immovable or bony, and the inter-
vening fibrous band, like that in the patella, may vary in length,
width, and consistency, but this by no means predicates future
disability.

Healing is complete in three or four weeks and at first there will
be a good deal of stiffness and lost power. The end-results are
usually good; in the widely separated cases there may be a knobbed
deformity and limited triceps action, requiring adaptation on the
part of the patients Some cases may require a bone graft but only
if the false motion interferes with function.

Disability, — Total, four to six weeks; partial, two to eight weeks.

CORONOm FRACTURE

This is exceedingly rare except when associated with backward
dislocation of the ulna; x-ray diagnosis is necessary for confirmation.

Causes, Symptoms, and Treatment. — Transmitted falls are the
usual origin, and the signs are those of backward dislocation, with
the possible association of a hard body felt in front of the joint on a .
line with the attachment of the brachialis anticus muscle, and this
area is likely to give tenderness and false motion.

Immobilizing the joint in a flexion position is the treatment; if
the fragment fails to unite or acts as a foreign body, operation may be
necessary to suture it in position, or to remove it.

Results vary; if reduction can be maintained, it will be good,
otherwise som^e stiffness is likely to persist.

HEAD OF RADIUS FRACTURE

This is a rather rare form of fracture requiring x-ray determina-
tion usually. It may involve the edge or cup of the head to varying
degrees (Fig. 353). Direct blows or forcible twists are the usual
sources; transmitted falls rarely are to blame. Frequently it is
associated with backward dislocation of both bones of the forearm.

Signs are local tenderness, crepitus, and false motion, especially
marked in cases with much displacement when the fragment can be
felt. Pain localized on rotating the wrist is often suggestive.

TRAUMATIC SURGERY

Immobilisation in a posilion of flexion or extension is the treat-
ment when such procedure restores the fragtnt;ntb to position. If

FlO. 353- — Fracture lines of the upper end of the radius: a, At the head, necL, and
tuberosity; b, at the head extending to the shaft; c, d, at the head, viewed from above.

wholly detached, operative removal is wisest because bony union is
unlikely and the fragment then acts practically as a foreign body.

Fig. 3S4.-

and radius.

NECK OF RADIUS FRACTHBE
This is rarer even than the preceding, but the causes, signs, and
treatment arc practically the same. The diagnosis is made usually by
a:- ray examination.

SPECIAL FRACTURES

375

SHAFT FRACTURE
This may involve either or both bones, most commonly in the
middle or lower third, and when both are broken the radius is broken
higher up than the ulna as a rule (Fig. 354)-

Causes. — Direct falls or blows or bends are more common sources
than transmitted impact from the hand or elbow.

Varieties. — Complete, transverse, or oblique, forms of both bones
[ are the commonest (Fig. 356). Overriding of several inches may

Fic. .

iIL fragm

occur. Compound (optn) forms are very common from crushes,
severe falls, vehicular, and machinery accidents. Rotatory displace-
ment of the radius alom^ may occur when the line of breakage is
above the insertion of the pronator radii teres (about the middle)

;- 356).

Incomplete or greenslick forms are more common here than in any

«ther location; they occur before the fifteenth year, generally from

s on the hand or bending forces. Bony union is complete in each

376 TRAUMATIC SURGERY

bone at the twentieth year, the lower epiphyses being the last to j<
(Figs- 357-359)-

Symptoms.- — Deformity in the helpless Hmb and the attitude ot
the patient are g;cncrally marked. Swdlinir, ccchymosis, and blebs

Fic 3s0,— Fracturi' ol upper Uiird of ulna and radius i
posterior views). Treatment indicated: reduction by true
plasteT'of-Parb splints (with elbow at right angle), from n
palm, thumb up.

1; antcioposlerioc molded
lie of arm to web space of

soon appear. Crepitus, false motion, and local pain exist; irregular-
ity and definite outlining of the fragments can often be determined
by palpation and sometimes by inspection. Measurement shows
shortening. In fracture of a single bone with little or no digplace-

SPECIAL FRACTURES

377

.^^ late
^1 exu

ment, transmitted pressure by jamming the wrist toward the fixed
elbow (or the reverse) will elkt suggestive local pain; likewise,
lateral pressure of one bone against the other causes pain.

Direct violence is more likely to break one bone than both, the

a far oftener suffering.

Treatment.^ Reduction is fay traction, flexion, or manipulation;
anesthesia b advisable to relax the muscles, altliough this to some
Mtent can be accomplishi?d by fi) hanging a dangling weight to the

Flc. J57

r the radius.

wrist; (2) shutting off circulation by a tourniquet above the elbow
until the "fingers feel asleep;" (3) by freezing the part in a mixture of
salt and ice.

Splintage is by (r) anterior-posterior molded plaster-of- Paris

splints reaching above the elbow to the web of the fingers in front,

and I inch lower behind (Fig. j6i). In fractures above the lower

Bid it is wisest to carry the anterior splint as high as the middle of

e arm. The position of the Umb is midway between pronation and

378 TRAUMATIC SURGERY

supination (thumb up), and the elbow is bent nearly to a right angle.
No bandage should be used under the splints, here nor elsewhere.
The splints may be held in place by straps of adhesive spirally placed
so that no pressure is applied on or near the fracture, and thus circu-
lation is unaffected. The limb must be carefully held until the
splints harden. A broati sling reaching well below the wrist and
above the elbow completes the dressing. The patient is told to keep
the dngers wiggling from the first.

Pig. 358. — Green -
stick or subperios-
teal rraclure oE Ihe i'lc. jjg. — Frarlurc of radius (complete) and ulna (
radiui and ulna. plete, ur greensLkk).

(2) Padded broad wooden or other splints reaching from above
the elbow to the same lower limits as the preceding may also be used
(Fig. 362).

(3) Operation is not infrequently needed where reduction cannot
otherwise be made, and then suturing is done by kangaroo tendon
or wire or some form of plating is interposed. My own preference is
to promptly resort to open operation when either or both bones show
much overlapping. It is often only necessary to coapt the fragments

SPECIAL FRACTURES

379

to make them hold; in other cases, kangaroo sutures are passed.
Hardware is never used. Operation is called for often in vicious or
non-union cases. Encircling plaster-of- Paris or other dressing, hiding
the part, are dangerous and unnecessary.

Fic. Jdo. — Compound

The patient shouid be instructed against early signs of pressure

gling, change in (be color of the fingers, or local pain and swelling)

if ttuse do not subside on elevating the limb, tlie splint must be

moved forthwith; it is better to instruct the patient to remove it immed-

38o

TRAUMATIC SURGERY

iately rather than await the physician^ s arrival at a time when the dam-
age may be already done. Ischemic contracture is more common in
the forearm than in all other parts of the body combined.

Fig. 361. — Dressing for fracture of the forearm by padded plaster-of-Paris, metal, fdt

or wooden splints.

^"^rri^r?rV-r<r.rr^1rrt^'-|

Fig. 362. — Padded plaster-of-Paris, metal, felt, or wood splints for wrist fractuns:
a, Proper arrangement of padding and relation of end of splints to allow free finger
and elbow motions; 6, proper position of adhesive strap>s.

In fractures above the middle, or at a point higher than the attach-
ment of the pronator radii teres, it is advisable to splint in a position
of supinaiiofi to prevent interosseous fixation or faulty rotation of the
radius.

SPECIAL FRACTURES 38 1

Greenstick forms that are not readily straightened are often best
converted into the complete type by bending under anesthesia.

In some cases, adhesive or elastic traction will gradually draw a
** bending" fracture into position.

Treatment for these is the same as for the others, except that
splints are not used for so long a period.

Complications. — Pressure from dressings earlier causes damage
in the forearm than in any other location, and may thus lead to the
ischemic contracture of Volkmann, which is characterized by local
cyanosis, atrophy, and a claw-like contracture of the fingers with-
out neural involvement. This condition is probably due to a de-
generative myositis, and may be irremediable even by prolonged
massage, forced use, tenorrhaphy, osteotomy, or special apparatus.

Fig. 363. — Jones "Cock-up Splint" for wrist-drop and other wrist or forearm injuries.

Interosseous union by callus between the radius and ulna occurs
rarely; it may be considerable without greatly interfering with
rotatory action.

Non-union is rather imusual; it is more common in the radius.
Three weeks of other treatment should be given before operative
measures are decided upon for its relief.

Results. — Union is complete in three or four weeks, and then the
anterior or both splints should be removed and the sling used for a
week or two longer. After the first week, splints should be removed
once or twice a week for inspection and massage.

Bowing or tilting sometimes persists, and at first rotation will
probably be limited. Secondary bowing occasionally occurs if the
limb is forcibly used too early. The end-results functionally are
generally good even when the external and a:-ray appearances seem
to indicate otherwise.

Disability, — Total, six to eight weeks; partial, two to ten weeks.

38>

TRAUMATIC SURGEIfY

COLLBS' FRACTORB
This break within the lowest inch of the radius is the commonest
of the extremities, and in my statistics ranks third of all, a per-

FiG, 364- — Colics' fracture (displaced variety): a, Deformity of soft puts; 6, defoimity
of bone.

centage of 8.3. Of all fractures, various authors rank it as second,
third, or fourth, in frequency.

Fig. 365. — Colles' fracture deformity in a typical case. Note the outward tilt of tht
entire liand (abduction attitude) and the widening of the wrist

The lesion was formerly regarded as a backward dislocation,
and it derives the name from Colles, the Dublin surgeon, who in 1814

SPECIAL PRACTURES 385

determined its true nature, differentiating it from posterior disloca-
tion of the wrist.

This injury shotdd be excluded in every disabling or deforming wrist
-injury before a diagnosis of contusion, sprain^ or dislocation is made.

Clinically, it includes all those fractures occurring within the
lowest inch of the radius.

Causes. — Falls on the palm or ball of the thumb with backward
bending of the wrist is the cause, and it usually results from an effort
at protection after tripping or stumbling on an irregular surface or
step. Very rarely it may follow a direct blow.

The condition in general is quite similar to, and for all practical
purposes can be regarded as, the "upstairs" form of Pott's fracture of
the ankle.

Varieties. — The line of breakage is almost always within an inch
of the lower articular surface, and it is usually transverse, but may be
oblique and is often comminuted or impacted. In many cases the
styloid of the ulna is also broken.

DispUicement of the lower fragment is usually angular, turning
upon its anterior edge hinge-like, so that the articular surface looks
down and back instead of down and forward (Stimson). Backward
displacement is the second commonest form. Ligamentous involve-
ment is rather rare ; the internal lateral ligament is the most likely to
participate.

Modifications of the usual forms go by the name of "modified
Colles' " or "reversed CoUes' '' fractures.

Symptoms. — Deformity in the disabled attitude of the patient and
wrist is characteristic, and from it alone the diagnosis can frequently
be made, inasmuch as there is sometimes a humped swelling on the
back of the wrist and a bowing of the partly bent hand; this swelling
is the so-called silver fork deformity so rarely seen and so often
expected (Figs. 364, 365). But this deformity is not nearly so
constant as a shifting outward (thumbward) of the entire hand,
with the ulna styloid unduly prominent. A line dropped down the
middle of the forearm normally strikes the middle finger knuckle;
now it strikes the ring finger knuckle. The wrinkles on the front of
the wrist are often less prominent. Palpation shows a change in the
styloid levels so that they are on the same line, or the radial styloid
may even rise the higher. The anteroposterior width of the lower end
of the bone is increased. There is quite regularly a sense of fulness
over the front of the wrist just above the skin creases; this is often
visible.

384

TRAUMATIC SUEGERY

False motion and crepitus are rare.

Local pain is present on direct pressure, or that transmitted from
the ball of thumb or laterally over the wrist. x-Ray examination to

I'll;. 30t>, — I'raclureai Imw i im ; -i : ■ ■■ ■ .i-i|'.i. Lid -l.iitral and BOteto-

poslcrior views). Trealmcnl iniliialed: Ridiutitm by iraciion. adduction, and palmar
flexion; anteroposterior molded plaster-of-Paris splints from below bend of elbow to
tveb space of palm; forearm in midpronation (thumb up).

be helpful must be in two axes, side to side and from before back-
ward; it is most valuable after reduction, but even then, may be decep-
tive and should not wholly supersede the ordinary chnical evidences
(Fip. 366-371).

SPECIAL FRACTURES 383

Treatment. — Reduction is the main essential, and if this is success-
ful it makes little difference what other means are used. Anesthesia
is advisable. The first step in the reduclian is to hureuse the deformity
by pushing the entire hand out and hack; thereafter several pro-

Fig. 367. — Compound
ulna (lateral and anteroposterior

ted fracture at the lower end of the radius and
ws). Patient, female adult, who fell one Bight ot

ccdures may be tried, such as: (i) Direct traction on the hand and
wrist and downward pressure over the lower fragment; (2} manipula-
tion so that lateral and flexion motions are combined with traction;
(3) circumduction to break up impaction, combined with traction

386

TRAUMATIC SURGERV

Fic. 3*1^ ( 1.1 - I r.ii iLirr iiiTli C'lJiiniiiuiTi^n nl railius anil avulBion of ulna slyloid.
Anlerofmslcriiir viciv shows litilc vcTtital, but much cmlwnrd displacement. A line
droppeiJ downward fmm [he inner side of radius strikes the fourth knuckle. Lateral
view shows much linckward displacement.

Fig. jfjQ.— Colics' iratlure nilh cnmniinuli.,!! ..I r.ulm- ,iiirl ,iMil>i.>no( ulna slyloid.
After reduction. Note that a line dropped downward from the inner side of radius
now strikes the third knuckle and not Uie fourlli; and that the backward disptacement
is corrected.

SPECIAL FRACTURES

Pffll

*^G. 370.— CoUea' fraclure (impacte<i) willi avulsion of the lip of Ihe styloid [iroc.
of tlic ulna.

Fig. 371. — Colles' fracture (Impacted).

SPECIAL FRACTURES

Pand pressure if necessary (Figs. 372-375). Sometimes a Thomas
J wrench may be used as a lever. (Fig. 376.)

n of Colles' fracture. Third step: Palm
bringing the hand forward jnd inviard — the "mailed fi

of Collea' fracture. Fourth step: Position cr
ine a rolled bandage ot piece of wood.

Whatever the method, setting has not been successful unless the
[.following "tests of setting" exist: (a) Crepitus is demonstrable; (i)

TRAUMATIC SURGFRV

the styloids are restored to their numial levels; (c) deformity disap-
pears; (d) the verlicai axis of the middle of the forearm is on a line

Fig. 370. — -Thoniis'

showing sliding prang.

with the middle finger; (c) the hand can be held in the same straight
line as the forearm by the weight of the surgeons' index-finger.

Splintage. — A position of some palmar flexion with the hand tilted
toward the ulnar side is advisable; or the position of fuU extension

Fig. 378. — Prepari

Wei plasier-uf-I'

moldi-d plaster-of-Paris splint" lor Colles
ige being folded alop tlic fiiundalion.

may be used. The essential is to overcorrect the deformity and keep
it thus.

SPECIAL FRACTURES

Splints may be of ( i ) molded plaster of Paris reaching from below
f the bend of the elbow to the web of the fingers in front and an inch
lower behind (Figs. 377-..?!^ot.

{2) Anteroposterior board splints covering the same limits as the
foregoing and cut to allow the ball of thumb to sink in. {Fig. 362.)

(3) Special metallic and circular bands of plaster of Paris or
*idlir.sive -"ovcriT^" ''".' v-wt and small areas abo\'f'and below it; these

^^^^ Appiiea

■Prcparuliun ot a '

Applied lo fronl and liack of fo

' 1 Ihe position of palmar 1

nulcifd plaster ol-Paris splint" for Collus
irm. N'otK bandage prippeil in palienl
(ion and adduction. The plitsler ib now."

are not usually efficient or comfortable. Moore's dressing is of this
last named type (Figs. 381-383).

The original deformity is up aiid out; the aim is to overcorrect this
into a position of down and in, and safely and comfortably hold it
thus.

TRAUMATIC SURGERY

FlC. 384.— -CliaulTeui'i frattutt" .-f the lontr . nd of tht 1

Fic. j.-ij, — -Chauffeur's (ratluit" oi ihc ).j»cr end of ihc radiu;

SPECIAL FRACTURES 393

this removal is easily accomplished by cutting one side of the adhe-
sive straps and lifting half of the splint like the lid of a hinged box.
Massage and passive motion can be given within a few days and some
slight active motion can follow on the seventh or tenth day, each to
be used twice or thrice weekly or even daily. The posterior splint
can be removed at the end of the first week, and all support is off at
the end of the second or third week. Then a strap of adhesive or a
leather band may be worn on the wrist for a week if desired.

The fingers are kept actively wiggling from the first, and if this is
done, tenosynovitis will be limited or wholly prevented.

Results. — Union is complete in two or three weeks.* There is
liable to be a good deal of swelling and stiffness of the wrist and fingers
after removal of the splints, especially in old people; much of this
is prevented if early massage and motion are given and if the splints
are not kept in place longer than indicated. Stiffness of the wrist
and fingers is often more the fault of the surgeon than the fracture.

Tenosynovitis generally means prolonged splintage and failure to
employ massage and motion. A great improvement in it is possible
by enforced use and massage or from the use of baking, a wrist-
machine, or gymnastic movements.

Dejormily may persist as a bony thickening or definite swelling.
There may be an undue prominence on the back of the wrist or a
raised ulna styloid. Some cases show a forward bowing and puffiness
on the front of the wrist and a tilt of the hand outward. Most of
these are proportionate to the success in setting. Bad appearance
does not mean disability, as many untreated and badly set cases are
functionally perfect. Deformity of this sort in the young may dis-
appear; in adults and the aged it is likely to persist.

Operation is indicated for cosmetic or functional reasons in some
cases. The procedure is to chisel through the fracture line, virtually
resetting by the open method. Sometimes the scarring is but a
poor substitute for the deformity.

Disability. — Total, two to six weeks; partial, two to six weeks.

"CHAUFFEUR'S FRACTURE"

This occurs from starting handles of automobiles, motor-boats,
and other gasolene engines. There are two forms:

(a) From indirect violence due to a "kick-back" from the handle
at the height of compression so that the ball of the thumb is thereby
janmied backward. This is practically the mechanism of a fall on
the palm of the hand.

Fio. 3S7. — Cftrpal bones in tdatioo to radius, ulna, and metacarpals: i, Lower Old
of ulna; i, ulna styloid; 3, radius styloid; 4, semilunar; s> scaphoid; 6, os maenum; 7.

SPECIAL FRACIURES

397

Carpal Fractures

These ate not so uncommon since x-ray confirmation has been
obtainable.

Of the eight bones, those of the upper row are most frequently
broken; the order of frequency is scaphoid, semilunar; pisiform, os
magnum, trapezium, trapezoid, unciform, and cuneiform (Codman
and Chase) (Figs. 387, 388).

Caoses. — Direct violence is less often responsible than falls on
the hand or ball of the thumb, indeed, the sources of origin are not
unlike CoUes' fracture. '

iU \

'Ta a lis

Fic. 388. — Carpal bones: a, Anterior view: i, Radius; », ulna; 3, scaphoid; 4, semi-
lunar; 5, trapeioid; 6, cuneiform; 7, trapezium; 8, unciform; 9, os magnum, b, Poste-
rior view: i, Ulna; a, radius; 3, semilunar; 4, scaphoid; 5, cuneiform; 6, trapezoid; 7,
unciform; 8, trapezium; g, os magnum.

The scaphoid and semilunar are affected more frequently than all
the others combined, and each may be associated with dislocation.
Young male adults seem most prone, and the right wrist is the more
often affected.

SCAPHOID FRACTURES

The signs may simulate a CoUes' fracture, and the differentiation
is made by finding: (i) Localized swelling behind and below the radial
styloid; (2) local extreme pain on pressure in the "snuff-box" triangle
between the thumb and its extensors; {3) fulness of the "snuff-box"
area; (4) tension, spasm, or pain of extensors of the thumb; (5) a;-ray
diagnosis is confirmatory (Figs. 389, 390).

A good many of these cases are self-treated for a sprain, and
then relief is sought after a few weeks because of localized pain and
inability to use the outer side of the wrist and thumb. This recur-

398 TRAUMATIC SURGERY

rent pain and disability is most marked when lateral flexion of the
wrist or abduction of the thumb is made, as in throwing or lifting,
tennis, and golf.

Treatment. — Reduction may be impossible without incision; some-
times pressure and manipulation are effective.

Splintage is like that for Colles' fracture. If more than three
weeks elapses without treatment, non-union is likely and excision
of the bone is wisest because it will probably continue to act as a
disabling foreign body. The results after partial or complete re-
moval are good.

FiG.389.^Fraciiireofthecarpa!scaphoid. Fin. 3^. — Fracture of the base of the

liist or thumb metacarpal (Bennett's

fracture).

Fibrous union alone occurs, but it is effective if displacement has
been corrected.

Results. — If seen early and if reduction can be made, the outcome
is good and function is perfectly restored. Late cases seem best
treated by operation, otherwise there is likely to be permanent swell-
ing and disability of varying degrees.

Disability.— Total, four to six weeks; partial, two to four weeks.

SEMILUNAR AND OTHER CARPAL FRACTURES

These generally accompany dislocations or are associated with
other fractures. Isolated fractures arc clinically too rare for separate
description.

Metacarpal Fractures

Of this relatively uncommon type, the third and fourth arc most
often involved, the thumb and little finger metacarpals are least

SPECIAL FRACTURES

affected. In many it is an associate of compound crushes and mul-
tiple fractures. The middle part is usually broken {Fii;. 392).

SiwAv

Flc. 391. — Fracture of tlit

Bennett, of Dublin, describes a special form of fracture through the
base of the thumb, and this hears the name of "Bennett's fracture"
CFig- 390)-

Fig. 393. — Common sites of fracture of the fingers cir metacarpals.

Causes. — Commonly they occur from direct or indirect blows ot
falls; less often due to twisting motions of the fingers (Fig. 393).

400

TRAliMATIC SrRGER\

Knuckle Jraclure is common m pugilists.

Symptoms.— Deformity is shown by swelling and perhaps some '
visible change in outline; crepitus, false motion, local pain, and ir-
regularity are also usually elicitabte.

Local pain obtained by upward pressure on a finger or squeezing I
the palm is quite suggestive in those suspected cases which show few
other signs. Shortening is often best shown by comparing the level of '
the finger-tips.

Fir. 353.— Fracture of liiij iuuttii mttacarpal at the site of pre-existing bone-cysl.
Patient was a laundress, aged twenty-six, a.nd she sustained tile injury while wringiog
wet lowel. Treatment instituted: Anterior padded wooden splint for hand and fore-
Excellent result.

Treatmeats. — Reduction is usually easy by flexion of the fingers
with or without traction and pressure.

Splintage is made by (i) Padded palmar splint and a gauze dress-
ing; (2) a ball, roll of gauze, or other material is placed in the palm,
and the clenched fingers and hand are fastened to it (Fig. 394, b);
(3) sections of rubber tubing are fastened in the intermetacarpal
spaces on the back of the hand and an anterior splint or bandage b
used for reinforcement; (4) traction by lateral strips of adhesive laid
along the adjacent finger, the end of the adhesive being drawn c

SPECIAL FRACTURES

the edge of a palmar splint; this is necessary only in cases with much
overlapping (Fig. 394, a). A small Thomas splint may also be used.

Fig. 394- — Two methods of treatment foi fracture of a metacarpal or phalani; a.
Adhesive trtiction straps fastened to margin of finger and brought over the end ami
fastened to the fxillom of a splint. Note counter! raction by adhesive passing spirally
around palm aod wiist; b, bandage or wooden cylinder clenched in palm nod held there
by adhesive.

Results. — Union is generally complete in three weeks. Some
bony thickening and stiffness is invariably present, at first; much or
all of this usually disappears after a few months and the final func-
tional outcome is good. Sometimes inflammation of the bone occurs
as an early complication.

Disability. — Total, three to five weeks; partial, two to four weeks.

» Finger Fractures

These commonly occur in the segments nearest the knuckles, and
they are due almost always to direct violence and often are com-
pound (open) fractures, as in run-over and machinery accidents.

Fio. J95— Kra

it joint of thumb.

403

TKAUMATIC SURGERY

Symptoms. — Deformity from swelling and displacement varies
being most marked near the articulation. Crepitus, false motion,
and local pain on direct or indirect pressure exist, and irregularity
may often be felt (Fig. 395).

Treatment. — Reduction is generally easy by traction and flexion.
Splintage by a molded plaster-of-Paris or padded wooden or hairpin
splint is usually efficient. (Figs. 396, 397.) In somp cases beoding
the fingers into the palm is a better procedure (Fig. 394).

Fig. 396. — a. Aluminum or tin shoe- Fio. 397. — Hairpin splint for a,

hom splint for fracture of a thumb fracture-dislocation or sprain of a,

metacarpal or phalanx; b, splint applied finger.
to maintain abduction.

Results.^Union is complete in three weeks and is generally firm.
The nearer the joint, the less likely a perfect result, and then some
permanent swelling and stiffness is often to be expected.

Pelvis Fractures

This includes fracture Involving the entire pelvis or any of the
three bones composing it, namely, the ilium, ischium, and os pubis.
These bones arc rarely broken except from extreme forms of violence ,
like high falls, run-over and crushing accidents, and frequently the
associated visceral and blood-vessel injury results in fatality.

Clinically there are two divisions: (i) With intrapelvic injury;
(2) without intrapelvic injury.

Anatomy and Landmarks. — A nierior Iliac Spine.— Otten visible
and always palpable as a sharp or rounded prominence.

Posterior Iliac Spine. — At the rear end of the iliac crest and often
quite prominent.

SPECIAL FRACTURES 403

Iliac Crest or Ala. — Visible and palpable along much of the margin.

Fubic Symphysis. — Sometimes visible at the inner lower margins
of the iliac crest, and usually it can be spanned between the fingers.

Pubic Spines. — Visible sometimes, and they can generally be
felt at each end of the symphysis.

Ischial Tttberosily. — Visible sometimes and usually palpable at
the margin of the internatal folds, and it always can be felt rectally
and vaginally.

Ischial Ramus.— VA\pa.h\e through the rectum and vagina.

FRACTUSES WITH IHTRAPELVIC INJUKT
These involve the so-called "ring of the pelvis," with sometimes
more or less damage to the bladder, urethra, and blood-vessels; less
commonly the intestines may also be affected.

Fig. 398. — Usual sites of fracture o£ the pelvis.

Causes.— ZWrcci violence from heavy blows or crushes usually, as
*om falling objects, run-over and crushing accidents.

Indirect violence transmitted from the hip or thigh is a much less
vommon origin.

Vaiities and Sites. — 'These depend upon the manner of the acci-
dent and place of its receipt. Force inflicted from side to side is likely
to involve the crest of the ilium and pubic ramus on the same or
opposite sides; from before backward, the horizontal and descending
pubic rami suffer mainly. In younger patients, the fracturing may be
through all or some of the three developmental lines. Figure 398
shows the commonest locations; the pubis is most often broken, next
the ilium, and the ischium very rarely. Displacement is ordinarily
not marked.

Symptoms. — Disability is generally instant and complete from
pain, deformity, and shock.

404

TRAUIL^TIC SITRGERV

Deformity may show by swelling and ccchymosis over the seat of
injury, and the anterior spine or iliac crest may show mal-alignment,
Crepitus, motility, and local pain can often be elicited ; pain transmitted
by lateral pressure over the buttocks or through the thigh is very
suggestive. Rectal or vaginal examination may give the best confir-
mation, as thereby the fragments or irregularity can often be felt
a:-Ray examination is often of determinative value. If both sides
of the pelvis are radiographed on the same plate, hitherto unrecog-
nized fracture lines or symphysis displacement may be discovered.
A palkognomonic sign is ecchymosis along the perineum that often

diffuses into the upper i

thigh and over the labile or scrotum;
indeed, ecchymosis that appears late
and which is located in a place distant
from the site of impact is always sug-
gestive of fracture in any part of the
skeleton.

Urethral involvement may be in-
dicated by bloody urine, dysuria,
retention, or extravasation into the
perineum, where it appears as a
boggj' swelling; the membranous
portion is most often affected and it
may be torn across, punctured, or
pressed upon by bone or effused
blood. Later the scrotum or labix
may be much swollen.

Bladder involvement is generally
intraperitoneal and can be determined
or by retention; careful cystoscopic
examination is valuable. The usual test of filling the bladder with
a known quantity of sterile solution, and then withdrawing and
measuring it, is dangerous. The extent of tearing varies from a
small hole to an extensive rent. Urinary tract involvement is most
often seen with pubic fractures (Fig. 399).

Blood-vessels, like the lUac, pubic, obturator, and gluteal, may be
torn or bruised, leading to hemorrhage or thrombosis and embolism.
Treatment. — Shock is given the usual attention.
Urinary tract damage treatment depends upon its extent If
extravasation from the urethra into the perineal region occurs and
a catheter cannot be passed after a lew cautious trials, an external
urethrotomy is performed and the torn urethra stitched at once; or,

Fig. 39g. — Rupture of hladrter and
deep urethra; Ihe black areas in-
dicate zones into which urine may
extra vasate.

by the passage of bloody urin

SPECIAL FRACTURES 40$

better, a drainage-tube is inserted into the bladder and repair made
later if the opening does not spontaneously close. Usually it is an
extremely difficult matter to identify a torn urethra after such an in-
jury as the tearing of the soft parts, and the clotted and fresh blood
eflFectually obscure the field.

Bladder damage requires opening of the abdomen and layer suture
of the opening if it be not too large; otherwise it is sewed about a
drainage-tube having exit suprapubically. In any event, drainage of
the skin incision must be provided to prevent subsequent breaking
down of the wound with fistulous formation.

Blood-vessels require attention only if intra-abdominal hemor-
rhage seems apparent; then laparotomy is done.

Intestinal involvement shows by early rigidity of the abdomen,
tympanites, and pain; vomiting and other signs of peritonitis may
follow. Early laparotomy is indicated to perform suture or
anastomosis.

Bony damage rarely calls for or permits setting unless it is to re-
duce a broken crest or ramus, which sometimes allows of replace-
ment by pressure or manipulation and subsequent retention by pads
and adhesive. Ordinarily all that can or need be done is to apply
wide bands of adhesive about the entire pelvis, with a bandage
about the straight or pillowed slightly flexed knees. In some cases
a single or double plaster-of-Paris spica reaching from below the
knees to the umbilicus may better immobilize, notably in bilateral
fractures. This is worn until loose and replaced as often as needed for
six to eight weeks.

Occasionally a laced harness of canvas or moleskin made like
"tights'' is very effective.

General care to prevent sepsis and hypostatic changes is impera-
tive. Urinary antiseptics, like urotropin, are advisable.

Results.— These are often serious cases from the start and quite
difficult to handle. If sepsis or peritonitis does not follow within the
first week, it is not likely to occur or be serious, as it is then generally
limited to a cystitis , to be treated in the usual manner. Urethral and
bladder drainage may be necessary for a month or six weeks, and
there-after any sinus, fistula, or stricture receives the appropriate
treatment. Sexual power may for a time be diminished or lost; it is
practically always restored. Deformity may persist in the pelvic
outline, and rarely it may result in a limp or other defect in extreme
cases.

As a clinical fact it may be stated that even with extensive lines

TRAUMATIC SURGERY

406

of fracture there are relatively few
injury or lasting disability.

s complicated by intrapclvic

FRACTURES WITHODT INTRAPELVIC ITIJURY

Dium Fracture. — Anterior spine may be broken by a direct blow
:casionally; less often muscular force is responsible. In one such
Lse seen by me it occurred in a boy while doing the hop, skip, and

ire of rami of pubis and ischium (bibtera!), Treatmenl mdicateil:
inn of limbs; double plastiit-of-Paris spica reaching from umbilicus

Symptoms and Treatment. — The detached fragment is usually
visible and always palpable. It is sometimes replaceable by relaxing
the thigh muscles and then is held by a pad and adhesive.

Union results with perfect function in four to six weeks; this may
be fibrous and otherwise incomplete, but is of no consequence because
the expanse of Poupart's ligament will not allow much motion.

Crest or ala may be broken along the margin or splits may radiate
centrally.

SPECIAL FRACTURES

408 TRAtnUATIC SURGERY

Symptoms and Treatment.- — Disability is generally complete and
immediate. Deformity may show by swelling and mal -alignment.
Crepitus, false motion, and local pain exist together or separately;
displacement Is not marked. Immobilization by an adhesive swathe,
with the bent knee tied to a pillow, is usually efficient.

J?cjuiii.— Union occurs early and after three weeks is usually
complete, with gradual perfect restoration.

PUBIS FRACTURE
Ramus involvement is the commonest, but even this is extremely
rare as an isolated occurrence (Figs. 400-402).

Symptoms, treatment, and results are similar to the preceding.

ISCHIUM FRACTURES
This bone is very rarely broken alone, and but 6 such authentica-
ted cases are reported by Malgaigne.

Symptoms, treatment, and results are like the preceding.

ACETABULUM FRACTURES
This is rarely broken except as an associate of other fractures.
Recently some case of depressed comminuted
fractures of the floor have been reported.

Varieties affecting the rim and floor are
described (Fig. 403).

Causes. — Generally extreme forms of \'io-
lencc applied to the hips or thighs are responsible;
very rarely direct injury is the source.

Symptoms. — Usually a dislocation of the
hip or fractured neck of the femur is sus-
pected until *-ray examination makes the
differentiation.

Disability is instant and complete.
Deformity is seen in swelling and changes
in the attitude of the patient and the limb.
Crepitus may be elicited on rotation. Local
pain from pressure over the hips and upon
the thigh is present. SItorlening may exist in fractures of the floor
of the acetabulum.

Treatment. — Selling is uncalled for except in floor cases with
impaction of the head through the depressed comminution; here
traction under anesthesia may be tried. Later treatment is im-
mobilization by some form of extension apparatus or a plaster-of-

Fio. 403.— U
fracture of tbe
bulum.

SPECIAL FRACTURES 409

Paris hip spica. Rim fracture needs only adhesive swathing or a
plaster-of-Paris spica.

Results. — Rim cases recover completely and union is firm in four
weeks. Floor cases generally have persistent stiffness of the hip and
perhaps some shortening and limp. However, Stimson relates and
illustrates a case reported by Moore in which a fractured neck of the
femur was suspected and the man was able to walk with but a slight
limp; several years later autopsy showed "the injury to have been a
fracture of the pubis, ilium, and acetabulum, with deep displace-
ment inward of the head of the femur."

SUMMARY OF PELVIS FRACTURES

In the absence of intrapelvic damage they do well, and working
capacity is usually restored within two or three months. The a:-ray
appearance often denotes almost catastrophe to the os innominatum,
but the clinical findings and the outcome are usually surprisingly
favorable.

The pubis and ilium are most likely to be involved.

When intrapelvic damage exists, the outlook is doubtful for the
first week; but if sepsis or peritonitis does not develop by that time,
the prognosis becomes that of cystitis, or a urinary fistula, sinus, or
stricture, and while these may be tedious and annoying, danger to
life is inconsiderable.

The bones knit usually before the complications get well and the
remaining deformity rarely disables, although it may be quite appa-
rent externally or in x-ray views. Working capacity may be restored
in three months; or with active complications disability may last
longer.

Fracture of the Femur

This is a relatively common injury, and in my list comprised 154
cases, a percentage of 3.5. Of these, 40 per cent, involved the neck
of the bone.

Anatomy and Landmarks. — Upper End. — Great trochanter: Can
be seen often and generally is readily felt. Fascia lata: Tension of it is
usually firm, but is changed in fractures. Scarpa '5 triangle: The nor-
mal feel is altered in certain fractures. Inguinal fold: Axis changed
in some fractures. Shaft: Partly palpable sometimes.

Lower End. — Condyles: Rather prominent and often can be
seen, and always are palpable, especially the internal. Popliteal
notch: Hollowed and sometimes allows direct palpation of bone
beneath.

TRAUMATIC SURGERY

upper ehd fractures
Neck Fracture
This is the "fracture of the hip" so cummon in persons over
forty-five years old; in those over seventy it comprises about three-
fourths of all fractures the rest being practically Colles'. It is
more common in young persons than was suspected before the
advent of i-rays, and in them is relatively more frequent than
epiphyseal separation.

Causes.^Age changes in the bone due to osteoporosis is the deter-
mining cause more than alteration in the axis of the neck in the aged;
the normal angle of the neck to the shaft is about 130 degrees. Cot-
ton aptly states that old people do not so well know "how to break
a fall." This osseous senile change generally begins about fifty.
Indirect violence usually is the source, and this is transmitted from the
hip, knee, or foot, due to a trip or fall or twist,
often inconsiderable in extent.

Direct injury is a rare source of origin.
In the aged, women arc more prone than
men, and the younger the patient, the
greater the necessary violence.

Lines of breakage are transverse, oblique,
vertical, comminuted, or impacted.

Varieties and Sites.- — The two Main
Forms (Fig. 404). — (i) Through Hie neck;
also called intracapsular or subcapital
(Kocher). Here the break is close to the
head or inside the path of the spiral line in
front, or the intertrochanteric line behind.
This type is rather more common after sixty
years of age. The periosteum is generally greatly torn, and hence
vitality is likely to be seriously involved, and this is the element
that is so important in the outcome. Impaction is infrequent, but
as the nutriment to the head comes through the ligamentum teres,
and vessels running across the periosteum, bony union is very
unlikely. In the usual unimpacted cases there is little or no
displacement.

{2) Al the base of the neck; also called extracapsular or intertrochan-
teric (Kocher). Here the break is at the outer end of the neck, and
usually it follows the spiral line behind as it passes between the
trochanters; in other words, cleavage is at the junction of the neck
and shaft. Deflecting lines of breakage may detach the lesser tro-

Ftc. 404.— Upper
of femur and usual lit
fracture.

SPECIAL FRACTURES

411

chanter, or more often split into or separate the great trochanter or
even radiate to the shaft.

"The common fracture is that in which the neck is bent backward
with crushing of the posterior part or penetration of the neck into
the trochanter" (Stimson).

The periosteum is less seriously iovolved in this form of fracture,
and hence vitality is not greatly affected and the chances of bony
union are better, especially as impaction is more likely; hence the
initial handling of these patients should be directed toward keeping

aciip.ular).

the impaction unseparated. The extent of this enmeshing of frag-
ments varies; in extensive splits or comminution it may be quite com-
plete. When there is little or no impaction, there is more upriding of
the shaft and hence shortening occurs. Where (rarely) the anterior
portion of the neck shows penetration, a position of inversimi occurs.
Formerly it was considered important to determine whether the
fracture was Ckrough the tteck (intracapsular) or at the base of the n^k
(extracapsular) , but now clinical regard is more for the presence or ab-
sence of impaction, and this is usually demonstrable in terms of short-
ening; if much exists, the chances of impaction are remote (Fig. 405),

I J

412

TRAUMATIC SURGERY

Symptoms. — DisabilUy is almost invariable, instant, and com-
plete; in some few impacted cases the patient has been able to stand
or walk short distances with much difficulty. Deformity is usually
typical, and visibly shows by: (a) Evcrsion, so that the foot is out-
wardly rotated and may rest on the whole outer margin of the sole;

Fic. 406. — To show the use □[ the suspension frame wilh Thomas straight splint
uid the method of obtaining traction. Note especially the building out o( the foot of
the frame, the wide abduction obtained, the angle of the supporting longitudinal bur
closely corresponding to Ilie angle of abduction of the leg, and the tourniquet method
of obtaining traction within the splint. The method of preventing foot drop is also
shoivn. (Blake and Bulkley.)

the outer edge of the bent knee is also visibly mal-aligned in flexion,
and, indeed, this outward tilt or external rotation involves the whole
limb. Inversion is a rarer finding, (6) Shortening is apparent, espe-
cially when the limbs lie close together, and then the drawing up at
the foot, ankle, and knee shows markedly; it is most prominent in

SPECIAL rRACITjRES

413

wumpacted cases and those through the base of the neck (extracapsular) .
The average amount is over an inch and it may be more; in many un-
treated cases it increases within the first week, (c) Inguinal and
gluteal /olds are higher and more vertical and internal, (d) Swelling
and ecchymosis are usually late in appearance and appear chiefly in
I the inguinal, gluteal, and upper shaft regions. Palpation elicits (e)

Fic. 407. — Landmarks for racnsurements of the lower extremities; ^, j4', Kight and
leftanleriorsuperiorspineof ilium:5, J', right and left internal condyle of femur; C,C',
«-ight and left internal malleolus tip; D, If, riehl and left patella tubercle; U. umbilicus.

For notation or history purposes the In a graphic form this diagram may be

findingB may be listed thus: used:

•

(Uion of the trochanter corresponding to the shortening. (/)
J-utness in the upper outer part of Scarpa's triangle; very suggestive
where other signs are not prominent, (.g) Fascia lata relaxed on the
outer side, (h) Crepitus should be sought for very carefully by
placing one hand over the trochanter and slightly rotating the limb;
it onJy can or should be demonstrated in unimpacted cases, (t)

UC"

UC =

AC -

A-C =

AB'

A'B- =

U D "

U [/,=

AD-

A-D-"

BC -

B'C ^

414

TRAUUATIC SUKGEKY

False motion should also be sought for by the same means as the pet-
ceding, and it appears in the same class of cases, (j) Active moJimis
greatly diminished or lost, notably inversion and elevation of the
limb or foot, (k) Passive motion is limited or lost, due to pain,
deformity, and spasm of muscle. (/) The distance between the
anterior spine and top of great trochanter is lessened when ^jamied
by the thumb and index finger.

Measurement. — (i) From the anterior spine of the ilium to the
internal malleolus there will be shortening; the same will appear from
(2) the anterior spine to the internal condyle (Fig. 407). Measure-
ment from (3) umbilicus or (4) teeth to the internal malleolus b less

Fig. 408. — Topographit markings about the hip-joint; — J ~B, Perpendkular liM
droppied from anterior superior spine (.4 ) to the table (B) with patient supine; jI-CUpc
juning anterior superior spine and topof );Tea.t trochanter {D);A ~~E, line joining inierior
auperiot spine to tuberosity of ischium; C—D, line drawn vertically upwAtd from gnat
trochanter. Kilalon's lint — A —E, normally with the knee at an angle of about is
degrees, the great trochanter touches thb line. Bryanl's triangle = A C—D.

valuable because of the intervening soft parts and respiratory mox'e*
ments; (5) Bryant's triangle and (6) N61aton's line measurements
afford confirmatory signs (Fig. 408).

There is a normal difference in the length of the lower limbs,
amounting to between ) s ^"d f'i inch or over, and this must be taken
into account in some cases.

Treatment. — Primary care in the transportation of such patients
is very important and may determine the outcome. Temporarj' of
improvised extension may be used as shown in Fig. 409. The limb
should be kept at rest between pillows or padded sand-bags or bricks;
or a long side splint made of padded thin board is used, reaching from
the axilla to below the sole, and held to the chest, hips, and lower limb
(Fig. 410). It must be wide enough to allow its edge to rest on the

SPECIAL FRACTURES

415

bed, and turns must be taken over the foot to prevent rotatory
changes. In old people it is needful to elevate the head of the bed
from the first to forestall hypostatic complications; this and, the
general treatment can be aided by placing wide boards (like the

Fig. 409. — ^Towel or bandage tractor for temporary or improvised extension of the

lower extremity.

household ironing-board) transversely under the mattress so that
they rest on the bed-frame beneath the shoulders, hips, and knees
(Fig. 410).

In all cases much attention is given the general condition and the
comfort of the patient must be a main item. Good nursing is essen-
tial. Fresh air and liberal feeding and tonics are of much value.

Fio. 410. — ^Long wooden side splint in fracture of the femur.

under mattrets to prevent sagging.

Note "ironing-boards*'

Treatment details vary, depending upon the age and condition of the
patient and the presence or absence of impaction.

Old patients who are "fussy," feeble, or suffering from bronchial,
cardionephritic, arterial, or allied ailments will probably die within a
few weeks if subjected to absolute recumbency and immobilizing
dressings; hence treatment here must be of the patient rather than of
the pari.

If rest in bed with supports from (a) sand-bags at hip and on each
side of knee and ankle, or from a (b) long side splint is irksome or

4l6 TRAUMATIC SURGERY

enfeebling, then the patient must be allowed to get out of bed, assum-
ing whatever position is comfortable. If, however, general condi-
tions are better, the (c) side splint and some extension (not over 20
pounds is needed) may be used for three or four weeks. Then {d)
piaster-of-Paris spicas may be used and the patient allowed up in a
chair. In selected impacted cases the immediate use of this [
spica is often the best treatment. In some rugged old people,
agement may be on the plans suggested further.

Fig. 411. — Showing the frame suspension unngemcnt for a fracture of the upper
third of the femur. A Stdnmui nail hu in this case been u^ed. Note the flexion
the knee, the abduction and external rotation, (Blake and Bulklcy.}

Other Methods of Treatment. — (i) Continuous traction, applit
by aid of a long side splint and a T foot-piece, the weights (10 to 30
pounds) hung over a pulley at the foot of the bed, a cord being
attached to straps of adhesive applying a pull directed from above the
knee. This may be a typical Buck's extension apparatus and a VoUc-
mann's track, or the limb may rest in a cradled splint (like Hodgen's)
suspended by a support reaching over the bed (Fig. 411). Pres-
sure over the trochanter by pads or encircling bands may also be

■per ]

SPECIAL FRACTURES " 417

included, (s) Abduction, a^ advocated mainly by Whitman. Here
the patient is anesthetized and the hips are placed oti a pelvic rest
and both limbs abducted to the normal limit, shortening being over-
come by traction; overcoming impaction by flexion if it exists. Soft
bandages and plentiful cotton padding are then placed, and a plaster-
of-Faris spica reaching from the toes to the lower ribs is then applied,
great care being taken to keep the limb abducted to the same degree
as normally possible in the uninjured limb (Fig. 433). With this spica

Thomas-Ridlon bi]i sptint.

in use the patient can be turned on the face or otherwise moved with-
out disturbing the alignment. In two months part of the dressing is
removed, the rest a few weeks later. Thereafter the thigh is abducted
daily and walking but no weight bearing is allowed, preferably at
first by the aid of walking calipers or a Thomas-Ridlon hip splint
(Fig. 412). Excellent results are obtained, especially in rugged and
young patients. (3) Splints of metal, like the Thomas or Ridlon,
with or without traction and pressure over the trochanter. ■ The so-
called "ambulatory splints" seem irrational in this fracture, of all
places. (4) Thomas splint and overhead suspension in a frame, the
limb weighted in wide abduction (Fig. 406), (5) Operation by direct
open exposure for reduction and fixation by a metal nail or long bone

4l8 TRAUMATIC SUKGERY

pin driven into the head of the bone. This is most applicable in sturdy
people for some cases of non-union (Fig. 413). (6) The traction ob-
tained by the Finochietto stirrup is suitable in some cases. (7) The
Delbet apparatus is favored by the French but has limited appUcability.
In selected unimpacted cases Cotton advises placing a heavy pad
r the trochanter and then with blows of a broad wooden mallet
making an attempt to jamb the parts to-
gether— in effect, an effort to deliberately
cause impaction, I have never resorted to
this, but it appears rational and worthy of
trial, especially in that class of cases where
traction overcomes shortening readily.

My personal preference as to splintage
depends more on the patient than on the
pari; but irrespective of the location of the
fracture (intra- or extracapsular), some trac-
Fifl, 413.— Bone peg or tion and especially abduction and internal
metal spike in fractured rotation, must be provided if shortening

neck of temur. , , . ,

and external rotation are to be overcome.
Having these factors in mind the procedures favored are:

(i) For the aged, infirm or debilitated:

(a) Patient supine, head of bed elevated 6-10 inches, with
a long sandbag or padded bricks so placed that external
rotation is prevented. If the side of the mattress is
raised, or the edge of a pillow is pushed under the outside
of the limb, the bags or bricks can be so placed that they
arc kept from touching the Umb, in effect making a trough
of the mattress or pillow. A thin pillow or bags may be
placed between the limbs to give added support. A towel
or wide bandage may be placed about the ankle to carry
weight, the entire limb to be abducted as much as

(6) Patient out of bed or in bed in a semi-seated position such
as is afforded by a Morris chair.

(c) Patient seated on a chair in the above position and a care-
fully padded pi aster- of- Paris cast applied reaching from
just above the malleoli to the navel. This I call a
"sitting up cast." To this may be added U-shaped
straps of adhesive reaching to the lower leg, a cord
passing to weights fastened into the loop of the adhesive
under the foot.

SPECIAL FRACTURES

(2) For the rugged:

(a) Plaster-of- Paris abduction cast (Whitman type) taking care

that it is applied with the limb in traction, wide abduc-
tion and internal rotation (Fig. 433).

(b) Finochietto stirrup.

After four weeks in a fixed position, the apparatus is
removed and the patient can be allowed to walk on

Fig. 414. — Fracture of neck of femur — end-result, showing yood bony union with little
shnrttniiit;.

crutches; indeed some patients in an abduction cast can
be allowed on crutches within a few days if able to carry
the weight of the cast. A Thomas caliper or Ridlon
splint applied after the removal of the cast will permit the
patient to bear weight on the splint without the aid of
crutches. Massage and flexion motions of the hip at
this stage will aid in recovery; abduction and rotatory
motions of the joint must however be disallowed for

430

TRAI'MATIC SrTKGERY

several weeks more. It is unsafe to permit unsupported
weight bearing for six to nine months in the average
case, otherwise angulation at the fracture site will pro-
duce coxa vara deformity (Figs. 41S, 419).
Differential Diagnosis. — -Any deformity or disabling injury of
the kip in a persoti over 50 sbovld be rcgurdcd as a fracture unlH proved
ollicm-ise. Dislocation of the hip of the forward type is the only

Fig. 415.

likely error. This is exceedingly rare, as the deformity is different,
the head of the bone can be felt to rotate, the disability is less ex-
treme, and the patients are younger.

Complications. — Pneumonia is very common, and if it occurs
earlj' may be lobar or bronchial in type; commonly it is hypostatic,
with few symptoms aside from slight cough and some fever, but with
■ a great deal of torpor, ending with a low-grade delirium and deepen-
ing coma. It is best guarded against by elevating the bed and allow-

SPECIAL FRACTURES

Ftc. 417.— Fracture neck temur. Alter

;;pi.licaUi,ii ^i ^bdiic

number of cases, shows the hne of fractures running from or near the
junction of the neck and shaft to or through the great trochanter.
The two divisions thus created have in the upper part, the head, neck,
and upper part of the trochanter. All of these foregoing were clin-
ically regarded and treated as fractured hips until disproved by
p-rays or autopsy-.

e of upper cnil of fi^miir dm
This patitDt had sustained numerous [raciures ot the
showed areas similar lo Ihose indicated here.

Subtrochanteric or diatrochanteric fractures are relatively com-
mon and in these the line of cleavage follows the spiral line, often
separating the lesser trochanter completely. These fractures occur
usually from some form of violence causing rotation of the trunk
while the lower extremity is more or less fixed. The symptoms and
I treatment resemble upper shaft fractures (Figs. 363-365}.

EPIPHYSEAL SEPARATION

^ueai

^H This also occurs infrequently, and is less common than true frac-

^H^ure at the same age.

^B Union takes place between the head and shaft between the seven-
teenth and twenty-first year, and hence the injury antedates this
period of life.

SPECIAL FRACTURES 427

Causes and Symptoms. — These are similar to fracture, and x-Ta,y
diagnosis is usually determinative. It is said that in some instances
complete disability may not occur at once, but that weight bearing
adds to the angulation of the neck, so that when the patient seeks
relief, coxa vara already exists.

Treatment. — (i) Traction and extension by the methods named
in the foregoing. (2) Abduction method of Whitman; this is
especially valuable and is the best management for the average case
(Fig. 433). (3) Thomas' hip splint.

Whatever treatment is employed, the after-care demands that no
weight bearing be attempted for at least four to six months, and
thereafter some support is given for a year.

Results are excellent if reduction has been properly accomplished,
otherwise coxa vara often occurs.

SHAFT OF FEMUR FRACTURE

This includes breakage from below the trochanters to above the
condyles; fractures of the upper end of this area are sometimes known
as subtrochanteric, those of the lower end as supracondyloid.

Causes. — Direct violence more often fractures the lower third,
often producing a compound (open) break, and heavy blows from
falling objects and jamming or run-over accidents are the main
factors.

Indirect violence from falls on the feet or knees may result in
spiral or incomplete lines of breakage. Muscular violence is a rather
rare producing cause.

Varieties and Sites. — Simple or compound, complete oblique frac-
ture is the rule, the middle and lower third levels being the most
usual sites. Spiral and incomplete (bending) forms also occur, the
latter in children only, and in them transverse complete forms also
ap{>ear.

Displacement is generally marked, the upper fragment being in
front and external, more or less angulation also existing; the over-
lapping may amount to several inches from the drawing up of the lower
fragment. Bony spikes not uncommonly penetrate the muscle and
may even reach the skin; this is commonest in the lower third. Effu-
sion into the knee-joint commonly occurs in the lower third forms, but
may appear in all; no adequate cause is known for this but it has been
ascribed to associated joint injury, extravasated blood, or venous
stasis. It appears within the first few days, and is commonest in

4a8 TKAUHATIC SURGEKY

injury by indirect violence in children; in adults it slowly disappears,
but in children it promptly subsides (Stimson) (Fig, 435).

Fig. 435. — Fracture of the shaft of the femur: o, Union with outwMd bmdag; b,
external appearance.

Symptoms.— Disability is instant and complete. Deformity is
generally marked, as the shortening and tilting is considerable; swtU-

Fic. 426.^Tr3ctian straps for making extension of the lower extremity. BrnmI
nebbing is passed around the malleoli and to it are sewed heavy tapes. This can be
used to attach weights or to secure the part to the foot-piece of the Hawley table.

ing and ecchymosis and knee elusion are later prominent. Irregular-
ity generally cannot be felt through the muscles. Mobility is made
apparent by placing one hand under and the other on top of the

SPErlAI, FRACTUKES

thigh and pushing one toward the other vertically or laterally; this
may also elicit crepitus and failure of rotation cf the trochanter.
Measurement verifies the shortening.

Fic. 437. — Thomas splint and adhesive. Useful as a lemporary or transport splint
fractures of the leg or thigh. Useful also in certain fractures of the leg or thigh as
lanent dressing.

^P Treatment.— The first-aid cure must be
effort to prevent compound (openi rriulurv.

■efully given in an
"In- limli shoTiUl be

■■■■

L..»J

'1 r

1 .^..^HM

n HIakc-Keller spiin

.yof Lt.Col. KdItT

Straightened and Itcpt thus by pillows, sand-bags, or padded bricks.

i long side splint from the armpit to beyond the sole is very valuable;

i may well be reinforced by another reaching internally from the

43°

TRATIMATIC SUUGERY

permeum to the same distance as the preceding. A Thomas* splint
is the best method (Fig. 427). The bed should be firm and kept
thus by supports placed under the mattress.

Reduction is olten extremely difficult and in most cases anesthesia
is needed. It is often helpful to apply weight to the limb to stretch
the muscles for a day or more before anesthesia replacement is at-

Fic;. 430. — Thomas splint with author's take-
apart niodilicalion.

tempted in cases with marked displacement. Direct traction on the
straight limb or with the knee bent is the usual maneuver; in some
cases disengagement of the fragments can be brought about by press-
ure or fle.Klon directly upon them. Traction is made by: (:) Holding
the shoulders while pulling of the foot is steadily carried on. (2)
Futing the pelvis by a sheet passed about the groin and pulling on the
foot by a bandage or sheet about the ankle and foot (Fig. 436). (3)
'Every Thomas splint should have the ring at an angle of 55°, and when fitted
should presa againsl the tuberosity of the ischium.

SPECIAL FRACTURES

(4) Extension tables.

Various forms of pulley or windlass de^
of which Hawley's is the best.

The success of replacement is indicated by the disappearance of
shortening, the presence of crepitus, increasing false motion and
the straight alignment.

I Splintage. — (i) With little shortening or deformity it is sufficient
apply direct traction (by any of the extension methods previously

I--k;, 43-.

Fig. 43^.

43'

, 4ii.-

-Perfect retlucUoa ot a compound cc
(Hawley extension lable 1

jmmin
ised).

LUted fracture of the femur

mentioned), maintaining it until displacement is overcome (usually
two to four weeks), and this is then followed by a plasler-of- Paris
spica from the toes to the axilla (Fig. 433). This is replaced if it
becomes loose and is used six or eight weeks, and thereafter the limb
is bandaged and allowed to carry weight in 4-6 months if union is
firm and no pain or swelhng occurs after guarded attempts at use.
(2) Buck's extension apparatus with a pull varying from 10 to 40
pounds. (3) Suspettsion splints like Hodgen's. (4) Suspension and
traction splint: This seems to combine the merits of all the devices,
and is regarded by many as the method of choice (Figs. 406-428).
(5) Double inclined plane is generally only used early, especially in
fractures near the knee. (6) Transfixion of the lower fragment by a
nail or drill to which extension pulb are attached, this is the

TRAUMATIC SURGERY

Fio. 434.^Inatrmiient5 used h
"Ymkee" brace and author's defr
drill ends: nasal sprculum for use

;" of fractures. Upper n
luntable drill; lower raw: rubber disk lu Lhread o
IS retractor; artery clamp; director; scalpel.

SPECIAL FRACriTKES

433

" Codivilla-Steinmann nail extension method." I have employed
this in a number of cases and regard it as an excellent procedure in
selected cases (Figs. 411, 434-436). (7) Tongs or calipers introduced
near the condyles. (8) The Finochietto stirrup introduced over the
OS calcls.

bBosGiJoii,

Fir.. 436.
in a lifleen-jear-old-lioj . Treatment
X months after iojufj . Perfect result.

Operation to aid reduction may be needed, and suture or plating
is frequently performed at the same time; these last are wisely reserv-
ed for very oblique, spiral, persistently displaced and mal-united
cases. Open reduction and plating is an exceedingly formidable
procedure and should not be undertaken by the inexperienced.

TKAITMATIC SURGERY

Compound (open) cases are best cared for by some suspension metbod
reinforced by a metal bar which has a wide curve over the wound to

Fig. 4jS.— Suspen}

allow change of dressings. The stirrup extension (with or without
a. Thomas splint) is excellent for this type as it is introduced far
from the seat of trauma and the wound itself is exposed for dressings.

Fig. 443.
;. 439-442. — Supracondyloid fracture of lemur before and after Codivilla-
Paticut pinned between trolley car bumpers. (Case of M.
it- Graduate Hospital.)

43^ TRAtllATIC SURGERY

Whatever method is used, special attention is given to counter-
acting shortening, angulation, and adduction by using traction,
elevation, and abduction positions respectively.

The general condition of the patient receives appropriate man-
agement Just as in fractures of the hip-Joint.

In children, especially those under six, vertical suspension (Schede)
of both legs, so that the limbs are at right angles to the abdomen, is

the best non-operative method (Figs. 437. 438). A Thomas splint is
also of use. The hips are raised by weights just high enough off the
bed to allow folded diapers to be inserted and extreme care is taken to
prevent excoriation from pressure, urine, and feces. In the verj'
young, folding the thigh against the abdomen and holding it there
by a broad swathe gives excellent results; this is especially valuable
in obstetrical fractures.

For older children, some preliminary extension and plaster of
Paris is satisfactory. Union in children is usually solid enough
within ten or twelve weeks to allow bearing in a plaster-of-Paris
spica or a Thomas or other splint.

SPECIAL FRACTURES

438

TRAUMATIC SURGERY

LOWER END OF FEMUR FRACTORES

These includt^ supracofulyloid forms, splitting of the condyles
{inter condyloid); brL-aking one condyle (condyloid), or separating the
epiphysis {epiphyseal).

Supracondyioid fracture occurs anywhere within the lower 6
inches of the shaft. The deformity resembles that of the below
described form, and in effect is that of a massive synovitis, plus a

an Hawley tabic, limbs in

deformity correcled.

bent, angulated, everted, and completely disabled extremity. The
pull of the gastrocnemius group tilts the lower fragment backward
and often fills up the concave popliteal space by a bony con\-exity.
I regard this as one of the most difficult fractures to succe;
treat (Figs. 443- 44S. 449).

xessM^H

llJT EH CONDYLOID FRACTOSE

These lines follow the notch between the condyles, and the cleav-
age is generally more or less T- or Y-shaped. The degree of sepa-

Fjo. 449.— Supragundyluiii fracture ,.f c^cli femur. Furlti,-r cxL,-ii^i..n. iin.i lalilc
top lowered to allow application of double plaster-of- Paris spica from toes to umbilicus.
Note bandages passed about lower fragments (o pull them forward.

FiG. 4SO. — Fracture ot the internal cori- I-'ig. 4_';i. — I'ratture of the posterior pot-
dyle of the femur. Uoa of the conilylcs of the femur.

440 TRAUMATIC SURG£RV

ration varies; it may be wide enough to allow the patella to ^nk into
it. Displacement is generally extensive and the shaft overrides in
front and spikes of bone often penetrate the muscles or skin; hence com-
pound (open) fracture is common. The knee-joint is generally
involved and always swells, and the popliteal vessels are sometimes
bruised or torn (Figs. 450, 451).

Sjrmptoms. — Disability is instant and complete. DeformUy is
marked and is shown by swelling of the bent knee and variable dis-

FlG. 451. — Hodgen's splint ("A:

Text-book of Surgery").

tOTlion and shortening. False motion, crepitus, and actual outlining
of the fragments may be possible. Measurement discloses the
amount of vertical displacement. The patella frequently occupies an
abnormal and more or less fixed position. a;-Ray examination is
advisable.

Tieaiment.^ Reduction even with anesthesia may be exceedingly
difficult and perhaps impossible without operation. Traction on the
flexed or rotated knee is the usual manipulation, and setting is
known to have succeeded when crepitus is felt and measurement shows
relief from shortening. A great deal of traction is often needed and
- may be aided by weight extension applied for several days before
actual reduction is attempted.

SPECIAL FRACTURES

Fio. 4S8. — Illustrates the method of suspensbn in fractures of the lower leg. The
HodgeD splint is bent to about 135°. (Redrawn from Blafce an<l Bulltley).

Fia. 4SQ, — To illustrate four methods of obtaining traction in fractures of the leg.
(Blake and Bulkley).
A. Weight atUched to canvas band. B, \V*inhi attached to adhtsive simpa. C, Weight
•ttached to Finochictto iiimip. O, Wcleht attached 1<J Sinclair'a skate.

TR,\CMATIC SURGERY

Within a month splints are removed and massage and gradual
motion used, the knee being protected by a lighter posterior or en-
circling removable splint for four or five weeks longer. Walking be-
gins when it does not produce great pain or rc-effusion into the joint.
Ifilemal epicondyle fracture is a clinical curiosity.
EPIPBySEAL Separatiok

Union between the shaft and this largest of all the epiphyses
occurs about the twenty-fifth year, and most cases of separation
occur just before the twenty-first year. Separalion here is second in
order of frequency to aU forms, the upper end of the humerus being
commonest (Poland).

Causes. — Usually some considerable twisting form of violence is
necessary, and it is said to be quite typically produced by accidents
in which the leg is caught and is forcibly hyperextended in the spokes
of a vehicle or whirling machinery. The resultant displacement is
generally forward or rotatory; rarely is it backward, and the knee-
joint is commonly but tittle involved. (Figs. 460, 461,)

Symptoms. — These simulate a dislocation somewhat, and diag-
nosis is usually made by noting deformily, due to the swelling above
and in front of the bent joint. Molility: The tibia partakes in this,
and thus dislocation is ruled out, Crepitus inconstant— the so-cailed
muffled or soft or cartilaginous sort. Irregularity or malalignment:
Occasional. Compound (open) forms often occur in which the jwp-
Hteal vessels are likely to be involved, leading to hemarthrosis,
gangrene, or amputation. *-Ray examination is very valuable.

Treatment. — Reduction by direct traction, flexion and pressure,
followed by gentle extension, is the usual manipulation. The pro-
cedure advocated by Reisman of making upward traction on the
upper fragment by a strap about the limb is sometimes helpful.
Splintage in full extension by plaster is usually the choice. This
may be split at the end of a week; or if the posterolateral type from
the start, massage may be used.

After three or four weeks the original splints are removed, and
then a lighter posterior or encircling dressing is used a few weeks
longer. Use of the limb should begin in four or five weeks.

Irreducible and compound cases demand operative reduction, and
often this may be quite difficult; very occasionally resection may be
necessary. Vessel damage is corrected by ligature if the artery or vein
is involved; if both are torn, immediate amputation to forestall in-
evitable gangrene should be done, assuming that vascular suture or
anastomosis cannot be accomplished.

SPECIAL FRACTURES

446 teauhatic suscery ^^^^^^^|

Results in Shaft and of Lower End Fbhok Fracturbs

Shaft cases almost always result in more or less shortening, and
this varies between ^-^ inch and 2 or more inches. It may be asso-
ciated with rotatory or -aersion changes, so that the foot toes out or in.
A great deal of it can be compensated for by a tilt of the pelvis, and
while the limp and gait defect may be marked at first, in the end much
or even all of it may disappear.

Excessive callus, bouing, and overlapping are most marked where
reduction has not been complete. The bony swelling may be irregu-
lar and painful at first, but later it grows smoother and painless.

Knee involvement may appear in the form of swelling and stiffness,
and even for the first year a good deal of this may persist ; later, under
massage and forced usage, considerable improvement is to be ex-
pected. When right-angled flexion capacity is attained, there will be
practically no disability for ordinary purposes, as this is the "phyao-
logic limit of function" for the knee-joint.

Atrophy from disuse is overcome for the most part within a year;
it is usually commensurate with the foregoing sequelaj.

Lower end cases may show remnants similar to the preceding, but
the knee manifestations are commonly the most marked and per-
sistent.

PATELLA FRACTtlRES

This sesamoid bone has attached to it from above, the strong
quadriceps tendon, and beneath, the patellar tendon binds it to the
tubercle of the tibia; laterally, there are ligamentous and fascial
bands, and thus it is seen to have a very firm but elastic anchorage.

It is a fairly common fracture, and in my list occurred 61 times, a
percentage of 1.2, It is analogous to fracture of the olecranon.

By some anatomists the patella is regarded as a displaced portion
of the tibial epiphysis.

Causes,— Men sustain the injury three times oftener than women.

Muscular violence is generally regarded as the more usual origin,
and this generally takes the form of a sudden bending or twisting of
the knee in an effort to regain balance to prevent falling after tripping
or stumbling; or where some strong pushing force continues to over-
bend the knee with the limb more or less rigid. Direct violence in
which the knee-pan is struck or impinges against an object is a less
usual source.

In deciding the origin in a given case it must be remembered that
quadriceps contraction may produce the fracture and result in the fall,

SPECIAL PRACTURES

447

and that the latter will often be looked upon as* the cause, when, in
reality, it is the effect.

Anatomically it is very difficult to fall directly on the knee-cap
because the bending knee draws the patella upward, and the bnmt of
the weight is then received on the condyles of the femur or the head
of the tibia.

Sites and Varieties. — The usual break is complete and more or less
transverse, most commonly in the upper half of the bone; this is es-
pecially true where muscular force acts. Comminuted, multiple, and
more or less vertical lines of breakage are more often due to direct
violence.

Separation of fragments varies, but usually they are apart enough
to insert a finger-tip; the extent of the gap depends somewhat upon
the initial degree of injury, and it
may sometimes reach 3 inches or
more.

In some cases there is splitting
and more or less incomplete breakage.

A certain amount of rotation or
angulation of the fragments may
also occur, especially if the patient
tries to arise unaided or otherwise
further flexes the knee (Fig. 462).

Symptoms. — Disability is com-
plete and instant from pain, effu-
sion, and distortion. In some few
cases, with little or no separation,
patients have been known to limp
short distances by keeping the knee

perfectly straight, usually by walking backward. Voluntary exten-
sion is lost.

Deformity is seen in a uniform swelling of the joint and occasion-
ally the distorted outline of the bone is apparent, but the first look at
the swollen often greatly ecchymotic joint suggests synovitis. False
motion, irregularity (depression or notching), and crepitus are usually
felt, the latter especially where little separation exists.

Tteatment. — First aid requires that the limb be kept straight and
this can be done by a pillow, sand-bags or a padded posterior splint.
An ice-bag or lotions over the front of the joint may be added. Re-
duction is difficult until the pull of the quadriceps and the effusion
decrease; the first is attained by full extension, the second by ice-bags

Fig. 462. — Bony prominence of
the knee-joint: i, Patella; 2, con-
dyles of femur; 3, tubercle of tibia;
4, head of fibula; 5, head of tibia.

448 TRAUMATIC SURGERY

or lotions and daily elastic bandaging of the joint from below up.
After a week or ten days the intra-articular reaction will subside
under these measures and further attention is then (a) non-op)erative
or (b) operative.

(a) Non-operative, — Here the plan is to coapt the fragments, and
whatever method is adopted, a posterior molded plaster-of-Paris,
wire, tin, or wooden box splint is applied from the mid-thigh to the
ankle. For the coaptation, zinc oxid adhesive straps are criss-
crossed over the fragments in figure-of-8 fashion; or a series of them
are applied and attached to the margins of the splint or to the limb.
They must not completely encircle the joint or in any manner ob-
struct circulation. These straps may be renewed if necessary, and
at each reapplication the same care to obtain coaptation must be
employed. Splintage is used four or six weeks, and after the first
week massage will be of great value and should be used daily where
possible. After this period the joint is encased in a split circular or,
better, a posterolateral plaster-of-Paris cast and walking on crutches
is allowed. After three or four weeks the cast is left off for increasing
periods daily, strong admonitions being given not to overbend the
joint. At the end of this period an elastic bandage or leather knee-
cap is worn and bending of the joint is gradually increased, at first
given passively at the end of massage, and then permitted actively.

Operative Methods. — Hooks of various kinds (like Malgaigne's,
Levis', and Stimson's) were formerly used to coapt the fragments
by inserting the prongs through the skin into the front of the bone
above and below the line of breakage. Pins driven transversely
through the ligaments or vertically into the fragments to anchor and
coapt them have also been used. These foregoing methods are prac-
tically abandoned now.

Incision directly exposing the fragments for suture is the of>erative
method of choice where and when all aseptic details are possible.
Generally speaking, the operation can be done any time within the
first fortnight; if the conditions permit, there is no reason why the
repair cannot be made at once.

Vertical incision (Stimson's method) is very commonly used.
After the bone is exposed the fragments are held aside, and clots and
loose fringes are removed ani.hot saline solution irrigates the joint.
"A stout chromic catgut ligature is passed through the lateral expan-
sion and capsule close to the bone on each side; these are tied while
the fragments are held in exact apposition, and then the fibroperios-
teum and other superficial layers are adjusted and fastened with

SPECLU. FKACTURES

catgut" (Stlmson), No drainage b used. A posterior splint is ap-
plied, and the patient is abed with the limb elevated for a week, and

Ljiliiliuii by kangaroo

then the alk skin sutures are removed and a light plaster-of-Paris
cast is applied. The patient is then allowed on crutches. In a

TRAUMATIC SURGERY

munth the cast is worn only in the daytime. " Usually hy the end of
the third month, often earlier, the joint can be flexed at least 90 de-
grees, and the patient usually discards the splint entirely before that
time, since he is told it serves only as a protection against damage by
a fall" (Stimson) (Fig. 463). Kangaroo tendon is more often used
than chromic gut and massage is given from the beginning. Passive
motion is made in two weeks, active motion two weeks later.

Transverse incision methods are also used and frequently give
better exposure.

Semilunar incisions, convexity upward, are also used.

Bo7te suiure after incision is not much practised now; kangaroo or
other tendon and silver or bronze wire are the materials most often
employed (Fig. 464).

Before resorting to operation it is usually the practice to wait a
week or ten days for articular reaction to subside; some surgeons,
however, operate immediately, as previously stated.

Operative measures bring about an earlier and more complete
union, but suture should be done by an experienced surgeon, pref-
erably in the rugged and those who are able to combat surgical inter-
ference. Functionally good results are possible without it, and even
under the best conditions there is some danger of sepsis with sub-
sequent ankylosis, or perhaps amputation or death.

Early massage is a postoperative necessity and is not to be post-
poned beyond the time the skin wound unites. Some few surgeons
allow patients out of bed after ten days and permit walking then in a
cast, with bending of the knee after a few weeks.

Results. — Fibrous union is the rule; it may be so close, firm, and
tough that in effect It is bony, but true osseous repair is rare. The
fibrous bridging may be continuous between the fragments, or gaps in
it may intervene, and frequently motion between the joined segments
is quite marked, especially laterally. The fibrous bridge may be
several inches wide and yet permit very active function; it is not un-
commonly J 2 i^f^^ o'' more wide.

Joint motion is associated with a great deal of stiffness, swelling.
and pain at first, especially in the non-massaged cases. Much of this
disappears within the first six months, especially if massage and
increasing use are practised. When the knee can be bent to 90 degrees
the functional limit of usefulness for ordinary purposes is attained;
the normal extreme flexion angle isabout 125 degrees. The majority of
cases within a year have serviceable limbs.

Refraciure is most likely within the ficst six or ^ht weeks after the

SPECIAL FRACTUHES

451

cast is removed, and it is practically always due to a trip or fall. The
line of fracture may be at the original site or the lower fragment may
pull away the edge of the upper at a new place. Union generally
re-occurs promptly and operation is practically never needed to bring
this about.

E. M. Comer, of London,^ states that the patella is more often re-
fractured than any other bone, and that in the operated cases 69 per
cent, of refractures occur in the first year after the injury. Of the
uno[>erated cases 86 per cent, of refractures occur after the first year.

Fixation of the knee-cap by adhesions to the condyloid region is
rather unusual.

Disability Period. — Total, eight to sixteen weeks; partial, four to
twelve weeks.

FRACTURE OF THE LEG

This includes (a) upper end of
the tibia or fibula, or both; (b)
fracture of the ska/t of the tibia
or fibula together or separately;
(c) fracture above the malleoli
(supramalleolar) ; (d) malleolar
fracture; (c) PoU's Jracture.

Anatomy and Landmarks.
Tibia. — It enters into the
formation of the knee but does
not overlap the ankle-joint (Fig.

465)-

Tuberosities, especially the in-
ner, are often visible and always
palpable; in flexion the summit
of the tibia can be felt and is a
good guide to the joint entrance.

Tubercle can often be seen d
and is always palpable ; the patellar />
tendon is attached to it.

Shaft is largely visible and wholly palpable ahnost for the en-
tire extent; the crest and anterior surface are especially well marked.

Fibula. — It enters into the formation of the ankle, but not of
the knee-joint.

Bead is visible usually, and always can be left behind and be-

' Aniuils of Surgery, November, igio.

Fio. 465.— Bony landmarka about

the knee- and ankle-joints: a, Patelk;

i, summit of tibia; c, tubercle of tibia;

d, head of fibula; e, external malleolus;

iternal malleotus.

4S2

TRAUMATIC SUKGERY

low the top of the tibia; it beaxs a relationship like the head of C
radius to the ulna.

Shajl lies well behind the axis of the tibia and is embedded I
muscles at the upper part, but can be felt below the middle, and t:
gradually becomes visible below this level.

Lower End.^ Malleoli: The internal b broader and thicker than t
external, and its lowest tip lies i-i or ^i inch above and in front of the
lowest end of the fibula. The external is more pointed and the ridge
on its back part can be made out; on its front tliere is often an
irregularity.

Fig. 466. — Commtm sites of fi
the tibia and fibula: a. Anter
6, posterior view.

;. — Comminuted fmcture of
the upper end of tiio lilria and I
(side view).

DPPER EMD FRACTDRE
This may involve either bone separately or together; in the fon
the tibia is usually affected (Fig. 466).

SPECIAL FRACTrRES

Causes. — Direct violence is the commonest method, usually from
a blow or the impact of a falling object. Indirect violence is a less

I
I

Fro. 468. — Comminuted Iracturc uf th>
upper end of the tibia and libula linn
and aft view).

Fir.. 461). — Compound comminuted
of tibia and libula {upper

end).

likely source, as from a heavy fall with a twisting of the leg, usually
outward. The line of fracture is ordinarily transverse (Figs.
467-469).

454

TRAUMATIC SURGERY

Symptoms. — These somewhat resemble a dislocation of the knee.
Disability is instant and complete. Deformity is seen in swelling and
perhaps irregularity. Mobility and crepitus are variable; local pain
is present on direct or lateral pressure, or that transmitted through
pounding on the heel.

Anesthesia is generally needed for diagnosis and o^ray examina-
tion may be requisite for corroboration.

Fig. 470. — Manual traction method for fractures of the leg or ankle.

Fig. 471. — Splintage for non-displaced fractures of the leg or patella: a. Posterior
molded plaster-of- Paris "gutter" splint; b, posterior padded wood or tin splint; c, same
as preceding, with anterior reinforcement of wood or tin.

Treatment. — Reductiofi is affected by pressure and traction, in
some cases with comminution or irregular lines of breakage, open
incision may rarely be needed (Fig. 470).

Splintage. — (i) Posterolateral molded plaster-of-Paris cast from the
toes to the upper third of thigh, the knee being slightly flexed j this is
the best method when reduction is maintainable (Fig. 471). (2)

SPECIAL FRACTURES

4SS

-Circular phster-of-Paris cast covering the same area, this can be bi-
sected if desired. (3) Posterior suspension splint, like the Thomas,
3Iodgen or modifications (Fig. 472). (4) Finochietto stirrup (Fig. 484) .
If removable splints are used, some massage is of great assistance
^ter the first week. Splints are removed after five to eight weeks,

/?(f.'np'irnnTn]ii^Y'fn'!i''' i?'^^^^

''•'''''W//|li'!;i)!i//f//////ji|ji

Fig. 472. — Traction splints for the lower extremity: a, Adhesive plaster for fractures
or to prevent knee-joint adhesions; 6, posterior padded splint to the bandaged leg as in
non-displaced fractures near the knee; c, as in 6, reinforced by coaptation splints; d^ e,
lateral splints for fractured femur, as in Buck's extension.

when union is usually firm. Then the usual treatment is given to
^Timber up" the stiff joint, some protective leather or light plaster
encasement being provided and worn for several weeks longer.
Weight bearing is not allowed for ten or twelve weeks when the tibia
is involved.

458 TRAUMATIC SURGERY

separation and displacement will be greater and the tibia may be
forced through the skin, resulting in a compound (open) break.
Compounding of the fibula is quite uncommon (Figs. 474, 47 5). Over-
lapping of fragments may amount to several inches, the lower frag-
ments are in front generally and often almost penetrate the skin
because the tibia is normally so subcutanenus. \Vhen one bone

Fig. 474. — Comminuted fraciure of the
lower end ot the tibia and fibula. Enii-
rcsult; note Erra callus and good align-
ment of tibk in relation to astragalus.

riG. 475. — Cotnpouad coramiiiutcd mul-
tiple fracture of the tibia and fibula.

alone is broken, especially the fibula, displacement is not generally
marked, as the unbroken bone splints the other (Fig. 476). Vio-
lence great enough to break or displace the tibia is usually sufficient
to break the fibula also, notably if indirect force is the causative
factor. Fracture of the lower third of the tibia (oblique or spiral)
is very often associated with fracture of the upper third of the fibula.

SPECIAL PBACTUSES

459

This combination is so frequent that the surgeon should always
suspect it. If the associated fibula fracture is sufficiently high it
may occasionlly involve the peroneal nerve.

Incomplete or greensliek forms are rather rare and always occur
before the sixteenth year (Figs. 477, 478).

'.. 476.— Mull i[>lf fr..Lli
I palicnc also rtccivi'd a
e Figs, S57i 5SS-) Note lack of diaplac
ic vhen the tibia is not broken at or nea

: of the internal malleolus-
of Ihe spine in the same accidenL
of the fibula: this [s quite chaiacter-

Compound [open) forms are notably common because the tibia
is so close to the surface (Figs. 479-481).

Symptoms. — Disability is instant and complete when both bones
are involved; in some few cases of unseparated tibia or fibula frac-
ture, weight bearing has been possible for a short time. Dcjormity
shows as distortion or angulation of the twisted or dangling leg;

460 TRAUMATIC SUKGERY

later, swelling, ecchymosis, and blebs appear. False motion, local
pain, crepitus, and irregularity are present. Mensuretncnl from the
tubercle or inner tuberosity of the tibia to the inner malleolus dem-
onstrates the shortening. In cases with marked displacement the
diagnosis has already been made by the patient or others, and at all
events is usually apparent when first inspected by the phj'sician.
In undisplaced cases diagnosis rests upon finding irregularity in the

crest or border of the tibia, and in this same region local pain will be "
elicited upon direct pressure or that produced by pounding the beet
or pushing the shafts or malleoli toward each other.

Mobility and crepitus are demostrated by firm grasps of the
limb, one whole hand being above and the other below the suspected
site, a rocking or lateral motion best bringing it out. Malaligntnettt
is suggested when the anterior spine, raid-patella, tubercle of tibia,
mid-intermalleolar line, and the space between the great and adja-
cent toe are not in the same straight line. If the fibula alone is

SPECIAL FRACTURES 461

broken, diagnosis is often determined by the one sign of "point" or
local pain, with perhaps the later appearance of ecchymosis. Meas-
urement must have in mind the normal variants in length, and this

Fni. 4;9. — Compound comroinuled multiplt Um iiin- of liiiU and fibula. Original
condJtioD (acteropoEtcrior and lateral vienl). This paLicnt was in 3 collisiun between
cars and for a time was in danger of amputation. Several sequestra of necrosed bone

may amount to }■■;; inch or more; confusion is most likely in bow-
legged, knock-kneed, or otherwise asymmetric patients.

Treatment. — Immediale care during transport to bed demands
that the leg should be kept absolutely straight and quiet, preferably

462 TRAUMATIC SUEGESY

■with some pull on the foot while the limb is placed in an impro\'ised

casing made of a folded coat, stirt, or petticoat, asshown in Fig. 471. A
pillow pounded lengthwise into a groo\'e is splendid for this purpose.
No pressure or constriction should be placed just aver the fracture
line. When the patient is abed the temporary piilow splint may still

answer, and the whole limb should then be elevated as high as com--
fortable, as this will tend to minimize edema and circulatory engoree- —
ment. A Thomas splint is very useful.

Su'ciliiig and blebs may be extensive enough to make it worth
while to wait a week or ten days before anything more is done; or,
better, the leg may be placed in a three-sided box or metal gutter

SPECIAL FRACTXniES 463

splint (see Figs. 220, 471) and the elevation continued making pre-
limary traction by an anklet or adhfsive straps (see Figs. 409, 426,
472). Traction in a Thomas splint is excellent. Lotions (like saline,
boric, or lead-and-opium solutions) sometimes aid in the absorption
of effusion. Ice-bags must be used cautiously if at all.

of tibia aaii fibula. At the end

Reduction should be made at once where practicable, and this is
accompUshed usually by traction on the foot, with the bent knee
steadied. In some cases this can best be done by causing a sharp
angulation of the fragments backward until they interlock, and in
this position traction and extension is then made. If there is much

TKAUHATIC SUKCEBY

Fio. 48a. — Cabot splint made of !^-iiich wire and covered with gauze or cotton.
Useful as a temporary leg splint, or as a posterior knee splint.

Fic. 483. — The device of Hawley in which a pin is passed over or through the os aJd$-
A substitute for the Finochietto-Chutro stimip.

SPECIAL FRACTURES

465

displacement anesthesia is advisable, and the patient can be allowed
to **come out" before the splint is applied.

In some cases operative reduction is necessary, and then the
wound is made on the outer side of the tibial crest where the tissues
are least subcutaneous. Preliminary weight traction on the foot
ior twenty-fours hours or more is a valuable aid to easier setting.

Splintage. — (i) Molded plaster-of-Paris, posterolaterally, with the
Jeg perfectly straight, can be used even where swelling and blebs

Pig. 484. — Finochietto-Chutro stirrup passed over the os calcis in front of tendo-
Achilles. A useful device in certain fractures of the leg.

are marked. This splint reaches from the toes to the upper third of
the thigh. The whole limb should be previously shaved and washed
with alcohol and then dried and powdered. Blebs are painted with
iodin and opened aseptically (Fig. 222); and if large, a layer of sterile
gauze covers them; otherwise dusting with powdered bismuth or
boric acid is sufficient. They often retard a smooth recovery and
may cause troublesome infection or eczema if unwatched. (2)
Circular plasier-of -Paris cast is safe only when swelling is not marked;
it is applied over the same area as the foregoing, and is safer and
just as efficient if split down the middle before it hardens, allowing
a gap to the skin of J'^ inch or more. (3) Suspension splints^ like

466

TRAUMATIC SURGERx

the Hodgen or modifications. (4) Wire frame splints ^ like the Cabot
or modifications (Fig. 482). (5) Traction by adhesive plaster or
weights, with some posterolateral splintage. (5) Thomas splint suit-
ably bent (Fig. 458). (6) Finochietto stirrup especially good in
compound and lower third cases (Fig. 484).

Whatever form is used, care must be taken to keep pressure off
the head of the fibula, malleoli, and heel, and this last can be done by

Fig. 485. — Methods of keeping pressure off the heel: a, Folded compresses; b,
"doughnut" or ring of gauze and cotton; c, cotton padding; d, adhesive fastened to
end of splint.

pads placed above the tendo Achilles or by a strap of adhesive run-
ning over the tendon and along the sole to the edge of the splint, or
by the other plans shown in Fig. 485. Undue pressure over the head
of the fibula may produce peroneal palsy and resultant foot-drop.
Every effort is to be made to correct shortening; but a slight amount
of lateral displacement wdll cause no serious trouble if overlapping is
remedied. Splints are replaced when loose, and they are used until
the bones are firmly knit, a period of five to eight weeks as a rule
Massage materially aids after the first few days; passive motioj
of the ankle can be given in two weeks and of the knee a wee

SPECIAL FRACTUBES 467

later. After the first few days, sweUing permitting, the patient can
be allowed out of bed with the leg on a chair; in a week it can be
allowed to rest on the floor; in two or three weeks going about on
cratches is allowed. The lower leg and foot will swell and become
blue and perhaps cold or painful at first, but later this circulatory

embarrassment disappears.

Fic. jSo. — Case of H. S.. astd sixty-ino. Compound comminuted fracture of
tibia and fibula, showing end-result. An aufogcnims bone-graft was inserted for non-
union; i-ray deformity apparenlly is great; clinically the leg is straight, very little
Gorier, and functionally nearly perfect.

After the heavy splint is removed, a lighter and shorter support can
used a week or two. After two months, assuming that no local
pain persists on increasing usage, weight b born and walking per-
mitted, the leg being bandaged.

TRAUMATIC StTiCESY

In compound (open) cases the use of molded or circular plaster
splints, reinforced by a bent iron bar or with a window, are convenient
for dressings, preliminary iodin sterilization havingbeen accomplished.
Operation seeks to bring about coaptation by suture, pinning, or
plating; neither of these act uniformly well because the main bone is
so poorly covered by soft parts, Hence the incision is planned as
much to the outer side as possible. The usual rule is to suture or
plate the tibia only, as the fibula
practically cares for itself (Figs.
486, 487)-

Results. — Union is generally firm
in four to six weeks; in compound
(iipen) cases that stay clean, it is
but slightly longer, infected cases
may be very much delayed or com-
pk-tejy fail to unite and sinuses may
persist for months.

Rejraclure through the original
line is commonest within the first
few weeks, and is usually due to a
trip or fall; in such cases reunion is
generally prompt and about one-half
the time is required to unite the new
break than was originally necessarj'
(Scudder).

Deformity may be evident by mal-
alignment, such as bowing (antero-
posterior or lateral) or overriding with
shorlcning. All of these may be con-
siderable without impairing the
ultimate strength or usefulness of
the limb; shortening even of several
inches can be sometimes compensated for without limp or gait
defects.

Fracture of the fibula alone causes no shortening and is rarely of
serious import.

Swelling, cyanosis, and other circulatory impairment always occur
to some extent, mui^h of this disappears after a few months of use
and ultimately ceases to cause trouble or notice.

Stiffness o/Uie knee and ankle is quite marked at first, especially in
the latter joint. A great deal of it may be prevented by early

SPECIAL FRACTURES 469

massage and passive motion; later, active use and special efforts to
limber up these joints are rewarded by increasing freedom of action
and ■virtual return of complete function. Tendo Achilles contraction
is largely prevented if the ankle is overflexed when splinted.

Callus is most marked where perfect coaptation has not occured,
and it may be visibly large, irregular, and tender; later it decreases
and becomes smoother and painless.

In my experience fractures 4 to 6 inches above the ankle are most
troublesome, as they are difficult to reduce or retain and often fail to
unite. Frequently also they are compounded.

Disability Period. — Total, eight to sixteen weeks; partial, four to
■farelve weeks.
W SUPRAMALLEOLAR FRACTURE

In these rather uncommon forms the line of fracture is above the
base of the malleoli, and roughly speaking, involves the shaft within a

Flc. 488.— !-■ rati uri' of tibia atui liLgla, Note rnin-scii;vr;ili(in iiii.l ;.i.|ir.i,n.h to a green-
slick variety.

inches of its lowest Umits. The joint is usually entered by a
'splinter, with more or less associated comminution or separation of
fragments. The tibia and fibula may be affected together or sepa-
rately (Fig. 488).

Causes.- — Indirect violence, as a fall on the foot with or without
lateral wrenching, is the usual source. Direct violence less often is
causative, as from a run-over accident or violent blows.

47© TRAUMATIC SURGERY

Symptoms. — Associated with disability is deformUy from sweD-
ing of the distorted ankle and foot, local pain, and perhaps crepitus
and excessive mobility ^ especially laterally. There is a change in the
appearance and level of the malleoli and irregularity may be felt.

Treatment. — This comprises reduction linder anesthesia, and
splintage with the foot in a right-angled inverted position, as in Pott's
fracture.

EPIPHYSIS FRACTURE

Displacement of the lower end of the tibia from the shaft is nearly
three times commoner than involvement at the upper end of the
same bone; despite this, it is among the rarest of all ankle injuries.
Union with the diaphysis occurs about the twenty-fourth year, but
most separations occur before the fifteenth year.

Causes are those associated with a twist of the foot, with or with-
out the added violence of a fall.

Symptoms. — These are like supramalleolar forms except that dis-
placement is less marked. Dislocation or "severe sprain" is usually
diagnosed, and x-ray examination is often the final determining factor.

Treatment is like that given the following.

POTT'S FRACTURE

This exceedingly common "fracture of the ankle" occurred 393
times in my list of cases, a percentage of 8.8.

It receives its name following the description given in the Chirur-
gical Works of Perceval Pott, 1779 edition (Cotton). Originally Pott
described a fracture above the external malleolus, a rupture of the
internal lateral ligament, and an outward dislocation of the foot.

Lately there has been a tendency to group all ankle fractures as
"Pott's" or "modified Pott's," and for practical purposes this is not
inadvisable (Fig. 489). The definition and classification given by
Stimson is regarded by me as most satisfactory clinically and patho-
logically, and he describes the injury as one in which the following
lesions exist as a result of (i) eversion or (2) abduction of the foot
(Fig. 490).

(i) Eversion, — The main force is exerted through the internal
lateral ligament, resulting in the combination of (a) fracture of the
internal malleolus squarely off its base, (6) rupture of the tibiofibula
ligament; {c) fracture of the fibula just above the malleolus. This
may rarely be modified by an a\ailsion or chipping of the tibia along
the line of the tibiofibular ligament attachment, the ligament remain-
ing intact.

SPECIAL FRACTUSES

471

(a) Abduction. — The front of the foot makes the principal move-
ment, resulting in the combination of (u) Fracture, oblique or marginal,
of the anterior portion of the internal malleolus; or oftener, rupture of

Fig. 489. — Bony iandmarksabouttheankleand tarsus* i, Front view; a, Astragalus
ooter upper edge; ft, astragalus outer side of head, c, fifth metatarsal head; d, internal
malleolus tip; e, scaphoid tubercle. 3, Lateral view (internal) a, Internal malleolus;
b, scaphoid tubercle 3, Lateral view (external) a, Fifth metatarsal head; b, peroneal

Fig. 490. — Pott's fracture showing lines of breakage with the typical abduc^on
deformity: a, Fibula broken obliquely; lower inner and outer articular end of tibia
broken, but unseparated; interatticular mortise slightly a£Fected; b, fibula broken trans-
versely; tip of internal malleolus broken and separated; interarticular mortise greatly

the anterior part of the internal lateral Ugament; (&) rupture of the
tibiofibular ligament; (c) fracture of the fibula 3 or 4 inches above its
tip. If the force fails to continue long enough, the fibula may not
break.

473

TRAUMATIC StJRGERY

Causes.' — Indirect violence is the cause, usually from "tuining on
the ankle," so that it and the foot are twisted outward and the weight
of the body is thrown on the region of the internal lateral ligament or
front of the foot. Direct violence is an improbable source of origin.

Fic. 4QI. — Pott's fracture deformity: a. Posterior view showing eversion ot foot
and prominence of the inner malleolus; b, anterior view showing the same and the mal-
alignment of the axis of the leg to the center of the ankle mortise.

Varieties and Sites. — As previously stated, these vary; but the
chief element, in addition to the fibular fracture, is the separation of
the tibiofibular ligament which permits the widening at the mortis*

-Typica

n I'lilt'a fracture.

between the malleoli and the astragalus and the consequent t
and backu'ard displacement of the entire foot. The outward d
ment is generally slight in extent; but the backward distort!

SPECIAL FEACTURES

473

amount to the entire width of the astragalus. The Internal malleolus

may sometimes be rotated and become so subcutaneous that com-
tound (openl fracliire results.

local ion of ankle

Fio, 494,^FractLitc
ankle. Stirrup alta.ch<:i
Deformity reduced. Sa

Fm. 455. — Fracture dislocation of
axikle. Stirrup attached over os calcls.
iJcformity reduced. Same case as Fig,

Cotton describes' a variant of ankle fracture thus: ". . . back-
ward dislocation with the splitting away oj a wedge, large or small, from
lite back oj the surjacc of the tibia at the joint — a wedge that is displaced
'Joiir. Amrr. Med. Assoc, Jan. 23, iglS.

474

TRAUM,\T1C SURGERY ■

backward with backward dislocation of the fool . . . Fracture of the
malleoli is associated with this luxation ..."

Symptoms. — Disability is ordinarily instant and complete, so that
in typical cases weight bearing or walking is impossible. Deformity
is prominent and pathognomonic, in that the entire foot is tilted out-
ward and backward, and in this position the inner margin of the
ankle becomes unduly prominent and quite subcutaneous (Fig. 491,
492). Lateral mobility is another tj-pical finding, and it is demon-
strated by placing the heel in the palm, with the other hand on the

pushing ihe foot oulward aad b-

Uflormitj' J

lower leg, and pushing one hand against the other. Crepitus ]
sometimes exist. Local pain is typically present over tJiree areas:
(1} Tibio-fibular ligament region; (2) base or front border of the in-
ternal malleolus; (3) base of or a little above the external malleolus
(Stimson).

Swelling and ecchymosis of the ankle and lower leg are prompt!
extreme; blebs are less common than in fractures higher up.

Treatment.' — First aid demands the same care as in a broken leg so
that compounding or pressure may be prevented and swelling con-
trolled.

Reduction is the key to success, and unless it is complete, perfect
function is unattainable; in this respect, and in many others, this
injury resembles, and for all practical purposes may be regarded as
the "downstairs" form of CoUes' fracture. Anesthesia is of the
greatest value; if it is refused or inadvisable, some muscular relaxa-

SPECIAL FRACTUBES 475

tion will result if (i) traction is made on the ankle for some time, either
by a fonn of extension with the leg straight, or by dangling the bent
leg over a table and hanging a weight on the foot; (2) plunging the

and elevation with Cul
itial step.

foot and lower leg into a pail of pounded ice and salt, thus attaining
local freezing; (3) injecting novocain J.^ ( per cent.) about the frac-

FiG. 498. — Steps

turesite; (4) pressing upon the popliteal or femoral artery until "pins
and needles" are felt in the foot.

Reductiofi is by manipulation, so made as to correct the hachward
and out-ward deformity, and hence pressure on the heel forward and

^H 476 TRAUMATIC SUKCERY ^^^^^^^|

^H inward will accomplish this. The fullest relaxation of the tendo- 1
^H Achilles is obtained by sharply bending the knee, and this poation 1
^^M will aid in the reduction. 1
^H (i) The first step is to increase the deformity, and this is done by 1
^H pushing the entire foot out and back, (2) The next step is direct 1
^H traction downward on the foot, the leg being held by an assisuM,
^H Then the foot is lifted forward andh eld in a right-angled pOMtion loi
^^M beyond that angle). (3) The final step is to invert the whole loot so
^H that the sole is almost in the same vertical line with the inner ade of
^H the leg (Figs. 496-499).

IH^I

^ Fic. 499.— Steps in the reduction of Potfs fracturp. Jones' lest of iedac£^^^^^H

^H The original deformity was an outward and backieard o^Ec^^
^H ment, and it is overcorrected into an inward and fonvarj position,
^H When setting has been successfully accomplished we are awart '"'
^H it by (1) relief of deformity; {2) return of the malleoli to their normal
^H levels; (3) crepitus is elicitable; (4) the leg axis is straight, so that liic
^H middle of the patella, the tibial tubercle, and the interspacr of the
^^M great and fourth toes are in the same line; (5) a position of righl-
^H angled flexion can be maintained without undue force and by the push
^H of the surgeon's index-finger^ — Jones' test.

^H Splints. — These are applied with the foot held as sharply ittTtrUd
^H and flexed as possible. This position is maintained by an assistant
^H who holds the toes and ball of the foot in his clenched hand ; or also by
^H tying a bandage or string about the great toe and making the patient
^K pull upon it (Fig. 502}. 1

SPECIAL FRACTURES

477

Kinds ff Splints. — (i) Molded piaster oj Paris: This is the "Stim-
son splint" and it is posterolateral in type. For the posterior
piece, eight to twelve layers of a 6-inch plastcr-of- Paris bandage are
folded lengthwise on sheet lint or wadding long enough to reach from

Fic soo — I'lacture of lowKr tliird cif libia and upper lliird of fibula.

the toes along the sole and over the heel and calf to the bend of the
knee. The lateral piece begins just in front of the external malleolus,
passes over the instep to the inner side and then under the sole, and
up the outer side of leg as high as the other section of the splint. A

478 TRATniATtC SURGERY

bandage is then applied, snugly encircling the splint and leg, and Ihe
foot is held in position by an assistant, a sand-bag, or a tape around
the toe, and the splint allowed to harden. Then the bandage is re-
moved and spiral straps of adhesive (or tape-ties) hold the splint in
place. The lateral splint may be used on the inner side in some
cases. (3) Dupuytren's or internal lateral splint (Fig, 501). (3)

Fig. 501,— Dupuy

for Pott's Tract uie.

Circular piaster of Paris: This is often dangerous because it hides the
part and fails to give early warning of pressure, if it is used at all, it
must be widely split to prevent pressure or tourniquet action.

After a week the patient may be allowed on crutches. Massage
can be given from the first if a molded or similar removable splint is
used, .\fter twn nr llir.i: wirks, tin- lalLT;il ^Lf^nient of a molded

P r

Fig. 5

ctolaleraJ moulded plaster-o£- Paris aukle splint; A, posterior purllon.

splint can be removed for cautious passive motion, and a week later
some active bending is permissible. No weight is born for eight or
ten weeks. The lateral portion of the splint may then be discarded
and the rest is removed in a week. Adhesive plaster straps placed
about the sole to hold the foot inverted^ a flat-foot insole (in each
shoe), or, better, a strip of leather H inch thick along the inner side of
shoe are useful when the patient first begins to walk. In stUcUd

i, 503. — Poslerolaleral moulded plasler-of -Paris ankle splint, compleled. Note
lalcial piece B.

, 504. — Posterolateral moulded plaster-of- Paris ankle splint, lateral purtioD (B)
removed. Note exposure for inspection and massage.

480 TRAUMATIC SURGERY

cases perfectly reduced, I remove the lateral part of the splint witiiin
a fortnight, the rest two or three weeks later. Massage is given
from the very outset, passive motion begins at the end of the first
week, guarded active motion a week later.

Operation for reduction is very rarely needed; in compound (open)
cases it may be expedient sometimes to enlarge the original wound to
bring about better alignment. Sometimes nailing or plating of the
fragments may be warranted.

Results.— i7m'(j« is firm usually in four to six weeks. Non-union
in this or any other fracture near a joint (except the hip and shoulder)
is exceedingly rare. Stiffness and swelling of the ankle are always
present, but are less in well-reduced and early massaged cases. A
good deal of this disappears and much impro^'enicnt is afforded by
active use. forced bending, and other "limbering up" methods.

In badly set cases, permanent stiffness to some degree is not un-
common; in the aged, rheumatic, and alcoholic the same is also true.

Deformity in the form of a flat, everted, or twisted foot is depend-
ent greatly upon the success of setting. Moderate degrees due to
lengthening of the internal lateral ligament are generally recovered
from by the aid of proper insoles, arches, or shoes; extreme or ancient
forms are likely to be permanent, with more or less limp and gait
awkwardness, due to carrying the weight on the inner margin and
not on the center of the joint.

Unreduced or deformity cases are often markedly bene6ted by an
operation which exposes the fracture sites by lateral incisions; then
the fragments are chiseled free and proper reduction is effected, and
the wounds closed and an enveloping plaster cast applied for four to
six weeks; in effect, this means refracturing the bones.

Disability Period. — Total, six to twelve weeks; partial, t
nine weeks.

" Modified Pott's " cases require no special mention inasmut
their importance is more academic than practical.

MALLEOLUS FRACTURES

These are the next in frequency to Pott's fractures. The external
malleolus is more commonly broken alone, but both may suffer al
the same time (Fig. 505).

Causes.— The usual source is falling or tripping, producing inver-
sion of the foot, so that the strain comes against the external lateral
ligament which (i) avulses the external malleolus, or the latter is
broken by pressure of the astragalus. (2) If the violence continues,

or tour to
Lsmu^^^H

SPECIAL FR.\CTURES

the tip of the internal malleolus is broken by astragalus pressure.
(3) When carried further a larger section of the internal malleolits
breaks (SUmson).

Symptoms. — Many of these are regarded as sprains or ruptured
lateral ligaments. Disability may not be instant or complete, and
walking may be possible for a time, especially in forms (i) and (2).

Fig. s°S- — Fraclure at base of exUmal and intenuil malleolus (anteroposterior and
^^teiul views). Treatment indicated: Posterolateral or circular pi as ter-of- Paris splints,
i'cfcot inverted and flexed,

Hejormity shows by swelling and perhaps some visible change in the
nialleolus level or outline. Crepitus, mobility, and local pain exist.

Treatment. — This depends very largely upon the extent of the
damage and the amount of displacement. In the more extensive
form, {3), the same care is given as in Pott's fracture. In fracture of
a single malleolus, or of both with little or no ligamentous involve-
ment or displacement, a light molded plaster-of-Paris cast for a
few weeks is all that is needed. Later, adhesive strapping or an
anklet may be used. Early massage is extremely useful.

Re8ults.^These are excellent in the usual form ; in complicated
forms the outcome resembles Pott's fracture.

TRAUMATIC SURGERY

Fio. 506. — Volunlary abduction.
In this posture the toot moves the astragalus, which is practically filed betn
malleoli. Adduction, the turning of the foot innard in its relation to th
always accompanied by elevation of its inner and depresaoD of its outer
This is known as supination or inversion of the toot. The reverse
attitude — ^pronation or eversion — is an accompaniment of abduction. C
"Treatise on Orthopedic Surgery.")

I'k;. 507. — Voluntary ilnr;
In this attitude the astragalus nio\'<.'s with the toot upon
contrasted with adduction and aliduction in which the center of
astragalus. (Whitman "Treatise on Orthopedic Surgery.")

SPECIAL FBACTHRES 483

Disability Period. — Total, four to eight weeks; partial, two to six
weeks.

ARTICULAR FRACTURES OF LOWER END OF TIBIA

These may involve the front or back of the bone, but are too rare
to need comment, esi>ecially as they are usually x-ray variants of
Pott's fracture.

LOWER EPIPHYSIS FRACTURE OF FIBULA

This is exceedingly rare alone and generally is an associate of
compound (open) fracture or dislocation in children fifteen years old
or less.

SUMMARY OF FRACTURES OF THE LEG

Upper end rarely involved.

Shaft, — Fracture generally affects the middle or lower third of
both bones. Even with considerable mal-alignment and shortening,

eventual good functional outcome may be reasonably promised
the vertical axis of the limb is reasonably straight. Compound
(open) fracture is probably more common here than in any other
part of the body, the skull and phalanges excepted.

Lower End, — Any disabling injury to the ankle associated with
:i3CLUch swelling or distortion should be regarded as a fracture until
I^roved otherwise. Pott's fracture is the common break of this
i"egion; next commonest is fracture of the external malleolus. Dis-
Xocation should be the last and Pott's fracture (typical or atypical)
"tie first thought in severe ankle injuries.

Reduction is the essence of treatment, and molded splints, early
xxiassage and motion are next in importance. A stifif ankle may
xxiean some gait defect, but not necessarily disability.

Fracture of the Foot

Tarsus fracture is usually of the astragalus, os calcis (calcaneum),
Or navicular (scaphoid) ; the other bones are rarely broken separately
(Figs. 508-510).

ASTRAGALUS FRACTURE

Causes. — Usually a heavy fall on the foot, as from a height; less
often a lateral crushing or twisting is responsible.

Varieties and Sites. — The ^leck or body of the bone are involved
separately or together; the neck is oftenest broken. The line of frac-
ture varies, and the fragments may be extensively comminuted.

TRAUMATIC SUKGERY

Fig. 508.— Bonea of the foot.

Fig. 509. — Fracture lines in bones of fool: a, Os calds (calcaneum); &, ostragalu)
(talus); c, plantat surface showing noriDBl bones.

SPECIAL FRACTURES 485

Symptoms.— Disability is extreme and immediate and the patient
annot walk unaided. Swelling and distortion of the ankle may be
Teat enough to mask all other signs; occasionally local pain, mobility,
nd crepitus give clews. The x-ray diagnosis is determinative in
learly all cases, these plates must be interpreted carefully inasmuch
s there is normally in many persons the confusing so-called "os tri-
:onum" on the posterolateral aspect of the bone, and it may exist as
. detached or knobbed prominence (Keen's "Surgery").

Fig. 510. — Bones of foot and their synovial pouches: 0, Tibia — os calcis; b, os cal-
ls— -astragalus; c, os calcis — cuboid; d, cuboid — metatarsals; e, astragalus — internal
unciform;/, interna! cuneiform — metatarsuls.

Treatment. — Reditclton in the non- or slightly displaced cases is
asily made by bending the ankle to a right angle; in compound
open) or badly displaced fractures excision may be needed. Splint-
ge is by plaster of Paris with the well-padded foot and ankle at a right
ngle in the axis of the leg. Operation for removal of irreducible
ragments is the best treatment for (o) many compound (open)
ases, especially if infection is likely; (6) when replacement cannot
le maintained, especially in neck fracture; (c) in comminuted cases,
ifter removal of the bone, the foot tends to slide forward. This
an be prevented by kangaroo suturing of the fascia and periosteum
iver the cuboid to the the tip of the external malleolus.

Removal of part or all of the bone produces no great functional
OSS. Suture and piruung is occasionally done.

Results. — Union is kindly in cases with little displacement and
he outcome is then likely to Tie good; in others a stiff ankle and fiat-
oot are frequent remnants.

OS CALCIS (CALCANEDM) FRACTORE

This form of injury is relatively common.

Causes.— Falls from a height on the foot or heel cause the largest
lumber; It may also be broken by severe contraction of the tendo
s and by twists of the foot.

486

TRAUMATIC SURGERY

VarietieB and Sites. — -Three forms of separation occur:

Ci) AJarge posterior heel piece; (a) anterior pc)rtioii, of ten spL^fc^za-
tered; (3) general crushing of t)ie central or anterior two-thirds (F :Sg.
511) (Stimson, quoting Cabot and Binney). An avtflston form isi^fc. -^g
to a pulling away of a portion of the bone by the tendo Achilles (Fi_ -r-^.
512- 513)-

Symptoms. — These simulate fracture about the ankle, and «-ray
differentiation is usually necessary. Swelling, indicated by increase
in the transverse diameter and filling out of tlie lateral hollows oj the
heel, is a main sign (Fig. 514); change in the level of the malleoli,
especially the internal, is also sometimes present. Crepitus, mobil-
ity, and local pain are variably found. EcchyTnosis at the margins
of the tendo Achilles is also rather typical.

Treatment.^ Reduction is easy if little displacement occurs;
otherwise operation may be necessary to accomplish it. In some
comminuted forms, the fragments may be driven together by blows
from a padded mallet. Splintage is by plaster of Paris with the

SPECIAL FRACTirRKS

487

S^^

488

TRAUMATIC SURGERY

padded foot and ankle at right angles; usually several days of tem-
porary splintage and the use of ice-bags or wet dressings precede
this encircling cast in an effort to reduce swelling. The cast is worn
six or eight weeks and is followed by adhesive straps, an anklet, or
special shoe devised to prevent flat-foot.

Operation is frequently needed in irreducible cases, and this
takes the form of (a) suture or pinning of the bone; (6) suture of the
tendo Achilles; (c) nail transfixion of the upper fragment to act as a
lever. Simple tenotomy of the Achilles tendo may answer in some
cases. After any of these a plaster-of-Paris dressing is applied.

Fig. 5x4. — Relation of tendo Achilles lateral recesses to the os caldi: o^ Mormil cod-

cavities; b, abnormal convexities following fracture.

Personally I am coming to the position of placing this fracture
in the operation-needed group because of failure of reduction and
consequent disability following other methods.

Results. — These are similar to those of astragalus fractuxe; flat-
foot and stiff ankle with impaired pronation and supinatkm of the
foot may persist to a greater or less degree in bad cases. Many of
the fairly well reduced cases show persistent widening of the hed,
and it appears flattened and dropped down when viewed from behind;
but, despite the deformation, the disability disappears in many cases.
The end result in the non-reduced cases is unfavorable and may be
quite disabling.

NAVICULAR OR SCAPHOID FRACTURES

These are very rare, and the diagnosis is made by x-ray examina-
tion.

Treatment and results are similar to the foregoing.

490 SPECIAL FRACTURES

direct violence is a rarer origin, as from a twisting of the foot in
dancing, running, or jumping; the fifth is most likely to be thus
broken.

Symptoms. — Disability from pain and swelling varies and the toe
lines may indicate shortening. Local pain (by direct pressure or that
transmitted from the toe), false motion, irregularity, and crepitus
generally are present.

X'Rsiy diagnosis is wise for confirmation; but the normal peculi-
arities must be kept in mind when interpreting the plates.

Treatment. — Reduction is generally unnecessary, as displacement
is slight. Splintage is by posterior molded plaster of Paris reaching
from toe-tips half-way up the calf. Some compound (op>en) cases
need plentiful drainage, as they are prone to develop necrosis.

Results. — Union is complete in three weeks. Some callus may
remain prominent and painful at first, but later it decreases and
becomes painless. Flat-foot may occur if two or more bones are
broken and if replacement is ineffective.

TOE FRACTURES

These are uncommon by comparison with the fingers.

Causes. — Usually direct violence is causative, as in crushing,
vehicle and machinery accidents, hence they often are compound
(open) ; less commonly they occur from "stubbing a toe.''

Symptoms. — Disability varies. Swelling, local pain, mobility,
irregularity, and crepitus are the usual signs.

Treatment. — Traction or manipulative reduction is made if neces-
sary. Splintage may be formed of a mold of plaster or a thin padded
board along the sole to bind the whole foot for a couple of weeks; or
two adjacent toes can be made to splint the broken toe by encircling
all three with adhesive. Traction or extension may sometimes
become necessary.

Results. — Generally the outcome is good; "hammer-toe" or
allied deformity may result if setting is imperfect

CHAPTER VIII

DISEASES OF THE BONES
Periostitis

By this is meant inflammation of the periosteum or fibrous cov-
eribig of the bone.

It is exceedingly rare as an isolated acute traumatic process
because present-day methods of diagnosis usually demonstrate more
or less inflammation of the bone as an accompaniment; hence cases
formerly regarded as involving periosteum alone are now usually
regarded as examples of osteoperiostitis.

However, in the form of chronic periostitis, a localized thickening
of periosteum often occurs, notably in connection with long-continued
or repeated irritation of bone not well covered by soft parts. This
manifestation is quite common along the shaft of the tibia in connec-
tion with contusions and hematoma ta of the shin; it is especially
frequent in leg ulcers and infected wounds thereof. Likewise it
occurs in certain infections, notably syphilis, tuberculosis, and less
often in typhoid fever.

In connection with long-continued suppuration there may develop
over several of the bones a peculiar general periosteal thickening
known as toxic osteoperiostitis ossificans , not unlike the rather general
periosteal thickening often seen in syphilis.

Traumatic periostitis, as the outcome of falls, blows, joint violence,
wounds, and other forms of irritation, occurs only when the bone is
relatively superficial or subcutaneous, and the most typical forms are
seen on the shin, as stated. Such a manifestation is known to the
laity as a "stone bruise," and the barefooted occasionally develop
thickening over the os calcis from continued pressure, and the same
may occur on the shin from direct blows or infected wounds. In
certain occupations, a form of pressure-periostitis sometimes occurs.

Periostitis in protected bones is, then, exceedingly rare in the ab-
sence of involvement of the cortical or other bone layers.

Symptoms. — Nodulation, swelling, or thickening, usually localized,
is the main feature, and this is associated with pain which becomes
more marked on motion or pressure. Local heat and redness oc-
casionally occur; and in infective cases there is fever and sometimes

491

49^ TRAUMATIC SURGERY

chills, together with adhesions of the soft parts to the underlying
bone or its covering. In most instances of traumatic origin the
periostitis is but a part of the associated injury to the soft parts
(as contusion, wound, hematoma) or bone (as fracture or osteitis).

The «-ray examination in cases of periostitis discloses a wavy line
of thickening that blends more or less abruptly into the adjacent
bone.

Treatment. — Rest, elevation, and the application of some mild
lotion usually suffices in the acute cases; in those of longer duration
incision and perhaps curetting may be needed, and in such instances a
thin shell of bone may also be involved and require removal. It is
unwise to interfere for swelling or thickening alone, for such an irregu-
larity is benign, and the vast majority subside unless made worse by
meddling that often leads to bone infection.

OSTEOMTELmS

This means an inflammation of the bone due to some infective
agent, most cases developing from pyogenic organisms (staphylococci
or streptococci) ; other cases may arise from infection by the germs of
tuberculosis, typhoid, gonorrhea, pneumonia, and other agencies.

The process usually begins in the bone-marrow and may spread
throughout this before penetrating the tougher cortical layer of the
bone. Often the process is metastatic in origin, as the infective or-
ganisms arc carried by the circulating blood often from a far distant
fiH us auil not infrequently at a period quite remote from the receipt
of the original lesion.

It not uncommonly occurs as a more or less ancient complication
of an illness so trivial that few if any symptoms were originally pres-
ent, 'l\^nsillitls and other forms of oral sepsis, la grippe, boils, furun-
\ K^. infivtod wounds, and other germ-caused affections are all poten-
tially capable of producing osteomyelitis.

.Munit oni^half the cases occur between thirteen and seventeen,
that is, at the age of bone development (Nichols, in Keen's "Sur-
gery "V Long bones, like the femur and tibia, are usually involved;
hut it may appear in any bone.

'l\ilHTCulosis of bone almost always begins at the joint end or
epiphysis; however onlinary osteomyelitis almost always begins in
the shaft or iliaphysis, and this topographic relationship is very often
A valuable factor in differential diagnosis. Usually one bone at a
time is involvi^l, but it may affect several bones coincidently.

DISEASES OF THE BONES 493

Ttauxnatic sources of direct origin are limited practically to in-
fected compound fractures and wounds that harbor infection. Less
often an infected amputation stump or an ulcer over a subcutaneous
bone may become a source of origin. Many of the cases due to injury
begin as a periostitis and by contiguity aifect the subjacent bone.

It is sometimes asserted that a direct injury to a bone so lowers
the local resistance that circulating germs migrate thither and set
up osteomyelitis. This does occur, but it must be rather rare because
of the very great number of direct injuries to bone and the relatively
small number of subsequent cases of osteomyelitis. For this reason
such a source of origin would only prove adequate in the absence of
any other more probable or usual causative factor. In such an in-
stance the microscopic examination of the exudate might prove of
value in determining the nature of the infective agency. In this
connection, however, it is to be remembered that an osteomyelitic
sinus generally shows a mixed infection, staphylococci predominat-
ing; but in practically all cases streptococci will be found also.

Oral sepsis (tonsils, teeth, and gums) must not be overlooked as a
potential etiologic factor; indeed, a pus focus in any part of the
body may be the initiating element entirely independent of any sup-
posed source of origin the exact relationship of which is recalled only
by questioning the patient.

Pathology. — As indicated, the process almost invariably starts in
the marrow and nearly always invades the diaphysis (metaphysis)
first, but may spread therefrom to or through the epiphysis and thus
involve the joint. In development the condition is not unlike a
furuncle, and, indeed, it has been called '^bone furunculosis" inas-
much as from a given focus in the marrow an area of necrosis occurs,
and this subsequently is infiltrated by leukocytes leading to a pus
collection or "bone abscess." Extension then proceeds through the
various marrow-cells until more or less of the central part of the bone
is involved. The cortex soon becomes invaded, and thus the exudate
reaches to the surface and appears under the periosteum in the form
of a "subperiosteal abscess." This may remain localized or strip the
periosteum over a large surface. The next step is invasion of the
soft parts and the development of an abscess in them, and this may
subsequently perforate the skin.

Occasionally a definite separation of diaphysis from epiphysis
may occur because of the burrowing or pressure of the exudate, and
this is known as one form of "spontaneous fracture."

Repair is brought about by the development of new bone from

494 TRAUMATIC SURGERY

the outer layer fperiosteum) and inner layer (endosteum) of tie cor-
tex. The new shell of bone formed by the periosteum is known as ihe
involucrum, and it surrounds the remnants of the necrotic shait
known as the sequestrum, and in time tends to wholly replace it.
The endosteal new bone walls off the sequestrum by an osseous plug,
and this may become dense if the process long continues.

Fig. s'7' — Diagram of cbanges occurring io a case of acute os teu myelitis if Ux
tibia. la the &i5t figure there is diSuse suppuration in tlie medulla of the diapb^Si-
In the second figure the products of inflammation arc seen, lilling the space bctwcB
the cortex and the periosteum. In the third figure new subperiosteal bone ha; ha
formed, and witbia this involucrum is seen a large sequestrum, surrounded h? pus,
which discharges through openings in the involucrum, known as ctoacie. In the louili
figure only a small cortical sequestrum remains, the Involucrum has become vei7 desK.
and the meduUaiy cavity is replaced by ebumated bone (de Quervain).

Sometimes, notably near the epiphysis, a definite sequestrum doe
not form, but instead an abscess occurs within a wall of eburnaled
bone, and such a purulent collection is then known as a "Brodk
abscess." A somewhat similar area of softening sometimes occius
with gunamata, but the surrounding bony wall is then soft and not
ivory- like.

DISEASES OF THE BONES 495

Symptoms. — ^The various manifestations are often said to con-
ist of four Stages: (a) Acute stage of necrosis, suppuration, and sep-
is; (6) subacute stage of purulent discharge; (c) chronic stage of
equestrum, involucrum, and sinuses; (d) stage of localized bone
bscess.

In all stages the symptoms are (a) local and (6) systemic.

Local Symptoms. — The onset in metastatic forms is sudden with
ery acute pain as the main element; fever and chills may be accom-
animents. Pain generally appears in the shaft or near the epiphy-
is, and it is accentuated by pressure or percussion. Swelling, heat,
nd redness occur very promptly over qr near the site of the pain,
nd in many cases the signs then resemble an abscess of the soft
arts. The adjacent joint may also become swollen, tender, hot or
ed, and, indeed, the appearance is such that an arthritis (rheumatic
r otherwise) is often simulated. If an abscess appears subcuta-
eously and ruptures, the sinus may be single or multiple, and the
largins of it are pouting and irregular, and an introduced probe
iscovers rough, uncovered bone.

(6) Systemic Symptoms. — Fever, pulse rise, and signs of sepsis are
[uite to be expected, and, indeed, these patients are often very ill.
n some instances the constitutional signs are so overwhelming that
he local evidences are lost sight of, and the picture then is not unlike
. fulminant typhoid, especially as deliriimi is quite common. Blood
xamination gives a high leukocyte count as a rule.

Subacute, chronic, subsiding, or recurrent cases present symptoms
imilar to the foregoing, but far less urgent or severe. In these, pain,
welling, and sinuses are usually present, and from the latter more or
ess foul purulent discharge exudes. Occasionally abscesses occur in
he shaft without any communicating sinus (Brodie^s abscess).
These abscesses may remain dormant for long periods and give no
iymptoms aside from slight enlargement of the bone and perhaps
tenderness on pressure or percussion. From various causes (ascribed
or ascribable) such abscesses may become temporarily active with
many evidences of acute osteomyelitis, and then subside for varying
btervals; in many such the pus collection may be exceedingly small
and even escape a;-ray localization, especially as no definite seques-
trum may ever form, but in other cases large collections of walled-in
pus are found.

Treatment. — Acute cases are regarded as abscesses and treated
accordingly, namely, by incision and drainage over the place of maxi-
mum swelling, fluctuation, and pain. The cortex is chiseled or tre-

4g6 TRAUMATIC SUKGERV

phined so that the exudate in the marrow may freely escape. The
interior of the bone is manipulated only enough to aUow a free vent,
and all cureting or scraping is contra-indicated.

In early or favorable cases no sequestrum may form and the
opening closes by granulation; but in the majority of instances sepa-
ration of the sequestrum is the next indication for treatment. The
rule formerly as to this was to wait until the sequestrum was movable
before extracting it, but this has numerous exceptions. According to
Nichols (Keen's Surgery), the treatment of such a condition is in
four stages:

(i) Removal of Sequestrum while tfie Periosteum is Plastic. — This is
mainly applicable in the leg or forearm where one bone only is in-
volved and where there has been extensive destruction of the diaphy-
sis. The time for the operation is when the periosteum shows well-
marked ossification in the deeper layers, usually about the eighth
week. At this time the layer of bone formation on the periosteum
should be about yie inch thick. The periosteum at operation is
stripped from the necrosed parts beneath, and then the sequestrum
is removed and the ribbon-like periosteum fastened together to later
develop a new shaft. The first evidence of new bone formation is
generally visible at the end of three weeks, and the shaft is strong
enough for use in from five to eight months.

(2) Removal of Sequestrum when no Accessory Splint Bone is Pres-
ent.— This operation can be undertaken when the total diameter of
the involucrum equals one-half the diameter of the normal shaft, and
this occurs approximately three months after the acute infeclioiL.
This procedure should be reserved for selected cases only.

(3} Chronic Stage with Dense Involucrum and Extensive Seques-
trum.— Here we find an old necrotic shaft perforated by many sinu-
ses and often freely movable within a shell of dense periosteal bone.
Removal of the sequestrum may be indicated, but as a matter of fact
the cavity left after such removal is very difficult to close. Attempts
may be made to induce closure by blood-clot organization or by the
method of Mosetig-Moorhof or Neuber.

(4) Chronic Localized Abscess of Bone. — These are chiseled or
trephined add the remaim'ng cavity is allowed to fill in by blood-clot,
Mosetig-Moorhof's wax, or Neuber's skin-fiap method.

Many of these bone cavities are also obliterated by the use of
bismuth paste, as advocated by Beck, and a certain proportion of
these cases are markedly benefited by serotherapy.

At the onset of pain and other local signs in or near a joint it is

DISEASES OF THE BONES 497

€sp)ecially necessary to apply extension, so that the articulation may
not become fixed by adhesions or joint exudate.

Traumatic Forms. — War experience proved that the Carrel-
Dakin technic was a method of choice when there was a sufficient
opening for the introduction of the tubes. Given an infected com-
pound fracture resulting in osteomyelitis, the treatment consists of
intensive chemical sterilization through a wide exposure. Dakin's
solution introduced by the Carrel tube technic or by gauze tapes
packed into the cavity, will accomplish this. Sterilization is realized
-when the bony cavity is lined by healthy granulations, and when the
examination of the secretion shows a progressive diminution in the
<juality and quantity of the organisms, notably the disappearance of
streptococci. At this stage the filling in of the cavity may be at-
tempted by operation designed to smooth the margins of the excava-
tion, implanting into it a flap of adjacent muscle, fixing the latter in
situ by sutures. In making the operative approach to such an area,
the incision should be curved so that it will not have any chance of
l>ecoming adherent to the involved zone. This procedure is virtually
carrying out the principle of secondary suture following chemical
sterilization and it is modeled on the procedure of treating an infec-
tion of the soft parts.

Less drastic means may be employed in more superficial cavities
or in those in which all sequestration has ceased. Exposure of the
part to open air and sunlight is an excellent method. Filling the
cavity with "bipp,'' a favorite antiseptic of the British Army
surgeons, is also of value. The formula for '^bipp" varies, but for
this purpose a good combination is bismuth subnitrate, 2 parts;
iodoform, i part; petrolatum, 12 parts. The name is derived from
the initials of the component ingredients. Bismuth and petrolatum
alone may also be tried in a strength of from 10 to 50 per cent.

A certain number of subacute and chronic cases of osteomyelitis
are subject to exacerbations or "flares" in which local signs of cellu-
litis occur very rapidly with high temperature, rapid pulse and
sometimes chills. Many of these cases will have a temperature
numing up to 105** and yet the pulse may not reach more than 1 10
and the patient will not appear at all ill. In others, the manifesta-
tions of an acute sepsis will be apparent in the local systemic signs.
All of these "flares" subside by lysis under rest in adequate splintage
and wet dressings of saline, boric, magnesium sulphate or
iodine solution. Under no circumstances should any operation be
performed during a "flare" unless a definite abscess is known to

498. TRAUMATIC SURGERY

exist. I have found such manifestations most commonly in the
osteomyelitis following infected fingers and toes. Rough handling
of an osteomyelitis focus may also induce a "flare" if the protective
barrier of bone-granulation tissue is broken down enough to permit
infected material to migrate to contiguous areas (lymphatic spread)
or more distantly (vascular spread, embolic or thrombotic).

General treatment requires the use of the same remedies applicable
to other forms of sepsis, and of these, forced feeding and abundance
of fresh air and sunlight are exceedingly important.

Myositis Ossificans

This is a rare condition in which osseous material is deposited in
muscles, often in a form that simulates a neoplasm. Pathologically,
' it is a chronic productive osteitis. It may be traumatic or arise from
unknown sources.

Occurrence. — Traumatic cases are due to direct violence, such as
severe blows or falls, and the lesion most commonly is found in the
front of the thigh, next oftenest in the adductors of the thigh, and
next in the flexors of the arms.

According to Coley,^ there are three more or less well-defined
forms, viz.:

(i) Myositis ossificans progressiva, which invades many muscles
until nearly all are involved; it commonly begins in the trapezius or
latissimus dorsi.

(2) Localized forms due to repeated or chronic irritation, resulting
in osseous formations like the dancer's heel, the rider's leg, and the
soldier's chest, due respectively to persistent dancing, riding, and
pressure of a weapon.

(3) Myositis ossificans traumatica, due to a single trauma, such as
a heavy blow, a kick of a horse, or an injury received in some such
sport as football.

Most of the cases are reported by Binnie,^ Robert Jones,^ Cahier,^
and Lapointe.^

Many of the cases were first diagnosticated as osteomata or sar-
comata, and in some instances amputation was advised. DaCosta

^ Annals of Surgery ^ March, 1913.

* Ihid.y September, 1903.

^ Arch. Roent. Rays, 1905, 1906.

* Rev. de Chir.j 1904.

^ Ibid.y November, 191 2.

DISEASES OF THE BONES 499

reports one case that subsequently developed into sarcoma and Coley
adds another of the same sort, so the question arises as to whether or
not these enlargements are not allied more or less intimately with the
sarcoma group.

Their origin is not definitely known, and of the four theories
advanced most weight is given to that in which the enlargement
is supposed to proceed from a piece of periosteimi detached by
the original injury and implanted in the muscle. Others believe
the origin to simulate that of a true neoplam. Jones (quoted
"by Coley) states that nine- tenths of the cases show marked tumor
ionnation within the first two months, the majority appearing
^thin a month.

I had a soldier patient in France who developed the condition
over the lower thigh from the kick of an army mule.

Symptoms. — Soon after the injury, a hard, painful, and rather regu-
lar swelling is found embedded in muscle, and it may or may not be
Armly attached to the bone beneath. The nearer it is to the joint,
the greater the loss of function, and the stronger the probability of
vascular involvement leading to edema. The size and contour are
variable. a:-Ray examination should be made in all cases.

Differentiation has to be made from contusion, hematoma, myo-
sitis, periostitis, osteoma, peri-arthritis, or syphilitic tumors, and
jc-ray examination is the best means short of exsection of a portion
of the mass for microscopic examination. The radiograph of
a sarcoma, according to Coley, fails to show the sharp outline at
the tumor-bone junction characteristic of myositis ossificans, al-
though early sarcoma formation may closely simulate. Sarcoma
is less painful and less uniformly hard than the tumor of myositis
ossificans, and the latter is more likely to cause early disturbance
of function.

Treatment. — Conservative treatment is advisable, as many
cases spontaneously retrogress if given absolute rest. Makin,^
quoted by Coley, was able to show 2 cases practically well after six
years, and in these ' resorption was almost complete without
interference.

Early removal is inadvisable and maybe harmful and lead to recur-
rence, for as stated by Godlee- and quoted by Coley, "... the
operation is inflicting another traumatism upon a part, which for
some reason has shown a special tendency to the development of

^ Trans. Royal Soc, of Med.j 191 1, p. 133.

' Trans. Royal Soc. of Med., Surg, Sect., 1911.

500 TRAUMATIC SURGERY

bone, and it cannot therefore be sxirprising if renewed activity of the
process should follow."

The propriety of excising a section for nucroscopic examination
is debatable and should be limited solely to cases resembling sarcoma.

Exsection may become necessary if function is impaired, and then
the mass should be removed as carefully and as late as possible.

The best practice seems to be to wait, meanwhile keeping the
patient under careful observation, only interfering if the enlargement
menaces or the clinical and oc-ray examination indicate a change in
the pathologic structure of the mass.

CHAPTER DC

DEFORMITIES OF THE HANDS AND FEET

Some of these are due to injury, but the majority are congenital
or the outcome of various systemic infections or other non-traumatic
agencies.

GANGLION; WEEPINO SINEW

This is a cystic swelling occurring along the tendon sheath, especi-
ally on the dorsum of the wrist. According to the latest views they
are regarded as colloidal degenerations of localized areas of connec-
tive tissue adjacent to a joint or tendon. Paget says they are due
to cystic degeneration of the synovial fringe inside a tendon-sheath,
and that the fluid of the ganglion and that of the sheath do not inter-
communicate. Others maintain that a simple ganglion is a hernia
of synovial membrane through a rent in a tendon-sheath, and that
the canal between soon becomes obliterated. See also p. 1 54.

Varieties and Causes. — Simple ganglion is unilocular and soli-
tary and may be due to long-continued strain, pressure, or other
factors capable of inducing inflammation of the tendon-sheath (the-
dtis). In some instances it may arise from any of the producing
causes of synovitis, of which rhexmiatism is a type.

Compound ganglion is multilocular and more than one swelling
exists. They are nearly always tubercular in origin, constituting
tubercular thecitis.

It is certainly unusal to have the condition occur from sudden or
acute trauma, and they are rarely if ever seen in association with such
injuries as sprains, dislocations, and fractures. Most of the cases
arise from unknown or forgotten causes, but the patient is usually
able to revert to some muscle-strain which may actually be more or
less directly connected with the enlargement.

Sjrmptoms. — A painless rounded swelling is usually visible on the
back or front of the wrist, and this may vary in size from a pea to a
small egg, and certain motions may cause it to partially or wholly
disappear, Fig. 90. Occasionally they may also be found as small
swellings on the fingers and at the metacarpophalangeal junction.
The lump is not adherent to the skin, but is found to be attached to
the parts beneath, and when extruded it can be moved laterally.

501

502 TRAUMATIC SURGERY

In the early stages the enlargement is apt to be harder than when the
cystic process has caused softening and a greater degree of fluctua-
tion. Variations in volume may occur, and some spontaneously
disappear. The contents are viscid or gelatinous and of yeUowish
color.

Treatment. — Subcutaneous rupture is the old-fashioned form of
treatment, and this is administered by making the limip prominent
and tense and then smashing it by some heavy object, such as the
edge of a book. Injection of iodin, carbolic, or iodoform is also ad-
vised. Incision and evacuation of the contents is another form of
treatment. Excisiofi of the sac and its contents under local or gen-
eral anesthesia is the best form of treatment.

Whatever method is chosen, one essential is to later firmly com-
press the part and enjoin complete rest for several days. Recur-
rence is not unlikely if exsection has been incomplete.

Small ganglia and others that are not cosmetically anno)ring are
let alone, and it is to be remembered that many spontaneously
subside.

TRIGGER-FINGER; OR SNAP-, LOCK-, OR J^RK-FINGER

This is an odd condition in one joint so that when the patient
tries to flex or extend the digit the act is normal up to a certain limit,
and then the joint locks and is made to act beyond this by a sudden
strong muscular effort which causes the finger to snap or jerk, and
often this is audible and is always visible, although it may be done
very quickly by an adept. It occurs most commonly in the middle,
ring, thumb, and index digits.

Causes. — It may be congenital or acquired. Rheumatism,
gout, arthritis deformans, and other inflammatory non-traumatic
causes are frequent sources of origin. Elongation of a tendon-sheath
from nodulation, loose cartilage, a sesamoid bone, or ganglion may
also be at fault. Isolated injury is a rarer cause than prolonged or
repeated trauma, and thus occupation may be the producing ele-
ment. Occasionally it may be learned as a trick.

Abbe {Medical Record, March 7, 19 14) says that the exact loca-
tion of the difficulty is under the extreme flexor crease of the palm
and is caused by a crumpling up of the tendon at this point, just as
a tape might crinkle and refuse to pass through a slot. He reports
a cure by an incision 1/2 inch long over the tendon at this flexor
crease.

DEFORMITIES OF THE HANDS AND FEET 503

l^eatment — Operative removal of some mechanical cause is
the necessity, and in many instances this is followed by tenorrhaphy.
Acute cases are treated by rest, lotions, splintage, and later by mass-
age and gradual motion.

MALLET-FINGER; DROP-FINGER

This is a bending downward or flexion of the last joint of a finger
due to rupture or loosening of the extensor tendon at the dorsum of
the joint affected.

Causes and Symptoms. — ^Any injury severe enough to forcibly
bend the last joint of the finger is a competent cause, as in effect the
condition is one of ruptured or stretched tendon. Open and closed
wounds, some fractures, and occasionally rather trivial violence are
the usual etiologic elements.

Treatment. — The torn tendon is sutured to the periosteum of the
distal phalanx and a padded splint is applied for three weeks, and then
motion is allowed increasingly.

BASEBALL Finger

One form is the reverse of the preceding, and is due to a forcible
bending backward of the distal joint, the tip or end of which is struck
by a baseball. A dislocation, fracture, or arthritis may be an accom-
paniment. This condition is treated by tenorrhaphy if no bony in-
jury is at fault. Another form of baseball finger resembles a gouty
arthritis with a thickened distal joint bent forward or laterally, or
both, and this variety is often the outcome of a dislocation, fracture,
or arthritis.

FLAT-FOOT; PES PLANUS; SPLAY-FOOT; PRONATED FOOT

This refers to a common deformity of the foot in which the antero-
posterior arches are weakened so that an abnormally large portion of
the sole touches the ground. It is frequently associated with con-
siderable abduction, eversion, or pronation of the foot, so that a line
drawn down the center of the leg and continued over the dorsum of
the foot strikes well inside the web junction of the great and adjacent
toe. The process is not, in reality, an anatomic disarrangement or
malposition of the bones of the foot, but rather a stretching, sagging,
or shortening of the soft parts binding the bones together, so that the
articular surfaces of the tarsal bones, especially the astragalus, face
the wrong way. The report of the Surgeon General 's office indicated
that the examination of the first million draft recruits showed flat

504

foot in the i

TRAUMATIC SURGERY

ot;

: thousand, nearly eight t

rickets,
icatjons I

? proportion
frequently as any other defect.

Varieties and Causes. — Congenital and acquired forms are
scribed, and it may be unilateral, but frequently is bilateral,
somewhat more common in adult women than men.

Of the acquired type, the commonest is the so-called static it
due to aji incapacity of the foot to properly balance or support the
superimposed body weight. This may be due to inadequate muscu-
lature from a wide variety of causes, such as general bodily weakness.
^ obesity, prolonged standing or walking,

occupational flat-toot, improper shoes
(especially the narrow-toed, high-heeled
sort), shortening or contraction of the
calf muscles or tendo Achilles.

The paralytic form comprises the
group due to poliomyelitis, rickets,
arthritis, spasticities, and other
matory conditions.

Traumatic factors are Pott'j
tures, fractures of the leg; dislocatioi
of the ankle, and some severe lacerations
of the ligaments of the ankle. Less
often, fractures of the tarsus may be
responsible.

The cases due to injury are quite uniformly associated with bony
deformity of the ankle or the parts above, and most of them are due
to imperfect or improper reduction and immobilization.

Symptoms. — These depend upon the degree of deformity and the
weight and general physique of the patient.

Early cases complain of weakness, pain, and fatigue on standing
and walking, and this may be most marked in the foot or radiate to
the ankle or leg. Many of these patients are treated for and regarded
as having "rheumatism" or "neuritis." The gait maybealtered
and the patient may shuffle along or develop a method of walking
that is found to relieve strain, and thus toeing-in is acquired in many
instances.

Advanced cases show exaggerations of the preceding, and the pain
becomes more marked and continuous and may radiate along the
sciatic distribution and into the back, and simulate sciatica or a
spinal neuritis. Such patients usually have more or less abduction
or cversion, and the soles indicate that the inner side of the foot bears
most of the weight, and the gait is correspondingly affected.

e de- I

1, Imprint <
impritit of B

ears I

DEFORMITTES OF TEE HANDS AND FEET

505

Some of these patients have radiating pains inasmuch as muscu-
lar equilibrium is badly maintained, and they may show static ataxia,
and because of this and the other signs are sometimes suspected of
havii^ "spinal" or other forms of "neurasthenia."

Either grade of severity may be rigid or flexible and some marked
cases give no symptoms whatever; others of minor grades may be
quite painful or actually disabling.

The exact extent of flattening can often be determined by making
an impress of the sole and comparing the relation of that outline to
the normal. For this purpose the sole may be moistened with ink,
oil or water, or dusted with talcum, and then the weight of the entire
body is home on the feet and the impress thus obtained (Fig, 518).

Treatment — Paralytic forms require special shoes, braces, opera-
tions, or other orthopedic agencies.

Static and traumatic forms are much benefited by systematic heel-
and-toe exercises, prof)er shoes, and the wearing of a flat-foot insole
or "arch supporter." Rigidity is converted into flexibility by opera-
tive or non-operative means when indicated. Very severe and other-
wise intractable cases require osteotomy, and in some cases the tendo
Achilles has to be cut.

HAUMER-TOB

This is a flexion deformity of the first interphalangeal joint (usu-
ally of the fourth toe), so that the tip touches the ground and the
distAl end of the first phalanx forms a dorsal prominence.

Fic. 519. — A, Hammer. toes ;£, a, 6, c,calloaty of soft parts; if, bursitis and prominence
of proximal phalaiuc.

It is usually congential and only resiilts from trauma if the toe
extensor tendon is involved at the site of the lesion, as by a wound or
other severing cause. Corns and bunions and actual ulcerations
may occur from pressure (Fig. 519).

508 TRAUMATIC SURGERY

The name arises because of Dupuytren's classical descrq)tum
growing out of his studies and operations at the Hdtel Dieu in Paris.
I have had the good fortune to receive a copy of Doane's English
translation of the "Clinical Lectures on Surgery" delivered by
Dupuytren, published -in 1832 by "An Association of Physidans^"
who were apparently his students, and from this volume it appears
that Dupuy tren's accurate knowledge and description of the condition
was orginially based on a postmortem dissection in a patient dying
from an independent cause. Up to that time it was his belief , like
that of his contemporaries, that the contractures depended upon
tendinous or articular involvement, as the fascia had not been hitherto
suspected. In this connection it is interesting to note that Dupuy-
tren's first case was that of a wine merchant on whom he operated
June 12, 181 1, and by making multiple minute subcutaneous incisions
he was able to obtain a good result. The condition was attributed
by the surgeon to the patient's occupation so frequently requiring him
to lift the edges of casks and barrels, thus producing more or less
constant palmar pressure. This surgeon's next case was operated
upon December 15, 181 1, and in this instance the patient was a
coachman with a well-marked bilateral aflfection attributed to his
occupation. Mention is made of the poor general physique of the
patient in explanation of the fact that only the right hand was
operated upon, and that a poor result was obtained by the author's
method of subcutaneous division. After operations of this type
Dupuytren insisted that a dorsal splint be worn several weeks, and
his cases were apparently much benefited in many instances.

In 1834 Gayraud, of Aix, as a result of dissections, in the main
agreed with Dupuytren as to responsibility of the palmar fasda, but
he thought that the lateral prolongations of the latter belonged to the
disease and were not anatomic.

In 1864 a patient of William Adams, of London, who had declined
operation for his bilateral contraction of the fourth and fifth fingers,
met with an accident by which "... the contracted fingers of the
right hand were suddenly torn open, and the skin in. the palm twn
across. . . ." There was a quadrilateral gaping woimd in the
palm exposing the transversely torn palmar fascia, but the tendons
were intact. This surgeon excised a few torn strands of the fascia
and was able to extend the previously contracted fingers, and he
sutured the wound in the skin and splinted the fingers. He ends the
narration of the case by stating "... the healing process proceeded
without interruption, and the fingers remained nearly straight

DEFORMITIES OF THE HANDS AND FEET 509

without their power of flexion being lost; . . . he has since
died, but no recontraction had taken place. ..." This surgeon in
1879 published a small book on "Contractions of the Fingers," and
in 1892 a second revised edition of the same work, the publications
being based on lectures delivered at the Royal College of Surgeons.
He gives credit to Stromeyer for calling attention to the subcu-
taneous method of treatment in 1831, but says that Delpechin 1816
first suggested subcutaneous methods, although for other purposes.

In 1875 Madelung reported the value of the open method of
operation as performed by Busch at Bonn. Sir William Ferguson
did a' linear dissection of each contracted band, making a transverse
incision at the constrictions. In 1876 Professor A. C. Post, of this
city, did an open flap operation. In 1879 Adams published his
method of multiple subcutaneous divisions with a special scalpel.
In 1884 Abbe, of this city, read a paper at the Academy of Medicine
in which he advanced a very ingenious reflex nervous theory of
origin based on the following working hypothesis, which I quote in
his own language:

"First, — A slight traumatism to the palm often entirely forgotten.

"Second, — ^A spinal impression produced by this peripalmar
irritation.

"Third, — A reflex influence to the part originally hurt, producing
insensible hyperemia, nutritive tissue disturbances and new growth,
shown in the contracting bands of fascia and occasional joint lesions
resembling subacute rheumatism.

"Fourth, — Through the tense contraction, a second series of reflex
symptoms, neuralgias, general systemic disturbances, and a reflection
of the trouble to the corresponding part of the opposite hand."

In 1886 he reaffirmed the same theory, and again in 1894 in his
"Carpenter Lectures" at the New York Academy of Medicine on the
general sub ject of "The Surgery of the Hand." Under date of June
13, 1909, Dr. Abbe writes me that this original theory" . . . seems as
plausible as any yet given,. . . The origin is still an unsolved
puzzle. There are some cases traceable to traumatism, but not
many. There are some which have marked neuroses, but most
compel some research to elicit the connection between the neuralgia
and the hand lesion. This remark applies to so many surgical con-
ditions that the absence of marked neuralgia in most is no proof of
its not being present. . . . It is more absurd to call it a rheumatic
condition than a neurosis. If it be not the latter, I do not know what
is the causative factor."

S'o

TRAL'MATIC SURGERY

This hypothesis does not seem to have been given much wei^t,
apparently because the pathology on wliich it is based seems so specu-
lative that it is difficult to conceive of a spinal "impression" registered
by an almost forgotten slight trauma to the palm. Keen (who has
written much on the subject), quoted in agreement by Adams, suj-s:
"Abbe's theory of a nervous origin seems to me onjy probable in so far
as gout or rheumatism are possibly nen.'ous in their remoter origin."

This, then, briefly is the history of this interesting ailment, and it
is worthy of notice that Dupuytren's original statement as to the seat
of the lesion is universally accepted, and that his method of subcu-
taneous incision has still applicability in a certain class of case,
although his observations are now more than three-quarters of a
century old.

Anatomically the palmar fascia is a fibrous apron investing the
palm of the hand subcutaneously, being separated from the skin by
more or less fat, and acting as a protection and serving to hoUow the
palm in flexion of the hand. It Is divided into a central and lateral
portion. This central main portion radiates fan-like from a narrow
origin at the annular ligament; later it begins to divide on a level with
the extended thumb, and there sends a fasciculus to each finger
except the thumb. When each of these shps reaches the linger, it
splits to pass into the lateral margins of the anterior ligament of the
metacarpophalangeal joint, and smaller divisions pass to the skin at
the furrow where the metacarpals and digits join, and also to the
periosteum of the first phalanx. The lateral part of the fascia b
accessory and thin, and radiates to the thenar and hypothenar ~
regions, but it does not reach beyond the level of the extended thumb.
This briefly described structural arrangement predisposes to contrac — ■
tures on the ulnar, and practically confers immunity on the radiaL
side of the band.

Pathologically the condition is a sclerosis of ordinary type, and \t.
has been aptly called "fasciitis" by Ledderhose, and the proliferation^
is said to take place in the arterial sheaths as well as in the individual
fibrous bands. All grades of thickness arc met with, and in old and
well- marked cases the proliferations may be }-^ inch or more in thick-
ness and almost cartilaginous in consistency. In no instance are the
tendons or their sheaths involved, nor are there changes in the articu-
lations, periosteum, or bones unless the condition is very far advanced.

The etiology has always been a moot point and e^'cn now no uni-
formly adequate cause is known to exist. From the time of Dupuv-
tren, trauma has been held to play a part, but no one has maintained

DEFORMITIES OF THE HANDS AND FEET 511

that a single or isolated injury was productive, nor is such a theory-
tenable. The trauma held to be causative was that incident to occu-
pations in which the palm of the hand was more or less constantly
irritated, and hence coachmen, porters, soldiers, laborers, and others
who did manual work were supposed to be especially liable. Dupuy-
tren and many of his time believed repeated traumata to be the sole
cause. Others hold to the view that gout and rheumatism are factors;
others believed the condition to be of neurotic origin, in effect a dys-
trophy not unlike that seen in disorders of the central nervous system.
All authors mention the fact that heredity plays a part, and that
many members of a family in later years develop the condition
irrespective of their occupation.

At the present time there are, then, several ascribed causes, but
that trauma plays practically no part is my contention and the basis
for bringing this matter to your attention. This belief hinges on the
following facts:

1. Rarity of the Condition, — There are many physicians in active
practice who have never seen a case since student days, despite the
fact that they number all classes of manual laborers as patients.

2. Location of the Lesimis, — The vast majority of cases affect the
ulnar border of the hand which is the part least susceptible from occu-
pations requiring grasp, push, or pull — manual effort. Further, the
left hand is affected almost as often as the right, although the latter is
more often used. Again, it usually begins first in one hand, and then
progresses to the other, and it is almost never symmetric when
bimanual, and bilaterality itself is against traumatic origin.

3. Absence After Destructive Injuries. — Wounds of the palm are
exceedingly frequent and often associated with infection of the
tendons and their sheaths without producing contraction of the
damaged intervening palmar fascia, which must, of necessity, take
part in the surrounding inflammatory reaction.

5. Period of Onset. — The majority of the cases appear after the
fiftieth year at a time when sclerotic processes elsewhere are in
evidence and when manual labor has practically ceased.

6. Absence in Plantar Fascia. — The sole of the foot is constantly
subjected to pressure, but fascial contraction is exceedingly rare,
although anatomically the plantar and palmar fascia are analogus.

7. Occurrence in Non-laboring Class. — Cases are frequently observ-
ed in mental workers, and of 220 cases reported by Keen, 49 were
in manual and 74 in non-manual laborers.

It seems to me that if any occupation should predispose to this

TRAUMATIC SURGEET

condition it would be motormen, who in their work for eight or tea
Iiours daily fit the palm of the right hand on the rounded knob of a
metal brake-handle and the left hand on the similarly shaped metal
or wood controller-handle in the operation of trolley cars. 1 have
spoken with physicians who have to do with the treatment of this
class of employees and I have yet to hear of a case in which this
contraction has been brought to their notice, even though some of
their patients have been operating horse-drawn, cable, or trolley cars
upward of twenty years. So far as the steam railway men are con-
cerned, Dr. W, B. Outten, Chief Surgeon of the Missouri Pacific
Railway Company, wrote me that he has personal records of over
100,000 cases of injuries to rEiilway employees, passengers, and others,
and he had yet to see a case arising from trauma. Inquiry among the
surgeons of the local transportation companies elicited the same fact;
and personally, speaking from an experience of many years in the;
examination of those injured in local railway accidents, employees
and others, I have never seen a case in which the contraction aroscs-
f rom injury or occupation, and I can recall only two or three instanci
in which it was even alleged to have grown out of injury, and in thi
the claim was disputed and became the subject of litigation, prool
being offered that the condition antedated the alleged accident-
Likewise, inquiry among many visiting surgeons of general hospital
having to do with the treatment of the injured has brought a negatjvi
response to the inquiry as to whether they have ever known a case t<
arise from injury, and nearly all of these surgeons recall with difficult;
ever having seen a case in hospital practice except as a defonuity
passing notice.

These foregoing facts fortify the opinion that injury is not a pr

ducing factor, and the actual causation may yet prove to be a lesin
of the central nervous system, perhaps toxic in origin. In this com
nection there is on record a ccise in which the bilateral contracture
disappeared in a well-marked case after a seizure of cerebral hem<^- -
rhage. A similar remarkable case was also verbally related to n»- ■■
but not in detail sufficient for recording purposes at tliis time.

While rheumatism and gout and occupation are frequently fourrm ^d
in association with the disease, they appear to exist only as predi^s—
posing and not as actual producing causes, and cannot be lookeca
upon as constant etiologic factors.

The symptoms are slow in onset and the usual primary stage be-
gins as a painless puckering or more or less nodulation of the skin of
the palm close to its junction with the tingers, usually near tha baseof

DEFORMITIES OF THE HANDS AND FEET 513

the ring and little finger. This may be the sole symptom, and it may
and frequently does persist in that degree for five or six years, although
there are some few recorded cases in which after the lapse of a shorter
period some contraction of the finger begins. When the finger be-
comes aflfected, the proximal phalanx and the one adjacent to it
become involved, and the second or contracture stage is reached.
This may aflfect one finger alone or may invade the adjacent digit;
the usual order is for the ring finger to show the initial and most
marked change, with or without involvement of the adjacent little
finger. In 263 cases cited by W. W. Keen and Nichols, the ring
finger was aflfected in 249; the little finger, in 194; the middle finger,
in 93; the forefinger, in 24; the thumb, in 12. The same author says
that in 223 cases the right hand alone was aflfected in 70; the left, in
35, and both, in 125 instances. Hoflfa reports 1.59 per cent, of this
contraction in 1444 cases of deformities; in 227 cases there were
180 men and 40 women. In 198 recorded cases heredity was a
factor in 25.2 per cent, of patients. It is exceedingly rare in
children; however, one case at six months and a few congenital cases
are narrated.

In another class of case contraction of the finger at the metacar-
pophalangeal junction is the initial sign, the nodulation and pucker-
ing rugae in the palm occurring as later manifestations. After the
process has gone on in one hand to a moderate or greater degree, the
opposite hand often becomes aflfected, usually to a lesser extent, but
generally with involvement of corresponding portions. A well-
marked case will show, then, contraction of one or more fingers
(generally the fourth and fifth), with visible raised, tense, hard
fascial bands reaching from the palm to the metacarpophalangeal
joint like violin strings, with often transverse rugae and nodules. In
a severe case the fuigers will be contracted sufiiciently for the distal
phalanx to touch the palm, the latter being irregular from numerous
nodulations and rigid fascial strands. The distal phalanx can usually
be extended, but tie proximal and central phalanges are firmly fixed
in flexion, but can be further flexed by relaxing the binding fascia,
this being a diflferentiating sign.

From the beginning of the initial nodulation or contraction to

well-marked deformity, many years will usually elapse; and in certain

cases two decades intervene before the contractures reach extreme

grade, although all cases tend to get worse even after an apparently

stationary period. There are a few cases seemingly acute in type,

but the history in these is generally unreliable as to the actual initial
33

TRAUMATIC SURGERY

m H A ^ m, m

■•/ K

Fig. S20.— -N'udul.iUuii jJid puLkcrinj;.

fillh rm^i;rs and nuJulaliuia.

Fio. s J 3. —Dissection of contracted fifth fingci

DEFORMITIES OF THE HANDS AND FEET 515

symptoms because nodulation may exist a long time without com-
ment, or be attributed to other causes (Figs. 520-522).

Treatment is unavailing by apparatus designed to forcibly correct
the deformity, and operation is the only method affording more or less
complete relief.

Two operative procedures are in vogue, namely, subcutaneous
incisions and open dissection by longitudinal excision or by flaps.
The method of multiple incision by a special tenotomy knife is that
practised mainly by Adams, of London, who, as already stated, has
had good success with this method, and he has many followers. He
makes on the average six small longitudinal incisions at the sites of
maximal contractures, and then transversely severs the binding fascia
as completely as possible by successive nicks from above down, mean-
while extending the digit as he incises. In extreme cases he has made
as many as twenty-three incisions, each designed to liberate a series of
contracting fibers. He immediately applies a splint which is con-
stantly worn until the wounds have firmly healed, and it is then
gradually dispensed with. He first advocated this method in 1879;
and, writing in 1892, he employed the same technic with modification
only in so far as he now advises immediate extension rather than seek-
ing same gradually by splints after operation. In June, 1919, I
operated on a case by this method with an excellent result.

The flap method of Kocher, and others, dissects a triangular or
quadrilateral section of tissue from the palmar fascia and then excises
the latter; or, following the method advocated by Keen, the initial
incision includes the palmar fascia in the skin-flap and then dissects
the fascia free from the skin by an incision that runs along the ulnar
border from the inner part of the hypothenar eminence to the web
between the ring and little fingers, thence transversely to the web
between the index- and middle fingers, and thence upward to about
the middle of the thenar eminence, this making a U-shaped flap, with
the base well above the middle of the palm. After all the prolonga-
tions are released the fascia is dissected from the underlying skin,
and the latter is sutured in place.

The flap method is the one of choice, especially in advanced cases,
the disadvantage being that when the deformity is corrected there
often remains a gap at the lower portion to be later filled by
granulations, also because the lateral accessories of the fascia to the
metacarpal and phalangeal regions are often hard to reach, and it is
frequently impossible to divide them sufficiently to permit perfect
extension, and not infrequently sloughing of the flap ensues. The

Sl6 TRAUMATIC SURGERY

operative relief is usually prompt, although it may be incomplete, and
there does not appear to be much chance of recurrence if the after
treatment succeeds in keeping the fingers in their restored position,
and if there is no secondary contraction of newly formed granulations.
Splints (dorsal or palmar, or both) are worn for about two weeks, and
then massage and passive motion are begun, soon to be succeeded by
active motion designed to favor extension. In selected cases local
anesthesia can be used by infiltration of the palm; and in some cases
exposure of the median and ulnar nerves has been made and the dis-
section proceeded with after these nerves have been infiltrated by
cocain or allied agents.

The differential diagnosis is easy, as the main clinically allied con-
ditions are those of so-called "hammer-finger" or "trigger-finger"
and contractions of congenital, cicatricial, and tendinous origin.
Each is readily excluded by the history and the distribution of the
contraction and the absence of nodulations or superficial longitudinal
palmar bands, and by the ability to overcome in some degree the
existing deformity by manipulation.

In the absence of nodulations and longitudinal visible or palpabl^^
bands radiating from the palm, a diagnosis of typical Dupuytren'
contraction should not be made, especially if the proximal and cenf
phalanges can be extended.

i:i

'•vi '

CHAPTER X

FOREIGN BODIES

Various sections of the body are sometimes invaded by objects
accidentally or purposely introduced, and while these are usually not
immediately serious, their removal often requires considerable dexter-
ity and ingenuity.

Foreign bodies may be metallic, like bullets, hooks, various kinds
of pins, sections of instruments, or tools or j&lings.

Mineral bodies may be stone, cement, dirt, emery or glass.

Vegetable matter , like beans, paper, or pulp, may gain entrance.

Animal matter, such as insects or their eggs, may find lodgment.

EYES

The superficial or deeper parts may be invaded, most commonly
by small fragments of dust, coal, or metal; the depth of penetration is
the index to treatment and outcome. Certain occupations, like min-
ing and railroading, are actively predisposing; seafaring men and
others exposed to wind are prone to pterygium and allied irritative
conditions.

Superficial penetration is promptly followed by pain and signs of
conjunctivitis, iritis, or keratitis, notably tear flow, some swelling of
eyeball and lids, and injection of the membrane. The discharge later
becomes purulent and the lids often are glued by secretion, and vision
is temporarily affected.

Treatment is removal of the offending object either by boric
acid irrigation or by direct contact of sterile gauze, or aseptic
pointed instrument (probe or spud). If somewhat embedded, cocain
or novocain solution (i to 5 per cent.) is needed. Later, the inflam-
mation usually subsides of itself or it may be aided by instillations of
atropin (i per cent.) sufficient to* keep the pupil dilated (twice or
thrice daily is generally enough). Argyrol (10 to 40 per cent.) is
useful for controlling purulent discharge. Ice-cold or hot boric
compresses will prove soothing.

In deeper penetrations and where particles are visible to ordinary
inspection or much embedded, an oculist should be consulted promptly.
This is notably true if there is much obvious injury to the iris or

517

5l8 TRAUMATIC SURGLRV

vitreous, as by bullets or shot. Signs of this sort of damage show as-
aggravated conjunctivitis, iritis, or keratitis. If not too deep, a spud.
or other sharp-pointed instrument may remove it under cocain or~
novocain; if removable, the further treatment is the same as ther-
foregoing until inflammation subsides. Dark glasses, bandaging, or-
an eye-shade may prove comfortable. If metallic particles are pres-
ent, a magnet may be the best means of removal, x-Ray localizatioa.
is very valuable, but it requires much skill and training. ActuaL
destruction of deeper parts may callfor enucleation of the eyeball to
prevent involvement of the opposite sound eye.

Purulent secretion is prevented from spreading to the opposite^
eye by sponging or irrigation directed toward the ear, or by wearing
a watch crystal over the opposite eye attached to the nose, cheek, and
forehead by adhesive as indicated in Fig. i6.

Burns from lye, lime, and other irritants are best treated by flood —
ing the eye with boric or bicarbonate of soda (3 per cent.) solutions ^^
and later an oculist is consulted if necessary.

Results depend upon the depth and degree of damage; if readilj^^'"

removable, sight will be unimpaired even though the damaged aresB ?

shows ulceration. In extensive injury variable visual defects ma>^^ "
persist. After enucleation, deformity is measurably prevented by ^u
glass eye. Frequently, ill-advised efforts to remove a foreign bod>'^
results in prolonged inflammation from gonorrheal or other intro —
duced infection.

Ears

Children are especially liable to insert beans, shoe-buttons, pieces
of pencil, and other more or less ova! bodies into the meatus. Their
presence may be unsuspected until odor, discharge, deafness, and
other signs of otitis become manifest. In many cases bloody dis-
charge occurs from involvement of the drum or irritation of the lining
of the canal.

Treatment.— Direct inspection is a prerequisite, aided by reflected
light and a speculum. Irrigation with boric acid may float or force
out the invader. Insects, when adherent, can be first killed by in-
serting a chloroform- or ether-soaked plug of cotton, followed by
irrigation or instrumental removal. Instruments, like forceps or a
bent probe (or same improvised from a hairpin) may be needed.
Incision is practically never required.

Later the otitis is controlled by suitable boric or other irriga-
tions; permanent damage is very unlikely. ,

FOREIGN BODIES 519

Nose

Shoe-buttons, beans, and wads of paper are often pushed into
the nostril by children, and nothing is said until parental questioning
seeks to account for odor, discharge, nasal plugging, and perhaps
swelling and pain. ' Objects may remain long unsuspected and treat-
ment for a long time vainly given for a "stubborn cold in the head"
imder such circumstances.

Treatment. — Inspection is afforded by reflected light and aided
by the preliminary use of cocain or novocain. Irrigation with boric
solution may effect removal by the front or rear of the involved naris.
InstrumetUs like forceps or bent probes passed beyond and around
the object may be needed. Sometimes pushing may cause dislodg-
ment into the throat. Later, suitable irrigations and perhaps wet
dressings may be required.

THROAT

Food particles, or meat or fish-bones may find lodgment while
eating, or be ingested during vomiting, especially during the uncon-
sciousness of anesthesia or alcoholism. Coins and toy whistles are
also occasionally swallowed. S)anptoms may be urgent, and choking
imminent and apparent. Other cases show local pain and irritation
while swallowing or talking, and are cough inducing.

Treatment. — Removal by hooking the finger around the morsel
is successful in the urgent cases, and this is sometimes aided by head-
down positions and violent coughing.

Emergency tracheotomy is preferably performed by an incision
above or below the isthmus, which in an adult lies between
the second and third ring of the trachea; in a child it lies on or even
above the first ring. The high (above isthmus) operation is prefer-
able because intermuscular and more nearly bloodless, and also
because of the superficial position of the trachea.

Steps in high tracheotomy: (i) Head thrown backward as far as
possible and held exactly in the median line. (2) Locate the cricoid
and thyroid cartilages. (3) Incision begins at upper border of the
cricoid cartilage and is carried downward in the exact median line i3^^
inches, passing deep enough to penetrate skin, superficial fascia,
and the anterior layer of the deep (cervical) fascia. (4) Separate
the sternohyoid and sternothyroid muscles and divide the fascia
over the trachea which comes now into view. (5) Steady the cricoid
with a hook or mouse-toothed forceps. (6) Push the isthmus down-
ward if it gets in the way. (7) Plunge the knife in (blade facing up-

5*6 TKAUMATIC SURGERY

ward) close above the isthmus in the exact midline and cut upward
through two or three rings.

Retraction enough of the wound usually occurs instantly to per-
mit breathing; if not, the wound may be retracted
and kept open by improvised hieans, such as a
twisted hairpin (Fig. 523) in the absence of the usual
tracheotomy tube. The lower part of the skin wound
is sutured and at a suitable time the opening is
allowed to close.

Some of these cases subsequently develop so-
called irritation or swallowing pneumonia, usually
Fig. 553. — Im- of the bronchial type; the onset of this is some-
^^"^ f^"^'" ^™^^ prevented by upright posture and vigorous
tracheotomy or counter irritation to the chest by hot applicati)
other wound. and cupping.

TRACHEA AND BRONCHI
The windpipe begins on a level with the thyroid cartilage ani
extends to the bronchial division, which is opposite the space between

ous

Fig. 534.— The bronchial

bodies.

sites of lodgment of fc

the fourth and fifth dorsal verebrie. The right bronchus is straighter
and less angulated than the left, and hence foreign bodies arc the
more often lodged therein (Fig. 524).

FOREIGN BODIES

521

Occasionally portions of food are inspired and, if small, are forci-
bly expelled by coughing; other articles, like coins, false teeth, safety-
pins (Fig. 525), or toy whistles, become jammed and cause varying
degrees of pain and respiratory difficulty with signs of tracheitis and
bronchitis. A number of cases are treated for whooping cough or
Jier spasmodic manifestations until the true source is apparent.

kThe exact location of such objects is best determined by j;-ray exami-
nation if too low for inspection through laryngoscopic or broncho-
scopic examination.

Treatment.- — Removal is effected by pronged forceps, hooked in-
struments, or others of the ' coin-catching" type, perhaps aided by
the bronchoscope in dexterous hands (Fig. 526). If thus irremov-
able, open operation is necessary, the incision being made as tor a
laryngotomy, thus: (i) Incision i l-^ inches long in the midline from .
the lower border of the cricoid to above the lower edge of the thy-
roid. (2) Divide structures beneath; separate sternothyroid and
sternohyoid muscles; cut the deep layers of fascia. (3} Divide the

522

TRAUBIATIC SUBGERY

cricothyroid membrane transversely just above the cricoid, and insert
tube or extractor.

Laryngotracheolomy opens the cricothyroid membrane vertically
and the cricoid cartilage and upper ring of the trachea. The dangers

Fig. 536. — Bronchoscope seeking a pin in the right bronchiu. The numenJs denote
the relative length and position of respective portions of the upper respiratory tract in
relation to the teeth and vertebrie.

of pneumonia and abscess are greatest when the object is low down,
firmly wedged, and when tissue damage is increased by removal

LOHGS

Objects that pass the bronchi and reach the lung (usually th&
right lobe) may become more or less encapsulated and cause oCP
symptoms; frequently, however, signs of bronchitis, pneumonia^
abscess, or gangrene appear, and are regarded and treated as of non-
traumatic origin, especially when the foreign body is forgotten or sup-
posed to have been expelled. I know of a case in which a clergyman
swallowed a tooth and subsequently developed a cough and otbei*

FOREIGN BODIES 523

signs of lung irritation that later subsided, and he supposed he was rid
of his unwelcome guest; still later, while delivering a sermon, a violent
fit of coughing resulted in the production of the missing tooth. Local-
ized abscess of the lung is so commonly due to inspired foreign bodies
that x-ray examination should be made early in this class of cases.
Patients have even been treated for
phthi^s until radiographs demon-
strated abscess due to a foreign body
focus (Fig. 527).

'^eatment. — Removal by thor-
acotomy is necessary and this may
be accomplished without negative
pressure apparatus. Foreign bodies
entering through the chest wall are
mainly bulUts and drainage-lubes.
Drainage-tubing is occasionally
brought within reach of an empyema
or other opening by irrigation, or is
fished for with forceps with previous
x-ray localization preferably. In one
case I recall that a member of the Harlem Hospital house staff re-
covered the tubing in an empyema case through the inspection
afforded by the cystoscope.

The outcome in this class of cases obviously depends upon the ex-
tent and duration of the process, but in all it is problematic if abscess
formation has occurred.

ESOPHAGUS

The gullet is about lo inches long and begins at the lower border
of the cricoid cartilage (between the sixth and seventh cervical ver-
tebrae), and ends below the diaphragm opposite the tenth or eleventh
dorsal vertebrae. Food is the commonest source of obstruction, and
this may be a large bolus, or a fish or meat bone. Occasionally chil-
dren and others swallow marbles or keys and other objects; pins,
glass, and coins form another group. Most foreign bodies are arrested
about 6 inches from the incisor teeth, about opposite the lower edge of
the cricoid and the sixth cervical vertebra, where the diameter of
the gullet is approximately y^ inch; this point is practically the
beginning of the tube. Another constricted region is 4 inches below
the preceding, where the left bronchus crosses. A third zone is at the
diaphragmatic opening, which is approximately 15 inches from the
incisors.

524 TRAUMATIC SURGERY

Symptoms. — These are chiefly irritative, such as localized pain
and a " feeling of fulness " and difficulty in swallowing, and sometimes
dyspnea; in completely obstructed cases even water is rejected. If
the invader is sharp, blood may appear on coughing or vomiting.
The exact location of blocking may be determined sometimes by pal-
pation or the patient's gestures; in other cases diagnosis depends
upon the bougie or x-rays.

Treatment. — Removal by forceps, the bronchoscope, or esophago-
scope may be ejBFective in some cases; in others the obstruction may be
pushed into the stomach. These means failing, esophagotomy and
removal by direct inspection is necessary, preceded by x-ray localiza-
tion. If lodgment is above the lower third of the tube, external
esophagotomy is performed through an incision on the left side between
the trachea and larynx in front and the carotid sheath behind, the
cricoid cartilage being the level of the middle of the incision. After
opening the gullet and extracting the invader, the mucous membrane
is sutured with catgut and the external parts are drained. If the
foreign body is lodged in or below the lower third, then gastrotomy
is performed. If there is impaction, the passage of a string from
above may cause it to become entangled and thus permit it to be
pulled into the stomach.

Outcome is favorable where removal is prompt. Complications,
like abscess, stricture, or perforation, are relatively rare.

STOMACH

The normal position is subject to considerable variation, but the
upper or cardiac opening is usually on the level of. the sixth left costal
cartilage; the lower orifice is at the level of the eighth or ninth right
costal cartilage.

Foreign bodies in some instances are long tolerated without symp-
toms; in the majority of cases some signs of gastritis exist and the
vomitus or stools may contain blood. All sorts of objects are swal-
lowed, notably coins, pins, hair, and keys. Hysterics and the insane
may swallow objects of such size as to cause wonder and surprise at
the dilatability of the esophagus; indeed, professional "sword swal-
lowers'' and others of that class may be veritable museums.

Symptoms of an acute sort subside after the object has traversed
the esophagus; later, signs of gastritis may appear and there is likely
to be pain and loss of weight. Determinative diagnosis generally
depends on a;-ray examination in old or suspected cases.

FOREIGN BODIES 525

Treatment. — Objects capable of passing through the esophagus
are usually later expelled by rectum; it is, however, luiwise to hasten
their progress by cathartics, fearing that excessive peristalsis might
result in intestinal perforation.

Gastrotomy is occasionally required, and the incision for this is
through the midline or middle of the right rectus muscle a few inches
below the free border of the ribs. The stomach is brought out of the
abdomen and transversely incised on the anterior border midway be-
tween the curvatures, and then the interior of the organ is explored.
Closure is made in the usual way.

Intestines

Very rarely obstruction occurs from a swallowed object that has
passed the tract above; less often ulceration or perforation results.
Objects are occasionally introduced per anum either for punishment
or pleasure.

Symptoms are those of colitis or varying degrees of obstruction,
with the pain quite likely to be localized. The exact site of the
offender is often apparent by x-xzy examination. Rectal palpation
or Information gained through the proctoscope determines the diagno-
sis in case the object has been introduced per anum.

Treatment. — If symptoms are non-urgent, a waiting policy is
advisable, as the normal peristalsis may be spontaneously effective
and harm may be done by active catharsis. Cathartics or high
irrigation are effective in the majority of low colon cases; others may
need enterotomy. Rectal foreign bodies are removable by forceps,
with or without prior dilatation and the aid of the proctoscope.

mtETHRA

The female or male urethra often harbors foreign bodies, and most
cases are the outcome of attempts at sexual satisfaction, and then the
introduced objects are likely to be more or less cylindric. Rubber
tubing, catheters, pencils, hat and other pins are commonly used.

Symptoms are pain, swelling, dysuria, hematuria, or anuria. The
blockading object is usually visible or palpable. In boys, a swollen
penis, strangury, and discharge may be the signs, where the object is
too small to be seen or felt.

Treatment. — Removal is often quite a problem. Some objects
are easily extracted by forceps and others are accessible enough for
urethroscopic removal. Care must be taken to prevent pushing the
substance into the bladder; this last, however, may be done de-

$26 TRAUBiATIC SURGERY

signedly in some instances. Occasionally a pin is removable by
causing its point to penetrate the outer urethral wall and extrude
through the skin; then it is manipulated so that the head of the pin is
pushed toward and through the meatus (Fig. 528).

Fio. 5*8. — Removal of pin (torn urethra: a. Sharp end extruded; 6, sharp end depressed;
c, blunt end pushed through meatus.

Females more than males present fore^ bodies in this viscus,
doubtless due to the shorter urethra. Pins of various kinds are often
introduced; likewise pencils, candles, and various other objects.
Accidentally, catheters, pieces of instruments, or thermometers may
gain entrance.

Symptoms are those of cystitb, and the object may even go on to
calculus formation or be unsuspected unless a history b forthcoming.
In some cases hematuria, dysuria, and even retention will be marked.
The passage of sounds, cystoscopic or x-ray examination may be the
diagnostic factors.

Treatment. — Removal may sometimes be possible by the aid of
forceps, with or without previous crushing or alteration in shape.
Cystoscopic aid is very valuable and «-ray examination is also often
useful. Suprapubic incision to accomplish removal may be necessary.

VAGINA AMD UTERtJS

Catheters, long pins, pencils, and other more or less cylindric ob-
jects arc often introduced to produce sexual excitement or abortion.
Children and others occasionally rupture the hymen in efforts to in-
troduce objects into the vagina.

FOREIGN BODIES 527

Symptoms. — In the absence of history, vaginitis and endometritis
lay long exist and be readily enough ascribed to other causes.
.ater, purulent discharge and odor may arouse suspicion, and finally
true history may be elicited.

Treatment. — Removal is usually easy from the vagina unless
Iceration exists, and then incision may be needed to free adhesions.
Vide cervical dilation and the use of broad forceps or the dull curet
sually are successful in removing foreign bodies from the uterus,
''aginal or uterine irrigations are generally necessary before the
suiting irritation is relieved. Laparotomy is only required rarely.

CHAPTERXI

INJURIES OF IHE HEAD

When direct violence is applied to the cranium a variety of symp-
toms may appear depending upon: (i) Nature and extent of the
violence. (2) Place of the receipt of the violence. (3) The individ-
ual: notably as to age, cranial conformation, sobriety, general
physique, previous illness, and family history. (4) Treatment

In a general way head injury may produce (a) extracranial; (b)
intracranial; (c) extra- and intracranial effects. In this respect cranial
injuries resemble those of the thoracic and abdominal cavities.

EXTRACRANIAL FORMS

These refer to contusions and wounds of the soft parts j but no
special mention need be made of all of them, inasmuch as the causes,
symptoms, treatment, and outcome resemble similar injuries else-
where.

CONTUSIONS OF THE SCALP

These are prone to be localized or circumscribed, producing the
very common condition known as "hematoma of the scalp.*' This
is the outcome of a blow or fall, whereby the bnmt of the violence is
sustained over a circumscribed area which promptly swells from the
subcutaneous effusion of blood (generally venous); such a condi-
tion IS frequently referred to as a "bump on the head." This swell-
ing may be quite large, and is most often seen on the front and lateral
margins of the scalp where the soft parts are relatively lax.

In hairless regions the bruised skin is at first reddened and later
becomes dusky blue, and in the end this color fades into a yellow mot-
tling as absorption progresses.

Such a collection of blood may appear: (i) under the skin; (2)
between the muscular fibers; or (3) between the latter and the skull
(Fig. 529). The first form is commonest. The condition typically
occurs at birth due to pressure along the parturient canal or from de-
livery forceps, the well-known caput succedaneum then existing; it
is also known as hematoma neonatorum, and is frequently massive
and defoiming, but almost invariably disappears within a few weeks.

528

INJURIES OF THE HEAD 529

Sometimes hematoma of the scalp is accompanied by concussion
of the brain, and a depressed fracture of the skull may be suspected
because most of these collections of blood are depressible in the center
and give the sensation of a skull indentation. The differentiation
between depressed fracture and hematoma is made by noting that
the edges of the latter are usually smooth and rather regular at the
circimiference, and that the change from the normal edge of the skin
is rather abrupt. In fractures the edges are rough, irregular, and
sloping. Careful pressure or massage over a hematoma will ordina-
rily push aside any indentation at its center, but there is no such

Fig, sag. — Sites of heraaloma of scalp: 1, Subcutaneous 2 subaponeurotic (or Bub-

fascial); 3, subpcriostvitl ( VEter Llsendrath )

shifting of a depression due to fracture. Very rarely the conditions
may coexist, but then other signs of fracture are ascertainable.
When a depressed fracture cannot be reasonably excluded, inci-
sion should be made affording actual inspection, aided by the intro-
duction of a sterilized glove finger. In the event of incision, a
small drain is advisable for a day or two.

Treatment. — Pressure causes absorption in practically all cases,
and for this reason a cold-water compress (alcohol or lead-and-opiiun
lotion may also be used) and a tight bandage are all that are needed.
Massage is also an aid. In some rare cases aspiration of the "con-
gealed" blood may be needed; less often incision is required. Before
doing either of these, the operative zone should be prepared aseptic-
ally, lest infection converts a simple affair into a troublesome abscess
or sinus.

SCALP wouiros

These are exceedingly common and may be of the same variety

and origin as any other wound elsewhere. Their depth and extent

vary according to the inflicting source and the place of receipt.

Superficial wounds may bleed quite freely in certain locations, not-

TRAUMATIC SURGERY

ably over the lateral and frontal portions. If Ihey extend to the
fascial or muscular layers, gaping usually occurs. If the wound is
"down to the bone" the periosteum is likely to retract, and some-
times is rough or ridged enough to feel like a crack or fissure ia the
bone, and often is thus mistaken for a fissured or linear fracture un-
less inspection or further palpation disclose the real conditions.

Treatment. — Cleansing is best accomplished by first disinfecting
the wound and the surrounding region by flushing with tincture of
iodin. The hair about this relatively sterile area is then cut or
shaved enough to leave a bald area about the opening, and grease and
dirt and foreign matter are removed by benzine, gasolene, kerosene,
or olive oil. The part is then dried and iodin is reapplied; thus a
relatively sterile field is provided. Suture
and drainage are to be used in ail cases in
which the edges are not too seriously
crushed or otherwise devitalized; in such
an event no suturing is advisable. Catgut,
horsehair, silk, linen, or silkworm-gut may
be the selected material (Fig. 530). Metal
clips in my experience induce ulceration,
Drainage need not be extensive in re-
latively clean cases, but all should he
drained, A few twisted strands of the
suture material are placed at the lowest
angle of the wound in "clean" cases, and
they can be removed within forty-eight
hours if infection does not appear. In other cases a twisted or
folded piece of gutta-percha (rubber) tissue or a rubber band may
be inserted in one or more places along the wound line. Gauze
makes a poor drainage material, as after a few hours it acts as a
cork or plug because of super-saturation. If the wound edges are
much bruised or frayed they should be "debrided" (trimmed oS)
prior to suturing. See page 35 under "Wounds."

Interrupted is better than continuous suturing, because if infec-
tion occurs in one part of the wound, all the stitches will not break
down or demand removal.

If possible, the periosteum should be sutured separately; but the
otiier layers are generally embraced and coapted in the grasp of one
deep suture that also provides hemostasis.

Erysipelas is less likely to develop in the scalp than in the face;
if it occurs, wet dressings of saturated solution of magnesium sulphate

Fig. 530. — Strands of h;
used a3 improvised sutures
coapt a scalp wound.

INJURIES OF THE HEAD 53 1

may be employed. A 20 to 50 per cent, ichthyol ointment is also
frequently used.

BONE INJURY

This has previously been discussed under Skull Fracture (see page
280).

INTRACRANIAL FORMS

These comprise those (i) with skull fracture; (2) without skull
fracture. Those with skull fracture have been mentioned imder
Skull Fracture (see page 280). Without skull fracture j head injury
may result in concussion; compression; contusion and laceration;
meningitis; encephalitis.

CONCUSSION (COMMOTIO CEREBRI)

This is a condition usually due to a direct or transmitted blow
upon the head, and it is characterized clinically by immediate but
temporary unconsciousness associated with vomiting and signs of

shock, such as pallor, cold extremities, depression of the heart, and
respiration.

Pathologically, there are few if any gross lesions; but occasionally
minute hemorrhages are foimd in the cortex and brain substance.
The condition is ascribed by some to these minute hemorrhages
within the pituitary gland.

Causes. — It is the commonest of all manifestations of head injury
inasmuch as to some degree it is associated with nearly every accident
to this part of the body.

Direct violence is the causative factor generally, such as blows or
falls on the head due to a wide variety of accidents. Indirect violence
is an infrequent source of origin; arising in this manner the impact
is generally transmitted to the head from a hard fall on the feet or
buttocks, or a blow on the jaw.

Varieties and Degrees. — Three are manifested clinically: (i) mild;
(2) moderate; (3) severe.

Symptoms. — Obviously these are dependent upon the preceding
grades of severity:

(i) Mild forms show some giddiness, staggering, nausea, and mild
shock. The patient may merely "see stars" and ordinarily does not
fall if the violence is due to a blow, as from a fist or walking against
the edge of a door.

(2) Moderate forms are aggravations of the foregoing, and the
patient is temporarily unconscious and is generally "knocked out"

532 TKAUMATIC SURGERY

and may take several moments to "come to." Nausea and vomiting
occur and sufficient shock may exist to require aid in rising or standing.

From just prior to the receipt of the violence until the senses are
regained, memory ordinarily will be a blank; in many cases the
victim will assert that he "does not know what hit him/* Unsteadi-
ness of gait, weakness, and some prostration may last several hoius,
and in some cases even a few days. Headache, with soreness and
stiffness of the neck muscles, may persist a week or more. Vertigo
and various ocular and auditory subjective sensations may also be
assei*ted during the same interval. Marked irritability or apathy
sometimes occurs.

(3) Severe forms show complete unconsciousness and marked
shock, and often the bowels and bladder are involuntarily emptied.
The duration of unconsciousness * varies and it may last for hours;
when the patient arouses, vomiting occurs, often in a projectile manner.
Return to consciousness is generally gradual, but may be abrupt.
Motor power is usually regained last and until then aid is needed ia
standing or walking. Patients may remain comatose and die in
this stage.

The vast majority of the recoverable cases show what might be
called a period of depression^ in which the unconsciousness is the main
symptom; and a second period of irritation or reaction, in which
irritability, excitation, or apathy predominate.

It is to be remembered that true concussion is a state of immediate
temporary unconscioustvess only, and that periods of relapse or
secondary unconsciousness ("partial coma" or "semicoma") take
the case out of the typical concussion class.

Treatment. — Mild degrees require little if any treatment. Aro-
matic spirits of ammonia, whisky, or brandy may be given if necessary.
The headache is relieved by a cold-water compress, and occasionally
* an ice-bag may be helpful. Anodynes or hypnotics may be advisable
for a few days. Usually a few hours of rest is all that is required.

Moderate degrees require rest in a prone position and occasionally
stimulation by whisky, strychnin, adrenalin, or camphor. An ice-
bag or cold-water compress is useful for headache. A brisk cathartic
is advisable and the diet is limited for a few days. When the pulse
and temperature are normal for several days, the patient is allowed
to get out of bed and the next day is permitted to walk, and soon is
allowed to return to work if objective symptoms are lacking and the
subjective symptoms are not unusual.

Severe degrees usually demand hypodermic stimulation, but this is

INJURIES OF THE HEAD 533

withheld unless the pulse mdicates need of support. Shock is com-
bated in the usual manner, but main reliance is placed upon absolute
rest in bed. No strenuous efforts should be made to arouse the
patient, as these are not only ineffectual but also are dangerous
because the unconsciousness of itself is no measure of the gravity of
the condition.'

In old people, frequent change of position is needed to forestall
hypostatic changes. When those of alcoholic type regain conscious-
ness, bromids and chloral should be given if there is restlessness or
tremor of the tongue or fingers indicative of impending delirium
tremens. Headache is best treated by an ice-bag.

Rest is all important, and these patients should be kept in bed
until symptoms have abated. Pain in the head and vertigo,
especially on exertion, are sometimes complained of for a long time.
For severe headache, relief will be obtained by spinal puncture.

Diagnosis. — Differentiation is to be made from syncope or faint-
ing, shock, and comatose states, such as might be due to alcohol,
drugs, nephritis, apoplexy, diabetes, and other non-traumatic
conditions.

The preceding history of the case is very important, as in some
instances there may be an initial coma from a non-traumatic source,
and yet a fall may be the only apparent cause for the condition in
which the patient was first found. This is especially likely in alcohol-
ics, nephritics, and apoplectics, who often fall, striking on the head, at
the onset of coma from the preceding condition, and the first inference
is that the injury and not the antedating constitutional trouble is at
fault. In some of these cases an operation or autopsy may be the
final deciding evidence. It is to be recalled that central hemorrhage
is never traumatic, but cortical hemorrhage is rarely due to anything
but injury.

Results. — These cases get well, but in severer grades recovery may
be attended by decreasing subjective complaints, notably headaches,
vertigo, unsteadiness in gait or station, and alterations in the auditory
and visual mechanism.

CONTUSION AND LACERATION OF THE BRAIN

By these may be implied that series of effects somewhat more ad-
vanced than in concussion and less marked than in generalized com-
pression. The extent of bruising may vary to such a degree that
many regard contusion only as a form of concussion, and lacera-
tion is described as an independent entity. There is some confusion

534

TRAITMATIC SURGERY

among writers as to this classification and differentiation, but
clinically the following seems adequate.

Contusion means a bruising of the brain with definite extravasa-
tion of blood in variable amounts; if large extravasations occur
there is genially some associated tearing of the brain tissue, and then
laceration is said to exist.

Causes. — Violence of the direct or indirect type is generally pro-
ductive and a fracture of the base of the skull often coexists. Local-
ized violence is also a factor, such as bony depressions, bullet and
stab wounds.

The commonest sites of contusion and laceration are the regions
lying near the middle fossa, and the tips of the temporal and base of
the frontal lobes. Violence applied at one pole of the skull, yet affect-
ing the opposite pole, sometimes produces contusion or laceration by
the so-called contrecoup; in some cases, from a known place of
impact, the probable site of damage may be reasonably surmised.

Symptoms. — There are several groupings: (i) The cortex is ordi-
narily involved in that group in which basal fracture is absent, and
hence cortical irritative signs are promptly present, such astwitchiogs
or localized spasms of a limb or portion of the face; later, paralysis of
the part may occur. Concussion and compression signs generally co-
exist and meningitis or encephalitis may appear subsequently, (a)
Localized involvement of the cortex with transitory or no signs of con-
cussion or compression. Motor aphasia is a common manifestation
in this group. {3) Advanced results of concussion and compression
with paralysis more or less marked.

Diagnosis.^ — In a general way it may be stated that symptoms of
contusion and laceration are more pronounced and lasting than con-
cussion, and, in addition, signs of cortical irritation usually give further
differentiating evidences. Lumb? r puncture frequently obtains blood.

Treatment.^ — This is practically that of the advanced grades of
concussion in the absence of focalizing signs warranting operation.

COMPRESSION

By this is meant pressure within the skull, circumscribed or gen-
eral, of such a grade as to produce variable local or systemic signs,
depending upon the nature, extent, and duration of the pressure.

Causes. — Direct vtoleitce, as from blows or falls on the head, is the
cause in practically every traumatic instance, and the majority of
cases are associated with fracture of the skull, often of the depressed
variety. Indirect violence is a relatively rare factor.

INJURIES OF THE HEAD 535

Varieties. — Intracranial pressure and tension may be due to many
causes aside from injury, but the following are clinically inclusive for
traumatic and ordinary sources:

Bone: Fractures of skull.

Blood: Intracranial hemorrhages, contusion, and laceration.

Serum: Intracranial edema.

Pus: Intracranial abscess.

Foreign bodies: Intracranial bullets or other missiles.

New growths: Intracranial cysts or other neoplasms.

Meningitis: Serous and purulent.

Encephalitis.

Determining Elements. — There are two basic factors dependent
upon the tjrpe of the pressure, namely: (i) Local increase in intracra-
nial tension; (2) general increase in intracranial tension.

(i) Local Intracranial Tension, — This occurs when pressure is
exerted upon an isolated or circumscribed area of the brain, as from
a spicule of bone, blood-clot, abscess, or foreign body.

Most traumatic cases are examples of this variety.

The effects are directly dependent upon the site of the pressure, its
amount, and duration.

The vast majority of traumatic pressure sources affect a zone
two inches in front or behind a line crossing the crown of the scalp
from one ear orifice to the other. This I call *^the two inch zone."
Obviously, the greatest effects are felt nearest the seat of the pres-
sure, and the nearer this is to the vital basic centers, the greater
the systemic effect imposed.

(2) General Intracranial Tension. — This occurs when pressure is
exerted upon the entire cerebrum, as from a large extravasation of
blood or serum, meningitis, hydrocephalus, or edema of traumatic
or systemic origin.

Apoplexy is the best example of this tjrpe, and relatively few cases
of this class are traumatic.

Obviously the duration of the pressure or tension is important, as
it is well known that slowly increasing pressure (as from abscess or
tumor) may give few if any symptoms at first, whereas an acute
or sudden onset of pressure (as from cerebral hemorrhage or a bullet)
usually gives pressure manifestations at once.

When pressure is exerted over any area of the brain one of the
earliest effects is adjacent venous stasis and diminution oi cerebrospinal
fluid. If pressure still continues and reaches the point where it equals
that in the capillaries and arteries, a condition of cerebral anemia then

536 TRAUMATIC SURGERY

results, with loss of fiinction in the area robbed of its blood-supply.
In some cases where pressure over the medullary centers equals the
arterial tension the resulting anemia stimulates the vasomotor center
and the general arterial pressure is raised, and thus the medullary
centers continue to act (Gushing). This same condition may be re-
peated if the pressure still continues, and accordingly general arterial
tension may be increased markedly; in other words, there is the
familiar "rise of blood-pressure." This progressive rise in the cir-
culating arterial blood is due to constriction of the splanchnic field,
and, when it is fluctuating, respiration of the Cheyne-Stokes type
appears and may continue for hours (Gushing). If, however,
cerebral pressure continues to increase, arterial pressure finally fails
to respond, medullary anemia results and the respiratory center fails,
and finally the heart ceases to beat.

The foregoing statement aims to show that the essential influence
is not mechanical or structural, but is due to the anemia of the medul-
lary centers resulting in the major or bulbar symptoms of compression,,
which may be said to be:

(a) High blood-pressure from stimulation of the vasomotor center _

(b) Slowed pulse from stimulation of the vagus center.

Sjrmptoms. — Having in mind the preceding determining elements f.
it follows that the signs will depend upon the site, extent, and duration-
of the pressure.

It is stated that before signs of general pressure exist there must
be a displacement of over 6 per cent, of the brain mass (Archibald, in
Amer. Practice of Surgery),

It is to be remembered that the preceding history is of great-
importance, especially that portion of it relating to the progress or
''march", of the symptoms.

In conscious and rational patients careful inquiry may elicit the-
history of immediate unconsciousness after the injury, with subse-
quently a period of apparent recovery, during which the patient felt:^
well aside from variable subjective complaints. This practically^
means a history of concussion; however, following this "latent^
period" or "free interval," symptoms recurred, and this sequence-
brings the case into the compression class. In unconscious or"
irrational patients a history of value is often unobtainable fronx
friends or witnesses, and the diagnosis then depends largely on the
examination alone.

INJURIES OF THE HEAD 537

Ordinarily /(tmr stages ^x^ described, following out the classification
i most writers.

First Stage, or Stage of Compensation. — This mildest form produces
ew if any signs unless the pressure is in the vicinity of the medulla.
)rdinarily the signs are not unlike those of the postconcussion type;
tamely, headache, giddiness, mental inaptitude, and very occasion-
Jly some few temporary focal signs affecting a limb or special
ense.

Second Stage, or Stage of Manifest Beginning Compression, — The
oregoing signs are exaggerated and congestion of the upper part of
he face may be marked enough to produce cyanosis. The superficial
'^eins may be turgid. The eyes are congested and the ophthalmo-
cope may show some beginning edema of the optic nerve (papillary
dema). The pulse is generally slowed and the blood-pressure maybe
leva ted. Signs of meningeal irritation with restlessness or irritation
)revail.

Third Stage, or Stage of Acme of Manifest Compression, — Here
here are more wide-spread evidences of capillary anemia and med-
lUary signs are now apparent, and, as Gushing puts it, the fight is
veil under way on the part of the medullary centers to withstand the
irushing effect of the compressing force.

Paralysis of varying degrees occurs, the location of greatest pres-
lure determining the site of the paresis. Cyanosis is marked. Res-
Hration is ordinarily increased at first, and later is stertorous and
nay become Cheyne-Stokes ' in type. Pulse is slowed (40 to 50)
ind the volume is increased and may be **full and bounding;'' the
ate may not be slowed even in this stage, or in the presence of fever
)r shock. Blood pressure increasingly rises. Unconsciousness (proba-
)ly due to cortical anemia) will be partial or complete, and it may be as-
ociated with the delirum and marked irritability formerly held to be
o diagnostic of cerebral laceration. Reflexes are abolished. Optic
'dema is marked and the condition of "choked disk'' approaches.

Fourth Stage, or Stage of Paralysis. — Paralysis is complete and
laccid. Respiration is increasingly embarrassed. Pulse becomes
apid and weak. Coma is deepened. Pupils widely dilated. Blood-
Pressure falls. The patient is' dying, but even after respiration
:eases, the heart may beat for some time.

In the later stages spinal tapping shows fluid under pressure, per-
laps mixed with blood.

Differential Diagnosis. — Injuries. — Concussion and contusion are
he two conditions most likely to be confusing.

538 TKAUMATIC SURGERY

Concussion presents unconsciousness as the essential, immediate,
temporary sign ; if there is recurrence or progress of symptoms, it is
not concussion any longer.

Contusion is likely to give signs of inmiediate focal localizatira
with or without evidences of concussion.

Compression is essentially a later manifestation with progressive
signs delimiting more or less sharply into the respective stages.

Diseases, — Apoplexy, alcoholism, nephritis, gas-poisoning, and
other coma- and paralysis-producing causes are usually capable of
being excluded by the means previously named.

Treatment. — The main indication is to relieve the compresskm
by (a) removal of the originating cause; (b) reducing the intracranial
tension.

(a) Removal of the cause obviously only applies to those cases m
which the tension is dependent upon some circximscribed or accessible
source, like depressed bone, clot, serous collection, or foreign body;
in other words, relief in this class is possible when the origin is reh-
tively superficial, generally when there is "local increase of tension."
The methods to be used will be described in connection with the
treatment of Focal Pressure (see page 553).

( J) Reducing the Intracranial Tension, — ^This applies to that large
group of cases of extensive fracture of the skull involving vault and
base alike, associated with extensive bleeding and consequent pres-
sure. It also includes that group in which there is a large dural clot,
or any case like central apoplexy in which there is "general intracra-
nial tension. "

Relief in either of these contingencies depends upon reduction of
the blood-pressure, and in traumatic cases there are practically few
methods of accomplishing this satisfactorily. In fracture cases, <Hie
of the best means is by decompression , and this is done preferably by
the subtemporal decompression method so strongly advocated by
Gushing. In performing this operation, incision is made after the
manner stated in Fracture of the Skull (see pp. 302, 303). The tem-
poral muscle is then separated in the direction of its fibers so that the
underlying skull is exposed. A trephine opening is now made and a
25-cent-sized button of bone is removed, exposing the dura, which
usually bulges promptly into the opening. It is generally lusterlcss
and non-pulsating. If so, a rongeur forceps is used to increase this
original trephine opening, generally in a downward direction, untQit is
as big as a dollar or more. The dura is then incised in a semidrcular
direction in such a manner that the dural incision does not come within

INJURIES OF THE HEAD 539

J^ inch of the rim of the trephine opening, in order that no adhesions of
it to the bone may later occur. Cerebrospinal fluid under tension
may escape and the brain may bulge into the opening.

Careful note is to be made of changes in the pulse and respiration
during the operation, and generally improvement will be noted on
removal of the button of bone.

In most cases anesthesia is not needed. In some few cases it
may be possible to suture the dura, but in most this is not feasible on
accoimt of the great tension. In such a contingency a pad of fat,
muscle, or fascia may be interposed. The retracted muscle is then
allowed to fall into place and a few strands of twisted catgut or silk-
worm-gut or a thin rubber tissue (gutta-percha) drain leads down to
the dura, and is brought out between the muscle at the lower angle
of the wound. If necessary, the muscle may be coapted by a few
sutures. The skin is very carefully closed by interrupted stitches of
silk, silkworm-gut, or horse-hair. A dry gauze dressing and bandages
complete the dressing. The drain is ordinarily removed within forty-
eight hours. If decompression on one side is ineffective or insuffi-
cient, the same procedure may be repeated on the opposite side at
the same sitting or later. The patient is subsequently kept off the
back as far as possible to prevent hypostatic complications.

This operation is not for universal use and at present it is not prac-
tised as much as formerly, because we now know that many of these
patients practically decompress themselves by hemorrhage from the
nose, ear, throat, and sometimes through a compound fracture of the
vault or multiple cracks therein.

Lumbar Puncture. — This is another means of reducing intracranial
tension, but is dangerous in unselected cases, because sudden relief
of pressure in the skull often allows the brain to drop down upon the
rim of the foramen magnum, actually corking or plugging the latter
so promptly and effectually that death is instantaneous from me-
chanical pressure upon the vital medullary centers. I have seen such
a case in which death was sudden, and at autopsy the ridge in the
brain made by the edge of the foramen magnum was readily visible.

Lumbar puncture (or spinal puncture or spinal tap) is performed by
locating the top of the fourth lumbar vertebra which is on the level of
the highest part of the crest of the ilium. The hollow needle is intro-
duced in the interspace between the second and third, or the third
and fourth lumbar vertebrae about i inch lateral to the spinous pro-
cess. The skin is first painted with tincture of iodin and the patient
lies on the side or is supported in a sitting position. The styleted

538

TRAUMATIC SUR(.l

Conciissicyn presents unconsciousness
temporary sign; if there is recurrence oi
not concussion any longer.

Contusion is likely to give signs oi'
with or without evidences of concussi-
Compression is essentially a later r
signs delimiting more or less shaq^K'

Diseases. — Apoplexy, alcoholisn;
other coma- and paralysis-producin-
being excluded by the means previ«

Treatment.— The main indicati
by ((/) removal of the originating * .
tension.

(a) Removal of the cause ob^ i'
which the tension is dependent iij
source, like depressed bone, clol.
in other words, relief in this cla.
tively superticial, generally whi
The methods to be used will
treatment of Focal Pressure iV

(b) Reducing the Intracran
group of cases of extensive fi
base alike, associated with
sure. It also includes thai
or any case like central ap'
nial tension.''

Relief in either of thi'
the blood-pressure, and i
methods of accomplishii
of the best means is bv r
the subtemporal decom
Cushing. In perform i ..,^i

manner stated in Frac*
poral muscle is then s*
underlying skull is ex
25-cent-sized button
usually bulges prom'
and non-pulsating,
original trephine oj)*
as big as a dollar o-
direction in such a

' •

t *

rye as the lead

f the spine and

[)Lnding upon the

Vlt. Thisusuallv

iilored and spinal

: be allowed to flow

pt on the pulse and

icase of fluid. If anv

:uii of the needle, it is

iruduccd. If blood es-

iias been penetrated en

\»rospinal fluid rather uni-

i>i basal hemorrhage, con-

iucing intracranial tension,

- early third stage of compres-

\due. It is far less useful m

- >>uld not be employed unless

>Iood is best extracted from a

.'.mount is withdrawn sufficient

. :he pulse. I have never known

.r.jtic case.

n05 Ain> TOPOGRAPH7

r.cal research and careful clinicaL
. i the brain have been mapped out^
^ areas is now known with such a-
c-ige of them is very important in
. injury.

..-il standpoint it will be recalled that

.-,^i into an outer or superficial portion

.u ±e cortical portion or cortex; and of an

.jtia made up of white matter known as the

jiC main portion of the brain occupying"
^ j^'jil, and the cerebellum is that under .^
^ -mgc posterior fossa of the base of the skull—
that joins the cerebellum to the medulla --

^ oibers between the pons and the spina

; OF THE HEAD

541

■.Ui two hemispheres by the sagittal su-

■ rtex thus formed has numerous fissures

~ (or gyrO as indicated in Fig. 531. Of

•f greatest surgical importance are the

'Siire of Sylvius, and the parieio-occipikU

the Rolandic area, b located on the skull by

■:om. the root of the nose (nasion) to the ocdp-

.>n). On this line locate a point a Uttle back

-\557 accurately) and this will denote the upper

1. — Cianiometry with points for trephining (indicated o) t
lesions (indicated).

of the fissure. From this point drop an angle of 67 degrees
nward and forward for 3 1/2 inches, and this will outline the
■e extent of the fissure. This angulation is readily obtained
iractice by folding a square of cardboard or thin metal in
, thus forming a right-angled triangle. If now the right angle is
:ted, an angle of 45 degrees is formed, and if this is bisected an
B <tf 67.5 per cent, is produced, and the pattern thereof can be
as a guide by placing the summit of the triangle at a point mid-
between the nasion and occipital protuberance (Chiene method)
■ 531)-

luore of Sylvius is located by (i) determining "Raid's base
" which runs from the lower margin of the orbit to the upper
.er of the external auditory meatus.

542

TRAUMATIC SURGERY

(2) Draw another line parallel to the above, from the external
angular process of the frontal (upper border of orbit) backward i 1/4
inches. This is point **one.''

(3) Locate the most prominent part of the parietal eminence and
draw downward from it a line perpendicular to the base line, and on
this take a point 3/4 inch below the eminence. This is point " two."

A line (averaging 4 inches) joining points **one" and "two" will
delimit the Sylvian fissure, and the anterior limb of it Will be 2 inches
behind the external angular process.

Parieto-occipital fissure is found by continuing the above line
outlining the fissure of Sylvius to the median line, and where they
meet this fissure will be found. It is also defined as opposite or a
little above the Lambda; or 6 1/2 cm. above the inion (Thave); or
seven-eighths of the distance from the mid-sagittal point to the inion
(Anderson and Makins).

The convolutions or gyri with their respective fimctions are in-
dicated in Figs. 532, 533, 534. There is so much confusion in the
nomenclature of these convolutions that synonymous terms are here
given in brackets:

First frontal
Superior frontal
Gyrus frontalis superior

Third frontal
Inferior frontal
Gyrus frontalis inferior

Fusiform lobe

Lateral occipitotemporal lobe

Anterior central
Precentral
Ascending frontal
Gyrus centralis anterior

First occipital
Superior occipital
Third occipital

Second frontal
Middle frontal
Gyrus frontalis medlus.

f Quadrate lobule
\ Precuneus.

/ Lingual lobe

{ Median occipitotemporal lobe.

Posterior central

Postcentral
I Ascending parietal
[ Gyrus centralis posterior.

J Second occipital
\ Middle occipital.
Inferior occipital.

Likewise there is a good deal of confusion of terms denoting €
fissures or sulci, and the following bracketed names are us-
synonymously:

Fissure of Rolando
Central fissure
Fissura centralis

Second temporal fissure
Middle temporal fissure
Yirsi temporal fissure

Interparietal fissure
Parietal fissure.

Postcentral fissure
Sulcus retrocentralis.
Parallel fissure.

INJDKIES OP THE HEAD

Fio. 533, — Cortical centeis of the bnun fot the higher faculties.

. J34. — Motor-sensory cortical portion of the brain and its locationa] centers.

544 TRAUMATIC SURGERY

Functionating Cortical Areas. ^ — From a surgical standpoint the
region about the Rolandic area is most important, as it is now believed
that the fissure of Rolando (central fissure) divides the cortex of the
brain into an anterior or motor and a posterior or sensory field. Some-
times this section is called the sensorimotor cortical area.

In this regional division of function there is resemblance to the
spinal cord (Figs. 532-534).

Motor Area, or the Motor Cortex. — This lies along a narrow
strip about i cm. wide situated in the anterior central convolution
(ascending frontal), reaching to the depth of the fissure of Rolando.
The upper limit overlaps on the midline of the hemisphere (the para-
central lobule), and the lower limit does not extend as far as the
fissure of Sylvius. Gushing states that tKe Rolandic fissure is not
straight, but is broken by two and sometimes three angles (genua) of
surgical importance. Above the upper angle (superior genu) is a
small triangular area which, when stimulated, produces movements
of the hip, knee, and toe. Opposite to this lie centers for move-
ments of the chest and abdomen. Between it and the middle angle
(genu) are the centers for the upper extremity, the shoulder being
higher than the hand and fingers. Opposite this middle angle
(genu) are centers for the neck and below it those for the face and
eyelids above and lips below. Still lower and generally below an
inferior angle (genu) are centers for the jaws, tongue, vocal cord,
pharynx, and contiguous parts.

In other words, the upper third of this region has to do with motor
control of the lower extremity and chest and abdomen; the middle
third, with the upper extremity; the lower third, with the face and
head.

From this area the pathway of distribution is via the pjrramidal
tract, and this latter degenerates if the cortical area is sufficiently
affected.

Adjacent to this motor area are certain other centers which on
stimulation produce various complex acts, thus:

Pars Opercula. — This lies below the anterior central convolution
(first frontal), and it controls sucking, chewing, sneezing, and vocal-
izing movements (it is near the vocal speech center of Broca).

Second Frontal Convolution (Gyrus Frontalis Medius). — Stimula-
tion of this causes movements of the head and eyes to the oppK>site
side.

1 Cushing's article in Keen's Surgery is largely used.

INJURIES OF THE HEAD

545

Sensory Area. — This section for common sensation occupies a
place in the posterior central convolution (ascending parietal) corre-
sponding to that of the motor area in the anterior central convolution
(ascending frontal). It lies largely in the cortex buried in the fissure,
and occupies superficially only about one-half of the above-named
convolution. Tactile and muscular sense and the capacity of dis-
criminating points in contact lie close to this posterior central con-
volution (ascending parietal) (Fig. 535). Pain and temperature
sense are probably in the intermediate postcentral zone of Campbell.
The recognition of objects, notably the stereognostic sense, is located
as far back as the parietal lobe (Walton and Paul).

Fig. 535. — Cortical centers of the brain (left half).

The fibers to this sensory area pass from the optic thalamus in
the "cortical lemniscus^' (Mankow) of the corona radiata to the post-
Rolandic territory, and in their course they lie in the posterior part
of the internal capsule.

Visual Area. — The primary receiving station for sight impressions
is the occipital lobe, particularly on its mesial surface in the calcarine
area. The investing field (visuopsychic) extends on the outer surface
(of the left side) in the second occipital convolution as far as the
angular gyrus, where also lies the visual word center (reading) which
participates in speech mechanism. The lingual lobule below the
calcarine fissure appears to be associated with color perception
(Gushing).

Auditory Area. — Sensations of sound are primarily received in
some portion of the superior temporal convolution, and they are ** con-
verted into conscious perceptions" in adjoining parts of the temporal
lobe, those on the left side in particular being concerned with the

auditory end of speech mechanism. "Extensive lesions on the right
35

546 TRAIJMATIC SUKGEBY

side may give rise to no appreciable impairment of hearing on the
same side, and there is much confusion over the unilaterability or
otherwise of the registration of auditory impulses" (Cushing).

The elaboration of the primary sound-producing stimuli into tone
perception, word perception, etc., occurs In the district enveloping the
primary receiving station; this is known as the auditopsychic area.

Olfactory Area, — The center for the sense of smell is chiefly in
the pyriform lobe; there is some difference of opinion as to the part
played by the adjoining areas of the uncinate gyrus, comu
ammonis, etc.

Gustatory Area.^The center for the sense of taste is not definitely
determined, but Is probably at the lip of the limbic lobe, near the
uncus. The smell and taste centers are thus placed just to the outer
side of the pituitary fossa and hence are relatively approachable
surgically.

Speech Area.^ — In right-handed persons there are four speech col-
ters on the left hemisphere:

(i) Recognition of spoken words is in the outskirts of the superior-
temporal convolution (j, e., close to the primary auditory center)-

(2) The center for vocal or motor speech is in the posterior end of th^
inferior frontal convolution (third frontal); this is "Broca's convolu-
tion."

(3) The visual word center, concerned in reading, is in the angular-
gyrus.

(4) The writing center (it such exists) is at the posterior end of thi^
gyrus frontalis medius (second frontal).

It is not improbable that the fifth center exists in the parietal lobe^
associating the sense of touch with speech mecharusm. It is to be^
remembered that no part of this cortical speech mechanism can bc-
damaged without to some extent affecting the rest; the most serious-
disturbances arise from involvement of (i) and (2), these being koown^
as the "primary couple" of Wylie.

Frontal lobes have apparently to do with the higher mental facul-
ties (like reasoning, attention, and self-control), and lesions hcre^
especially on the left side, are commonly attended by dulness, apathy^
loss of concentration, and imperfect self-control.

Silent Areas or Association Fields.— This refers to those un—
charted regions of the cerebral cortex (mainly on the right side) con-
cerned in the complex processes of association, and lesions of theses
are "silent" or symptomless, so far as our present knowledge is
concerned.

INJURIES OF THE HEAD

547

Basal Ganglia, Crura Cerebri, Corpora Quadrigemina, and
Pons.^Injury to these is surgically inaccessible, and tumors, hy-
drocephalus, and apoplexy are the ordinary lesions (Fig. 536).

Caudate and Lenticular Nuclei and Internal Capsule.^Involve-
ment may cause hemiplegia on the opposite side; if the posterior part
of the capsule is involved there will be sensory changes, otherwise
none exist.

Fic. 536.— Sagittal

of the brain showing segmental sections.

Optic thalamus involvement may cause motor disturbances on the
opposite side (contralateral), like choreiform movements, athetosis,
or disturbances of sensation, and also hemianopsia In some cases (Fig.
537)-

Crura cerebri involvement may cause paralysis of the opposite
limbs and of the motor ocuU (third nerve) of the same side.

Corpora quadrigemina involvement may lead to ophthalmoplegia,
to blindness, and deafness when the geniculate bodies are implicated,
and to a reeling gait and vertigo and a tendency to fall backward.

Pons involvement shows variable signs; the most characteristic
is a combination of cerebral nerve paralysis on the same side (homo-
lateral) as the lesion, with paralysis of the lunbs on the opposite side;
thU is also known as "crossed hemiplegia." If the involvement is
above the decussation, the paralyses will be homolateral.

Cerebellum involvement produces inco-ordinaticn of gait and
station, with a coarse ataxia accompanying volitional movement.
If the middle lobe is involved, these s>-mptoms arc bilateral; if one

55°

TKALfMATIC SUKGERY

part is generally thickest, the main source of pressure, and the means
by which the dura is stripped from the bone.

The site, rate, and extent of the bleeding, and the cohesion of the
dura, determine the size of the clot.

Dural attachment is normally most marked in the young and the
old, and hence this variety of hemorrhage is least likely at age
extremes.

The average weight of clots is from 4 to 6 ounces; if larger than
this, intracranial pressure usually is suflicient to cause death.

Symptoms. — The essential element is the extent of compression.
as this is the determining factor in diagnosis as well as treatment. In
aU, the history of the case is exceedingly important, particularly that
portion relating to the sequence of symptoms in an effort to ascertain
if, after the primary concussion, there was a period of consciousness
and apparent well being— the so-called "free interval." The pre-
liminary examination is equaUy important, and when possible the en-
tire scalp should be shaved, so that an otherwise hidden abrasion,
hematoma, or area of ccchymosis may be brought into view. Care-
ful, systematic bilateral palpation with the flat hand is very valuable
as a means of determining irregularity or altered consistency in scalp
and skull. Percussion should be made just as carefully as if the chest
was being examined and in the same comparative manner.

Clinically speaking, there are four groups of cases, each dependent
upon the nature of the injury, the site, the extent and rate of the
clotting, and to a lesser degree upon the individual (age, habits,
general physique).

Group 1. Concussion, Free Interval, CompreBsion. — This is the
classical type of extradural hemorrhage, generally indicating middle
meningeal involvement.

After an injury to the head the patient is rendered unconscious for
a variable time (usually short), and then arouses or is aroused suffi-
ciently to talk and recognize persons and surroundings. Walking
may even be possible, and in some few cases return to work has oc-
curred. During this "free interval" there is usually complaint of
pain in the head, dizziness, nausea, roaring in the ears, and weakness;
some few patients assert freedom from all subjective symptoms.
This sort of patient, if seen by a physician, is usually regarded as
suffering from concussion (with perhaps a scalp wound or hematoma)
or an uncomplicated fracture of the skull. If the patient is drunk
when hurt, treatment may be given for a scalp wound or some minor
injury, and then sometimes the victim is returned to a police ceil or

INJURIES OF THE HEAD 549

INTRACRANIAL HEMORRHAGE

As akeady stated (see pages 293, 294), there are several traumatic
sources of origin for this within the cranium, either with or witl^out
fracture of the skull.

Depending upon the location of the bleeding we refer to four sites:

(i) Extradural or Epidural Hemorrhage; Hematoma of Dura

Mater; Meningeal Apoplexy. — Hemorrhage between dura and bone.

(2) Subdural or Intermeningeal. — Hemorrhage between dura and
arachnoid.

(3) Subarachnoid. — Hemorrhage between pia and cortex.

(4) Intracerebral or Cerebral Hemorrhage, or Central Hemorrhage,
or Cerebral Apoplexy. — Hemorrhage in the substance of brain.

In order oi frequency, bleeding may originate from: (a) Meningeal
vessels; (6) pia-arachnoid vessels; (c) venous sinuses; {d) intracerebral
vessels.

EXTRADURAL OR EPIDURAL HEMORRHAGE; HEMATOMA OF DURA
MATER; MENINGEAL HEMORRHAGE OR MENINGEAL APOPLEXY

This is the commonest place of origin and is generally due to
laceration of the middle meningeal artery, although the veins and
venous sinuses occasionally are implicated. The blood ordinarily
collects in the temporal region between the skull and untom dura; but
if the latter is damaged, the bleeding may be extradural and subdural
as well.

Anatomy. — The middle meningeal artery enters the cranium
through the foramen spinosum and then runs in a groove on the tem-
poral bone, and between the latter and the dura. It divides into an
anterior branch passing forward, and a />(?5/er«?r branch passing back-
ward (see Fig. 249). From its more vulnerable location, the anterior
branch is much more commonly involved.

Extradural hemorrhage may far less frequently occur in the
frontal and occipital regions.

Causes. — Fractured Skull. — Simple or compound, usually as
cracks or fissures of the temporal vault, spreading more or less into
the base. Penetrating wounds are another source.

Without Fractured SktUl. — A rather rare source, generally arising
from contrecoup and located on the side opposite to the receipt of
violence, then being associated with cerebral contusion.

Site, Shape, and Size of Clot. — Usually it is circumscribed and disk-
like, and in one of the three sites indicated on page 293. The central

552

TRAUMATIC SURGERY

curs with contusion or laceration, and in gunshot and foreign body
injuries.

A few o£ these patients are seen early enough to follow the transi-
tion from concussion to compression, and this is usually indicated by
a spreading of irritative signs (twitching or convulsion) into paralysis
and increasing compression.

Group 3, Compression Immediate. — These are generaUy frac-
tures of the base of the skull associated with considerable comminii-
tiou or depression of the vault, often compound. They occur also
from gunshot or other penetrating wounds ordinarily involving the
trunk of the middle meningeal, the pia-arachnoid, or sinus vessels
separately or together, and thus they resemble subdural hemorrhage
and contusion. The cardinal signs of generalized compression gen-
erally appear at once and most of the patients promptly die.

Group 4. No Concussion, Apparently Well, Compression. — This
is a very rare group, in which there may be few objective evidences
of injury, and yet in a few hours signs of compression appear. Some
in this group may exhibit evidences of a comminuted or depressed
fracture of the skull without other signs, and within a few hours a
spicule of bone or a release from clotting may induce sudden mas^ve
bleeding and accompanying intracranial tension.

Treatment. — The main indication b to stop the bleeding, and thus
prevent or relieve compression.

In case of doubt it is often safer to operate; but a reasonable time;
may elapse in stationary cases and when symptoms are subsiding.

To reach the meningeal vessels use the topographic zone already
indicated {see pages 540, 541) ; a safe and reasonably accurate rule is-
that of Vogt, who locates the main vessel by marking a point two-
finger-breadths above the zygoma and a thumb-breadth behind th«== — ^
vertical process of the malar.

A bone-flap, convexity upward, may be turned down here (afte"^c^"
the manner indicated on page ,100), or the site may be reachec^rr^^
through the subtemporal decompression incision of Gushing (sc-^^^^
page 303).

If a depressed fracture is present, the area adjacent to it "i''_ ■* "^
be first trephined for elevation purposes, the button of bone be'uL-^^^B-i
removed as near to the region of the meningeal vessel as possibl^i^=^^^

The original traumatic or operative opening is enlarged as far £^ ^

necessary to secure the bleeding vessel. Organized clot b geaeraiM-ZZ^'
scooped or irrigated away, and the dura is unopened imless it lam-^K-S
to pulsate or gives evidence of harboring a subdural eEFu^on. ^B^

INJURIES OF THE HEAD 553

opiened, the indsion is made in such a way as to be well within the
rim of removed bone; a semicircular or M- or W-shaped incision is
usually made, and it is loosely sutured, tension permitting, after the
clot is removed.

Sharp spiculae of bone are to be removed, but flattened segments
of depressed skull can be left unless caved in enough to actually touch
the dura. A wick of rubber tissue or a few strands of twisted catgut
or silkworm-gut are introduced to the dura level, and brought out at
the lower angle of the woimd or through a special stab made in the
flap. It is imwise to introduce drainage into the brain substance.

Bleeding points inaccessible to hemostasis by ligature or pressure
may sometimes be controlled by wicks of gauze, and these are brought
to the surface after the same manner as drainage; small pieces of mus-
cle or fascia may also act as hemostatic patches. Drains or wicks are
usually removed in twenty-four to forty-eight hours.

If the clot is not reached on the side expected, the surgeon is often
justified in trephining on the opposite side.

Prognosis. — Gushing states that 80 per cent, of these cases end
fatally if imoperated upon, 60 per cent, dying within the first day;
67 per cent, of the operated cases recovered.

The outcome is dependent very largely upon the degree of com-
pression, as this is a greater determining factor than the apparent
extent of the injury.

Compound fractures and certain fractures of the base with free
bleeding apparently decompress themselves to some extent, and the
same is true in some cases where there has been a loss of skull and
brain substance. In simple fractures I have known of a number of
cases in which the multiplicity of the cracks or fissures anatomically
prevented compression.

SUBDURAL HEMORRHAGE

This form is commoner than the preceding, according to Gushing,
but most observers rank it second in frequency. It occurs typically
in spreading fractures of the base of the skull with diffuse venous
hemorrhage. In other cases there may be foci of bleeding capable
of producing localizing signs.

Sjrmptoms. — The typical form presents a picture of coma with
signs of compression more or less marked; in other words, the signs of
"Gtoup 3" of extradural hemorrhage are very closely paralleled.
It is quite impossible to be certain as to the diagnosis in many in-
stances, but in a general way the symptoms of progression are less

554

TRAI'MATIC StiRGEHY

rapid because the bleeding is nearly always venous rather than arte-
rial. The temperature is likely to be higher, and irritative sjinptoms
(like twitching or convulsions) and signs of pressure are prone tu be
unilateral. Generally speaking, a diagnosis of subdural hemorrhage
can be entertained in any case of profound concussion plus compres-
sion. The diagnosis is rendered less conjectural if lumbar puncture
discloses bloody fluid. Contusion of the brain with or without
laceration may also coexist, and some added confusion may arise if
acute traumatic cerebral edema is sufficiently present to produce signs
of pressure. This last somewhat resembles the edema of delirium
tremens and it must not be confounded with it.

Treatment. — The expectant plan may be followed unless compres-
sion is advancing, and then some method of decompression must be
adopted. As stated, most of these cases are associated with basal
fractures (usually middle fossa), and for that reason the subtemporal
decompression method of Gushing (see page 303) Is probably the most
uniformly satisfactory, as it affords a good approach and reasonable
subsequent protection in the event of a hernia of the brain. After
the dura has been exposed and opened (in many cases it is already
torn and brain substance oozes out) the temporal lobes can be ele-
vated and bloody fluid or clots better removed. Drainage is usually
needed; none should be employed unless a reasonable amount of fluid
continues to flow out. If the brain should bulge, the split temporal
muscle and scalp should be sutured as closely as possible notwith-
standing. Lumbar puncture will prove diagnostic and in some cases
may make decompression unnecessary.

Prognosis. — This largely is that of fractured base, and about 50
per cent, of the latter recover; with early decompression the propor-
tion is perhaps slightly better.

SUBARACKNOID HEMORHHAGE

This variety occurs with contusion and laceration of the brain ar» *
relatively few cases are relievable because medullary compression ^^
so great that death occurs promptly. If the bleeding occurs over ti^^
hemispheres and is reasonably localized, then signs of subdural hef^*
orrhage usually exist.

Treatment. — Decompression and pricking of the membrane h^ "
tween the convolutions may benefit some localized cases with S-^
considerable contusion or laceration. At operation the involved p
tion is of a characterktic cherry-red color. In some of the unop-

IKJTJRIES OF THE HEAD 555

ated cases these arachnoid areas later organize and form thick-walled
cysts, giving ^gns of tumor.

Sometimes ruptured aneurysms of superficial cerebral vessels pro-
duce hemorrhage of this type.

Prognoeis. — This depends upon the associated injury. In the
localized forms over the hemispheres the outlook is good; otherwise it
is generally very unfavorable.

IHTRACEREBRAL HEHOSSHAGE (CESEBRAL APOPLEXY)

This never occurs as the result of e^itemal injury unless produced
by a bullet, weapon, or some form of penetration of the skull, and
such a rare occurrence would probably be immediately fatal because
of the damage inflicted on the intervening vessels and structures
before those deeper in were reached.

Fig, 538. — Areas usually involved in intracerebral hemorrhage (cerebral apople^) :
ArlJ..S., Lenticulo striate, or "artery of apoplexy"; Arl.L.O., lenlicular optic artery;
Art.O.E., eitemal optic artery.

This type of hemorrhage is ordinarily due to rupture of one of the
vessels in the circle of Willis; the anterior branch of the middle cerebral
("Charcot's artery of apoplexy") is involved in 60 per cent, of such
cases. Miliary aneurysms of these vessels, arteriosclerosis, heart
and kidney disease, syphiUs, tumors, and other non-traumatic causes
are at fault in the average case (Fig. 538).

5S6

TR-iUMATXC SUKGERY

LATE TBAUMATIC APOPLEXY

This IS the terra given by Bollinger and others to certain c
cerebral apoplexy occurring some days after head injury — the so-
called " spatapoplexie. " Eisendrath, citing Stadebnann. statw
that the longest recorded intervening clear period between the head
injury and the apoplexy is four weeks.

A connection between head injury and ordinary apoplexy is rarcij
sought to be established except in medicolegal cases, as in others thu
usual and ordinary causes are satisfactorily evident, and any more or
less remote incident is usually regarded as coincidental, I have known
3 cases in which such claims were brought to court. One "strokeof
apoplexy" occurred two days after the accident; another, seven
weeks; another, one year.

From a surgical standpoint it is impossible for the needle-caliberci)
"artery of apoplexy" to be broken by a blow on the head thai fails
also to break other vessels nearer the site of the violence; if this com-
bination occurred, death would doubtless ensue. The most exten-
sive forms of skull and brain injury at times may rupture many of
the other vessels, yet those at the base escape, doubtless due to their
splendid protection. The usual and ordinary cause of cerebral apo-
plexy is a diseased cardiovascular mechanism, and when the arterial
pipe is ready to burst, it bursts independent of any injury or other
extraneous element, although many so-called "exciting causes" maj
be regarded as productive and may, indeed, be coincidental. .^1
sorts of physical and mental strain are thus denominated a*
"exciting causes," such as sneezing, running, coughing, turning
quickly in bed, worry, grie£, and many others; but these are merely
coincidental, and not in the least producing, actualing, determining, oi
ascribable causes.

These every-day facts make it exceedingly dilJicuIt to place wy
reliance on the theoretic and unpathologic connection between I
remote head injury and a subsequent cerebral apoplexy. Even B
Germany, where this idea originated, there has been much disagiW"
ment; and in this country, as stated, it is heard of practically only •"
medicolegal exigencies.

In some instances a fall incident to a "stroke" causes head injuiy.
and some preliminary confusion may arise because of symptoms tblt
are regarded as traimiatic, but in reality are apoplectic; in othff
words, the preN-ious history and the examination will determine that
the apoplexy preceded and did not succeed the fall.

INJURIES OF THE HEAD 557

COMPUCATIONS AND SEQUELJE OF HEAD INJURY

These may be divided for description into (a) infiammaiary and
(b) nan-inflammatory.

(a) Inflammatory, — Infection of the meninges: Epidural abscess;
purulent pachymeningitis; subdural abscess; purulent leptomenin-
gitis. Infections of the brain: Encephalitis; cerebral abscess. Infec-
tion of the sinuses: Encephalitis; cerebal abscess.

(6) Non-inflammatory. — Structural: Cranial defects (holes, de-
pressions); hernia cerebri. Neural: Paralysis (limbs, special senses,
cranial nerves); epilepsy; insanity and the psychoses; hysteroneuras-
thenia.

INFLAMMATORY SEQUEL-ffi

Infection of the Meninges; Septic Meningitis; Epidural Abscess;
Purulent Pachymeningitis; Pachymeningitis Externa,

Ordinarily this is due to infected compound depressed fractures
of the vault, and occasionally from infected wounds, hematomata,
bums of the scalp, or superficial penetrations of the skull.

Symptoms. — In general, there are evidences of an infected scalp
wound, with such signs as fever, chills, headache, vomiting, local
tenderness, and percussion dulness. If the involvement is large
enough and pi'operly placed, there may be added signs of focal irri-
tation or pressure.

Ordinarily these septic symptoms do not appear within the first
three days, and in some exceptional cases they are delayed for several
weeks, but in such cases the interval is occupied by symptoms of
cortical or other irritation.

Infection may also enter from the frontal, ethmoidal and sphe-
noidal sinuses, and from the middle ear.

Treatment. — The focus having been located, the indication is to
evacuate the pus through a suitable opening in the skull, care being
taken to prevent damage to the parts about the abscess. When pus
is diflFused, multiple trephine opening may be necessary. The general
treatment is appropriate to the existing symptoms of sepsis.

Subdural Abscess; Purulent Leptomeningitis; Leptomeningitis
Interna. — This is the condition known also as mejtingo -e^icephalitis
and traumatic meningitis. The causes are the same as in the fore-
going, but ordinarily a fracture of the base exists and the infection
travels through a ruptured ear-drum or broken ethmoid or orbital
plate of the frontal.

5S8 TEADMATIC SURGEKY

The typical sigDs may not appear until evidences of the initial con-
cussion or injury have passed, and then gradually or suddenlya stage
of irritalion commences, with increased temperature and pulse,
headache, nausea, vomiting, chills. If the purulent collection is over
the vertex, theremaybe focal signs; if at the base, there will be rigidity
and tenderness of the muscles of the neck and involvement of some
of the cranial nerves, indicated generally by such signs as pupil-
lary contraction, squint, facial spasm or as>-mmetry. Soon follows
the stage of paralysis, and then the evidences of generalized compres-
sion appear (choked disk, respiratory involvement, and slow pulse),
Kernig's sign (impossible to straighten the bent knee without lift-
ing the pelvis) is present and there is a tache c&'ebrale. Lumbar
puncture obtains pus (usually showing staphylococci or streptococci)
and a leukocytosis is present.

Treatment. — Trephining may be effective in some cases of localized
purulent effusion; but in others with a generalized collection of pus
little can be expected even from multiple openings for decompression.
Autogenous and heterogenous vaccines are sometimes benelicial.

Prognosis, — Cases that recover may give permanent evidences of
muscular paralysis or contraction. The involvement of the cranial
nerves (especially the facial )is often recovered from. Hearing and
sight impairments are often benefited and sometimes entirely relieved.

Generally speaking, the outlook is poor as to life and ultimate
function.

Infection of the Brain. Encephalitis. — In^mmation of the sub-
stance of the brain is due to infected penetrating wounds or compound
depressed fractures; very rarely it may follow infection from one of
the sinuses* or canals. The condition resembles subdural abscess
(meningo-encephalitis) from a clinical standpoint and practically
cannot be differentiated from it.

Cerebral Abscess; Abscess of the Brain; Acute Suppurative Ea-
cephalitis. — The cerebrum is involved twice as often as the cerebel-
lum, and the temporal region is the usual site.

Frontal lobe involvement is very rare despite the contiguity of
. the frontal sinus and the frequency of fracture of this bone.

Abscesses may be solitary or multiple, and when due to trauma
they are contiguous to the seat of origin (McEwen, cited by Eisen-
drath), and in this respect they differ from abscesses due to other
causes. Recent abscesses contain a reddish pus in a more or less
well-defined cavity; later, the pus is green and odorous. Staphy-
lococci and streptococci are usually found in those of traumatic

INJURIES OP THE HEAD 559

origin; others may show pneumococci and typhoid or colon
bacilli.

Causes. — ^Infected fractures of the vault or penetrating wounds
of the skull are the usual traumatic sources. About 15 per cent, of
cases are said to be traumatic, and other sources of origin are otitis
media, sinus involvement, and metastases from pus foci elsewhere.
Middle ear disease is probably the commonest of all sources and
cerebral abscesses may result from it years after the process has
become chronic; cases are recorded following otitis media that existed
nearly half a century.

It is very questionable if an abscess can occur from head injury
in the absence of a fractured skull. If such an origin is to be regarded
as causative, a preceding hemorrhage, contusion, or laceration must
have existed, and any other more usual source of origin (as the middle
ear) is to be excluded.

Symptoms. — ^There are two clinical forms, the acute and chronic.

Acute forms ordinarily do not appear within a week of the acci-
dent, and the initial stage begins with headache, nausea, fever, and
chilly sensations. Mental torpor or restlessness may exist. There
may be local tenderness in the neighborhood of the original wound
or fracture.

A latent stage may then appear, lasting several days, with apparent
subsidence of the preceding symptoms. The manifest stage then
appears, in which all the foregoing symptoms are exaggerated and
the mental condition is one of irritation or apathy. If the purulent
collection is so situated that local pressure is possible there will be
focal manifestations (as facial paralysis or pupillary changes).
leukocytosis is present.

The terminal stage is that of compression often with pyemic evi-
<lences.

Chronic forms may develop a long time after the initial injury,
.and in some reported cases years have elapsed. As stated pre-
Mously, there is always a direct pathway from the original injury
"to the abscess in such instances.

The symptoms of this form are practically those of tumor, and no
evidence of trouble may exist unless the pus collection is large enough
^)r so situated as to cause pressure on some focalizing zone. Many
abscesses are discovered postmortem in so-called "silent areas" which
3n life gave no symptoms whatever; occasionally rather large abscesses
^ire thus found in regions that apparently should have produced
focal symptoms. Sometimes an encapsulated or quiescent chronic

560 TRAUMATIC SURGERY

abscess undergoes changes in size or location, and then symptoms
like those of acute abscess appear. Some cases are subject to peri-
odic exacerbations of this sort characterized by symptoms appro-
priate to their location.

Some of these patients are often regarded as epileptics (abscess in
region of motor cortex), insane (abscess in frontal region), or suffering
from tumors or cysts (cerebral or cerebellar), and the exact conditions
are often not determined until autopsy.

Difereniiation in the acute forms is to be made from meningitis
(especially purulent leptomeningitis), encephalitis, and sinus throm-
bosis.

The first two of these are difficult to differentiate; but in the last,
the typical rise and fall of temperature, the chills, and the usual
middle ear or mastoid involvement, or jugular tenderness usually
serve as distinguishing factors. A careful history is of prime im-
portance and probably offers the best clue to the nature and extent
of the condition.

Meningitis may sometimes be determined by examination of the
fluid obtained by lumbar puncture; with abscess the leukocytes are
not increased, but in meningitis (even of the tubercular variety) a
leukocytosis pertains. Normally there are but one or two leukocytes
in a 5-c.c. centrifuged specimen of cerebrospinal fluid; in ordinary
meningitis there may be 100, and in tuberculous meningitis 952
(Gushing,' quoting Fuchs and Rosenthal).

Lumbar puncture must be carefully performed if compressioi
exists, as the release of pressure may crowd the brain-stem into tl^^^
foramen magnum and produce instant death. For this reason only a
small amount of fluid should be aspirated.

Abscess pus may be sterile, especially in chronic forms.

or-Ray examination is sometimes helpful.

Treatment. — The primary antiseptic care of scalp wounds si^nd
compound fractures has done much to diminish abscess format:i<=>n,
and the importance of this sort of prophylaxis cannot be overesti-
mated.

Next in importance is early recognition and the institution o£ ^^"
ploration and drainage before the later stages of the process ^^^
reached.

Operation in traumatic cases is generally performed over the ^-^^^
of the initial injury, and the trephine opening is so planned thaC:^ it
affords the maximum exposure for drainage. When possible, acc^^^
can be readily obtained by the method described as subtemporal (M ^

INJUIOES OP THE HEAD 56 1

compression. If the abscess is not apparent on exposure of the cor-
tex, a thin knife or hollow needle is inserted into suspected territory,
and when the focus is thus reached, a channel of exit is provided and
gauze or other drainage introduced. Irrigation is unwise unless
the abscess cavity is well defined. The gauze is usually undisturbed
for several days, and the patient's head is placed in a dependent
position to aid the escape of the pus.

In otitic cases, and others in the petrous region, operation is pri-
marily of the mastoid type, with such added exploration as may be
required.

Prognosis. — ^At best this is serious; but if the abscess is relatively
superficial and attacked early, the outlook is better. The general
mortality in operated cases is about 50 per cent. ; those unoperated
upon generally end fatally.

Sinus Thrombosis. — This is relatively rare and is commonest
over the longitudinal sinus following infected woimds and penetrat-
ing fractures.

As a sequel of erysipelas and infections about the face, nose, and
ear it is not uncommon, but most cases are related to mastoid infec-
tions or operations.

Symptoms. — These are (a) local to the sinus involved, and (6)
general or systemic.

(a) Local Signs. — Longitudinal Sinus. — (i) Signs of injury in the
vicinity. (2) Tenderness or pain on pressure; nose-bleed is common.

(3) If the channel is completely blocked, there will be evidences of
general intracranial venous stasis.

Cavernous Sinus. — (i) Signs of injury generally in region of orbit
or brow. (2) Exophthalmos (one or both eyes) and edema of the
lids are the most typical evidences. (3) Choked disk, retinal hem-
orrhage, and congestion of the external orbital veins. (4) Supra-
orbital pain. (5) Paralysis of the oculomotor nerves (third, fourth,
and sixth).

Sigmoid Sinus. — (i) Signs of injury in the vicinity. (2) Tender-
ness along the dilated jugular. (3) Mastoid tenderness and edema.

(4) Involvement of the ninth, tenth, eleventh, and twelfth nerves, or-
dinarily shown by dyspnea, hoarseness, and slow pulse.

(6) General or Systemic Signs. — In some cases these are the only
evidences, and a diagnosis of typhoid, pneumonia, septic endocar-
ditis, or malaria is often made.

The temperature is of the septic type (ioo°-io5° F.). Chills and
sweats with increased pulse (100-140). Nausea and vomiting. Pain

562 TRAUMATIC SURGERY

in head is severe, and it may be localized to the scene of trouble
or wholly occipital. Leukocytosis always exists. Pyemic evidences,
notably in the subcutaneous parts, joints, spleen, and lungs; some-
times pyopneumothorax or empyema may appear. Mentally the
patient is usually alert and the mind is unaffected until late.

In every case the auditory canal must be excluded as a source of
origin.

Treatment. — In the longittidinal sinus exposure and removal of the
clots is indicated.

In the sigmoid sinus a radical mastoid operation is perfonned and
the sinus bared and opened. If the dura is invaded (meningitis or
abscess) it is to be opened and drained. If the jugular is involved, it
is ligated deep down in the neck, opened, and irrigated to wash out
the clot to the open sinus in the mastoid region (Zanf el's procedure).

In the cavernous sinus little can be done; but enucleation of the
eyeball and drainage from the sphenoidal fissure has been recom-
mended. Subdural approach by the temporal route is anatomically
possible, but surgically extremely hazardous.

Autogenous or heterogenous vaccines occasionally appear bene-
ficial in all forms. The general treatment is for sepsis.

Prognosis. — Early operation is effective often in the longitudinal
and sigmoid types of phlebitis, but it is nearly hopeless in the cav-
ernous forms.

If pyemia, septic meningitis, or abscess occurs, the outlook is
graver; but even then some of these cases recover if the general
physique is capable of combating the infection.

NON-mFLAMMATORY SEQUELS

. Cranial Defects. — These may occur as osseous depressions follow-
ing fracture, or indentations without fracture, as from blows, falls, or
missiles. These deformations are sometimes important in the frontal
or bald areas from a cosmetic standpoint, but they rarely assume a
dangerous significance unless the amount of depression is consider-
able. Stimson is authority for the statement that the brain can
safely withstand an indentation amounting to 2 cubic inches. In
some areas a very considerable depression would cause no effects
whatever because the underlying brain is relatively distant from the
skull, or because the contiguous brain region is "silent." In the
Rolandic region the indentation is likely to be of greatest conse-
quence as a possible inducing cause of focal epilepsy; but even in this
locality considerable inflexion is not necessarily a source of symptoms.

INJURIES OF THE HEAD 563

As previously stated, a diagnosis of pressure from a fracture of the
internal table alone, without fracture of the external table of the
skull, is so rare as to be negligible, and suspected cases have rarely
been proved at operation or autopsy. Sharp edges or spikes of de-
pressed fragments are generally smoothed off, and the underlying
brain appears to acquire a remarkable tolerance for these and other
irregularities.

Holes in the skull from the original injury (comminuted fracture,
bullets, or missiles) or from operation are very common. In children
the anterior fontanels usually remain open until about the second
year. Some operations designedly pro\dde apertures in the cranium.
In certain locations visible pulsation of the brain remains, but after
a time this usually lessens and often wholly disappears, even after the
removal of a large '^bone-flap."

The custom of covering such an opening by a plate of metal
(aluminum, silver, gold, or platinum), celluloid, or rubber is now com-
paratively obsolete, as experience has shown that a thick fibrous or
cartilaginous covering spontaneously forms, and that adhesions are
less likely to attach to it than to a foreign substance introduced with
the idea of preventing just such an occurrence. The irregular edges
about these openings are promptly smoothed away, and in many of
them a gristle-like formation completely occludes even a large open-
ing within a few years. A case is reported in which an opening of
about 2 inches square of the frontal bone was filled by osseous mate-
rial after a lapse of twenty-five years (Stimson). Frost reports a case
(cited and pictured by Gushing) of an extensive traumatic laceration
vdth sloughing of a large part of the right hemisphere resulting in a
cranial defect 5 by 6 inches.

The main factor is the condition of the dura, and if there are ad-
hesions to it, the cranial defect is advantageous, in that expansion is
permissible at each brain pulsation.

With an intact dura "the loss of bone should have no more effect
on the brain than has the fontanel of the infant's skulP' (Gushing).
If a hole is to be closed, a shell of bone can be taken from the
patient's rib or tibia and implanted, or a section of scalp, and the at-
tached periosteum and outer table may be slid over the defect (auto-
plastic method of Miller and Konig), and the place supplying the flap
can be allowed to granulate or is skin-grafted. War experience has
shown that cartilage from the region of the VIII-IX rib makes an
excellent covering notably because it can be shaped to conform with
the contour of the skull.

564 TRAUMATIC SURGERY

Hernia Cerebri. — This occasionally occurs in compound fractures
or with loss of bone following decompression, and it is always an
indication of intracranial tension.

Normally the brain, like the lung tissue, recedes when the dura is
opened, and the extent and location of the cerebral prolapse obviously
depends upon the nature of the injury, but in traumatic cases it rarely
becomes as marked as in tumors.

The herniated brain may occasionally take on a fungoid growth
(fungus cerebri) , and this very rapidly recurs after it is excised. If the
compression subsides or is relieved, the prolapse ordinarily recedes.
In infected cases the danger of extension to the adjacent herniated
brain is much increased, and such cases usually end fatally after a
period of sloughing and necrosis.

Treatment. — This should be directed toward relieving the com-
pression and preventing infection of the visible brain during the
period of active prolapse.

Traumatic brain hernia usually spontaneously subsides when the
internal pressure is relieved, and then the opening in the skull and
scalp is suitably cared for. Spinal puncture often relieves the
condition.

SEQUELS OF I9EURAL ORIGIN

Paralyses

These are comparatively rare, and when they affect the limbs the
involvement is usually partial, and the sensory and trophic changes
coexist equally with those of motion. The usual combination is for a
foot and a leg, or a hand and forearm of one side to become partly
incapable of functionating, sensation being impaired over the same
region. Atrophy, flexure contracture, and spasticity are usually
later manifestations.

Much can be done to prevent deformities by guarding against
contracture by suitable dressings and apparatus.

When present, considerable improvement attends the use of mas-
sage, vibration, electricity, baking, gymnastics, and forced usage.
Tendon and nerve re-implantation are operative measures capable of
bringing relief in selected cases.

Special Senses
Hearing and sight are most commonly involved, chiefly in connec-
tion with hemorrhage or infection incident to basal fractures. Re-
covery to some extent is quite probable in most cases, especially in the
absence of infection.

INJURIES OF THE HEAD 56$

Many of these patients show no structural aur^l or ocular defects,
and in these the outlook is excellent, and ordinarily marked improve-
ment can be promised.

. Craioal Nerves

In examining these, the best and quickest method of determining
the involvement of the usual grouping of them is to ask the patient
to shut and then open the eyes and at the same time to snap the
teeth forcibly; in this way the ocular and facial innervation will be
promptly indicated.

The seventh, sixth, third, and fourth are most commonly involved
in the order named.

First, or Olfactory. — Ordinarily involvement is due to hemorrhage,
infection, or fracture of the anterior fossa (cribriform plate) in basal
fractures.

Signs, — LosF or diminution of smell (anosmia) and diminution of
taste on the side of the injury.

Differentiation, — Nasal catarrh, hysteria, involvement of the fifth '
nerve.

Prognosis. — Recovery usually is complete, although it may be
quite slow.

Second, or Optic. — Involvement occurs under the same conditions
as the preceding, and also with compression associated with choked
disk or retinal hemorrhages.

Signs. — Partial or complete blindness on the side of the injury
(amaurosis).

Differentiation. — Preceding eye defects and constitutionaL sources
of atrophy or visual impairment.

Prognosis. — Good unless atrophy exists; recovery is the rule when
due to involvement of the dural sheath alone.

Third, or Motor Oculi (Oculomotor). — Third in order of frequency,
and generally it occurs from involvement of the anterior fossa due to
hemorrhage or infection from basal fracture or orbital wounds.

Signs. — Ptosis, dilated pupil, and loss of reflexes for light and dis-
tance, with external and slightly downward tilting of eyeball.

Differentiation. — Constitutional or toxic preceding causes, such as
syphilis, rheumatism, tobacco, alcohol.

Prognosis. — Good except when due to infection.

Fourth, or Patheticus (Trochlear). — Practically always involved
in connection with the preceding and from the same sources.

Signs. — Double vision (diplopia).

Differentiation and Prognosis. — Same as above.

566 TRAUMATIC SURGERY

Fifth, or Trigeminus. — This motor-sensory nerve is rarely affected
alone.

Signs, — The motor involvement prevents keeping the jaws shut
(pterygoid and masse ter), the sensation over the involved half of
face is diminished or absent, together with a similar impairment of
the conjunctival, nasal, lingual, and buccal membranes. A trophic
ophthalmitis with corneal ulcers may also occur sometimes.

Diferentiation, — Tumors and syphilis.

Prognosis. — Good except when infection is responsible.

Sixth, or Abducens. — Second in order of frequency, but usually
involved with the other nerves controlling the eye (as the third and
fourth).

Signs. — ^Internal squint (strabismus).

Differentiation and Diagnosis. — Like that of the third and fourth
nerves.

Seventh, or Facial. — More commonly affected than any other,
ordinarily from involvement of the petrous portion of the middle
fossa; the eighth nerve is generally affected at the same tune.

The facial supplies all the muscles of the face except those of
mastication (innervated by the motor branch of the fifth) and also
the stapedius, stylohyoid^ buccinator, and platysma.

Signs. — The involved half of the face is smooth and drawn to the
opposite side on attempting to grimace or laugh, the comer of the
mouth drooping. The eye will not close, tears collect, the eyeball
rolls upward and half the forehead cannot be wrinkled, and the
affected cheek cannot be inflated. The tongue deviates to the sound
side. Hearing is nearly always coincidently affected. Ordinarily the
involvement is on the same side as a hemiplegia; if unassociated with
a hemiplegia, it is due to involvement of the cortical facial center.

Crossed paralysis j with facial palsy on one side (that of the lesion)
and of the limbs on the opposite side, is indicative of injury in the
lower part of the pons.

Differentiation. — "Bell's palsy" due to rheumatism or exposure;
peripheral involvement from neuritis, tabes or hysteria; oritis media.

Prognosis. — Good, as the majority recover.

Eighth, or Auditory (Acousticus). — Ver>' frequently involved, and
ordinarily it is accompained by flaccid paralysis and is due to the
same cause.

For methods of examination, see page 801.

Signs. — Deafness may be partial or complete to bone conduction
and higher tone sounds.

INJURIES OF THE HEAD 567

In ordinary or catarrhal deafness hearing is deficient as to aerial
conduction, but normal or nearly so to bone conduction. If aerial and
bone condition are both involved, the nerve or its connections are
affected.

Differentiation. — Otitis media, nasopharyngeal, toxic, and other
inflammatory causes.

Prognosis. — Generally good.

Ninth, or Glossopharyngeal; Tenth, or Pneumogastric; Eleventh,
or Spinal Accessory; Twelfth, or Hypoglossal. — Very rarely involved;
but if so, they are coincidently affected.

Signs. — Disturbances of speech, swallowing, and taste, with anes-
thesia of one-half the pharynx and larynx.

Trophic disturbances at the root of the tongue also occur when the
ninth is affected.

Spinal accessory affection causes inability to raise the arm be-
cause the trapezius is innervated from it.

Epilepsy

No satisfactory estimate has ever been made of the number of
cases of this disease due to head injury. This is mainly because it is
so easy to obtain a history of head injury and so difficult to connect
even marked operative findings in such cases with the seizures. Like-
vrise in the vast majority of patients with marked cranial and brain
damage no epilepsy occurs, although the extent and site of the injury
are such as to theoretically make seizures almost inevitable.

At the present time epilepsy is regarded more as a symptom than a
<listinct entity, and injury is not now generally suspected of being so
potent an originating factor, the best opinion holding that ^^ there is
something back of the lesion itself, some circulatory change, some
disturbance with the cerebrospinal fluid circulation, as Kocher be-
lieved, or some autotoxic agent of metabolic origin, which is the torch
to set off the discharge, cannot be doubted. Cholin in abnormal
quantity has been found in the cerebrospinal fluid of epileptics at
the time of the attack and is thought by some to be the exciting
agent" (Gushing). Disturbance of the pituitary -gland is also
regarded as a possible element.

Personally, 1 believe it to be a very rare sequence of head injury
because the number of cases subsequently seeking surgical relief for
fits is exceedingly small considering the enormous number of head
injuries treated by surgeons in hospitals and private practice. For
example, in my first fracture statistics there were 276 cases of frac-

568 TRAUMATIC SURGERY

tured skull, and of that large number it is reasonable to suppose that
a certain proportion would return for treatment of developing com-
plications. Compilation of thousands of cases treated in various
local hospitals for all sorts of medical and surgical conditions would
show exceedingly few cases of traumatic epilepsy.

With a very close personal knowledge of the recorded surgical
findings in nearly 50,000 cases of railroad injury (some of these
personally examined), 1 can recall very few instances in which daims
have been made for damages on accoimt of this complication, and it is
reasonable to suppose that this type of allegation would be exceed-
ingly frequent if traumatic epilepsy was a usual or ordinary compli-
cation of head injury.

Out of 52.790 claim cases reported to U. S. War Risk Insurance
Bureau there were but 312 (0.5 per cent.) alleging epilepsy as a result
of war wounds'.

Traumatic epilepsy (so-called) is supposedly due to irritation of the
cortical areas of the brain (notably in the motor cortical region), and
in this respect it differs from idiopathic or essential epilepsy, which is
of unknown origin; and also from that group known as reflex epiUpsy
due to more or less distant irritative foci, such as nasopharyngeal
inflammation, notably polypi and adenoids; auditory irritation; gas-
tro-intestinal conditions; adherent prepuce; neuritis; painful scars
and stumps; hysteria; menstrual, menopause and pelvic disturbances,
and a variety of other extracranial sources.

The injuries most commonly looked upon as causative are those
affecting the Rolandic area to such an extent that it is more or less
constantly subjected to pressure or irritation by bone, foreign bodies,
adhesions, new growths (tumors, cysts), or scar tissue.

Bony sources are generally compound depressed fractures in the
temporal region; fractures of the base are very exceptionally causative
from complicating spreading fracture, hemorrhage, or infection.

Foreign body sources are usually bullets and unremoved portions
of hair, fabric, glass, wood, or metal.

Adhesion sources relate to dural attachments to the cortex,
bone, or scalp, ordinarily associated with depressed, adherent,
tender scars following infected or granulating wounds. Occasion-
ally pia-arachnoid adhesions coexist or occur independently
from meningitis or encephalitis. This is probably the most potent
factor of all, and in many of this origin, external pressure over the
involved area is capable of inducing an aura or convulsion (epilep-
togenic zones).

INJURIES OF THE HEAD '569

New growth sources are generally in the nature of localized areas of
edema, organized clots, cysts, tumors (fibroma, glioma, malignant).

Scar tissue sources are connected usually with adhesions, but occa-
sionally occur independently from a scar on the dura or cortex.

Onset. — The time-limit varies greatly, but usually the nearer the
time of beginning to injury, the greater the probability of relation-
ship. This is particularly true in healthy adults whose family his-
tory, early life, habits, and physique are such as to indicate that the
symptoms are imrelated to idiopathic or reflex epilepsy. In children,
traumatic epilepsy is less likely because of their capacity to better
withstand cerebral irritation owing to the elasticity of the skull, and
also owing to the fact that the age of onset in ordinary epilepsy is
usually in early life.

Symptoms. — Usually this type begins with evidences of focal irri-
tation of the motor area, exhibited by such signs as twitching, spasms,
or tonic convulsions of a part of the face or extremity (usually the
fingers) on the side opposite to the lesion.

These irritative manifestations are kAown as Jacksonian or jocal
epilepsy. Consciousness is maintained, but aurae may occur and
offer a clue to the probable site of trouble because of their relation to
the sensory part of the Rolandic area; thus, postcentral involvement
may be indicated by such paresthetic signs as numbness, tingling,
burning, itching, or painful sensations in the region later convulsed;
occipital lobe origination is indicated by visual sensations of colored
or bright lights; uncinate convolution involvement by taste and smell
impressions; cerebellar involvement by vertigo and ataxia signs; apha-
sic types by speech involvement.

Sometimes a unilateral convulsion may be the originating evidence,
but usually there is a progression of symptoms from a limited twitch-
ing or spasm that invades adjacent cortical areas until the entire half
of the face, limb, or trunk is the scene of a tonic convulsion that may
become clonic as it advances, and occasionally invade the other half
of the body. In some cases unconsciousness ensues, the tongue is
bitten, and a generalized convulsion occurs, as in the idiopathic or
reflex varieties; this grade of seizure, however, does not usually occur
until the Jacksonian manifestations have existed a long time, and in
these the differentiation from ordinary epilepsy is correspondingly
more difficult.

"It is characteristic of many cases of focal epilepsy for the seizure
to abort before the convulsion has involved the entire body and before
consciousness is lost" (Gushing).

5?o

TRAUMATIC SURGERY

Occasionally the traumatic forms begin as "fainting spells" with
temporary loss of consciousness {petit mal) ; and others may be ini-
tiateti by aurie with generalized convulsions and unconsciousness
(grand mal). This type with unconsciousness, as stated, is tjpical of
ordinary or idiopathic or reflex epilepsy, and tlie Jacksonian manifes-
tations are typical of traumatic forms, although unconsciousness may
occasionally occur with the so-called non-traumatic Jacksonian
epilepsy.

Epilepsy, or epileptoid manifestations, said to proceed from zones
of injury remote from the brain, are probably invariably due to other
sources; painful scars, stumps, and neuromata were at one time
accused, but better knowledge has disproved this view.

Differentiation. — To be reliable, non-traumatic sources of origin
must be excluded, and the history and examitmtian of the patient are
therefore of extreme importance, bearing in mind that external evi-
dences of head injury may have occurred at the time of the convulsion
and not before it; and also that injury to the head is so common that
patients, parents, and friends, because of pride or other personal rea-
sons, are likely to look upon it as the producing factor, forgetting that
the vast majority of cases are due to other and perhaps less apparent
causes. A reliable family history is often obtained with difficulty,
but the surgeon should inform those interested in the outcome that
without a proper history Uttle can be accomplished. The immediate
family history is, of course, most important, but that of several
preceding generations should be sought also.

SyphiUs, alcoholism, and mental defects in the parents, and mis-
carriages, premature births, and the condition of other children should
be subjects of inquiry. The manner of the patient's birth (instru-
mental or "dry"), convulsions in infancy, early feeding, dentitions
and illnesses are inquired into. The nature of the accident and the
succeeding symptoms and treatment are important; but more than
all, the surgeon must be credibly informed as to the early signs of
onset and the "march of symptoms."

If possible, the patient is observed in a convulsion, or intelligent
parents are instructed to watch for certain symptoms of onset, taking
care not to suggest the manifestations of a tv-pical case. Obviously,
adult patients, or those who remain conscious during a seizure, are
often in the best position to narrate the occurrence, assuming that the
mentality is unclouded.

Traumatic origin is given most weight if: (i) The preceding family
and personal history is satisfactory. (2) The injury has been

INJURIES OF THE HEAD 57I

adequate as to extent, site, and sequence. (3) The symptoms are
Jacksonian in type. (4) The onset is reasonably close to the time of
injury. (5) The examination discloses no other more reasonable
source of origin. (6) The patient is a healthy adult over twenty-five
years of age. (7) There is no epileptic fades, habitus, or other sign
of chronidty. (8) There are no neuropathies or obvious defects
physically, particularly of the sexual or internal glandular systems.

Treatment. — To be effective this must be limited to carefully
sdected cases, preferably those in whom the "epileptic habit" has not
been established by a long continuance of symptoms.

The object is by exploration to remove apparent sources of cortical
irritation, and when practicable a bone-flap should be turned down so
that a reasonably wide area can be exposed . Faradic stimulation may
become a necessary guide to indicate the involved area, as this ordin-
arily responds more promptly and violently than the normal cortical
zone; stimulation also aids in more accurately determining the
topography.

Involved portions may present adhesions, surface irregularities,
changes in color or superficial drculation, or definite tumors of solid,
semisolid, or fluid consistency. Manipulation must be as gentle as
possible and great care is taken to leave the field absolutely dry so
that fresh adhesions may not form.

In cases in which a cranial defect does not already exist, the ques-
tion of making one for decompression purposes will depend upon the
amoimt of intracranial pressure; if this is great, a portion or all of the
bone-flap may be exsected. In some cases a decompression is done on
the opposite side to afford better relief from tension, after the manner
of Kocher.

Bilateral removal of the superior cervical sympathetic ganglia is
advised by Jonnesco, and exsection of layers of the cortical area is
advised by others.

The usual procedure is the formation of a bony defect and the
removal of apparent adhesions or growths.

Results. — Many of the cases operated upon with every hope of
finding obvious cause for symptoms prove disappointing, as no gross
lesion is discoverable after careful search and exploration.

Gushing states that of 128 cases referred to him in five years as
suitable for operation, he rejected all but 59 as unsuitable. Of these,
40 had focal and 19 general attacks; 20 cases were "following trauma-
tisms in the adult," and the others were due to birth palsies, tumors,
meningitis, adhesions, hydrocephalus, hemorrhagic pachymem'ngitis.

572 TRAUMATIC SURGERY

syphilis, and "idiopathic" causes with focal symptoms. Of these 59,
12 have remained free of attacks from one to five years; of the re-
mainder, 30 assert they are "greatly improved," and 17 showed no
improvement and 2 have died in staliis epUepticus.

These statistics are similar to those of M. A. Starr and others.

Many operated cases are temporarily benefited, probably due to
alteration in cerebral circulation or change of habits and outlook^ and
some cases appear to be rendered more amenable to medicinal and
hygienic regimen.

If postoperative bleeding occurs there will usually be monoplegic
or other evidences of cortical hemorrhage, but these subside on
absorption of the clot; but there is always the likelihood of re-estab-
lishment of adhesions unless the operative field is left wholly bloodless.

Insanity and the Psychoses

It is often difficult to determine if the mental disturbance is
wholly, partly, or at all related to the injury, and in this respect such
alleged complications have to be weighed as carefully as in epilepsy.

The time and manner of onset and the associated evidences (rf
neural or constitutional disturbances are quite important. A Wasser-
mann reaction and the examination of the fluid obtained by lumbar
puncture (spinal tap) often determine the exact nature and origin d
symptoms. These reliable dia^ostic aids should be final parts of a
carefully conducted neurologic examination, preferably made with
the co-operation of a neurologist in doubtful cases.

Symptoms of mental disturbance may follow the manifestadons
named under the psychoses, appearing soon after the accident (pri-
mary or immediate), or after a lapse of years (secondary or remote).
Obviously, this last group is less likely to stand in causal relationshq),
especially if they occur at a time of life when arteriosclerotic, senile,
or constitutional effects of vicious habits are likely to become promi-
nent. Alcoholism, physical and mental strain, and other predisposi-
tions are also to be considered as possible factors.

BaDey states that traumatism to the head can be regarded as
responsible in only 2 per cent, of insanity cases even in the presence
of marked evidences of cerebral injury.

Krafft-Ebing (quoted by Eisendrath) states that these late or
remote psychical changes are divisible into three groups: The^i^
is characterized by f eeble-mindedness and idiocy, associated with in-
co-ordination and paralysis; the second eventuates from a long pre-
liminary stage of mental irritability and change of character, followed

INJURIES OF THE HEAD 573

y mania and progressive paralysis; the third seems to have only an
idirect relationship to the injury and develops as the result of associ-
ted or accompanying causes. The severer forms of head injury
extensive vault and basal fractures, hemorrhages, infections, contu-
bns, and lacerations) are the type ordinarily suspected. Many of
lese cases occur in alcoholics with or without delirium tremens.

Thb Pstchosbs

Many of these are of the subjective type and often in the nature of
hysteroneurasthenia," "traumatic neurasthenia," or "post-trauma-
c neuroses." See page 757.

Early manifestations may present as memory defects, headache,
ausea, vertigo, and more or less mental apathy. This state may
ecome more or less active, with delirium, delusions, disorientation
r hallucinations, and restraint may be necessary.

Some of these cases are the outgrowth of secondary edema or more
r less localized serous meningitis, especially if there has been no
ecompression from the injury or operation.

Most of these go on to recovery.

Later manifestations may be the outgrowth of the preceding or
ccur after apparent recovery, notably in patients who are not sub-
jcted to a reasonable period of enforced rest and quiet, or in those
ho too quickly return to work or former habits. These patients are
»tless, nervous, and often refer to painful or paresthetic areas near
le suspected site of injury. Their speech, habits, and character are
>metimes changed ; they may be readily disturbed by trivial occur-
ences, or become imaginative, irascible, introspective, moody, sus-
icious, and sometimes violent. Their mental processes may be
iterfered with and they become incapable of sustained effort,
lemory for figures, dates, and recent or remote occurrences may be
eficient, and peculiar aversions to persons or things may occur,
[itolerance to alcohol and tobacco may exist, and "one drink sets
lem off." The majority of the symptoms are subjective, but there
re nearly always objective verifications, notably: changes in the
iperficial and deep reflexes (ordinarily showing exaggeration),
icrease of pulse, ataxia, sweating, alternate blushing and pallor,
3ld extremities, tremors of the tongue, closed eyelids or fingers,
yperesthetic areas on skull or spine, and changes in the appearance.
ever is usually absent. Marked cases sometimes develop insanity.

Some of these cases are more or less conscious malingerers and
lany of them do not recover pending litigation.

574 TRAUMATIC SURGERY

Treatment. — The preliminary management is very important, and,
as already stated, no case of manifest head mjury should be denied
adequate observation and reasonable rest until all symptoms of irri-
tability and definable trouble subside. Alcoholics are guardedly;
treated from the onset and warned against drinking.

The pyschoses are best treated by isolation and rest, and it is
especially necessary to restrain well-meaning but misguided friends
from suggesting lines of treatment. The patient can have the assur-
ance that these symptoms subside in time, assuming them to be of
the ordinary functional type without organic basis.

In a general way, the management of this sort of case resembles
that of traumatic hysteroneurasthenia (see page 787).

The insanities are given the benefit of decompression if there are
indications suggesting intracranial pressure or irritation as a definite
or focal cause. In some instances, as in tumor formation and foreign
bodies, radiographic examination is helpful. When operative indi-
cations are apparently absent in that group in which trauma seems
the only adequate cause, it is justifiable to give the patient the bene-
fit of an exploratory craniotomy. Some cases do better under asylum
regimen, and violent, delirious, or otherwise irresponsible patients
are carefully watched in the hope that focalizing tell-tale symptoms
may indicate a site for surgical procedure.

However, no case should be subjected to operation xmtil tests of
the blood and cerebrospinal fluid exclude syphilis.

CHAPTER XII

INJURIES OF THE SPINE

There are two general classifications (as in the cranium, thorax,
and abdomen) depending upon the presence or absence of damage to
the spinal cord, and hence we speak of (i) extraspincU, and (2) intra-
spinal types of involvement.

(i) Extraspinal Types. — Spinal column: Contusions, sprains,
lacerated ligaments, dislocations, and fractures.

(2) Intraspinal Types, — Hemorrhage, inflammation (meningitis,
myelitis), and fracture-dislocation.

The foregoing types are often combined, resulting in extra- and
intraspinal grouping of symptoms.

Anatomy. — The spinal column or spine is a bony box made up of
33 flexibly joined segments or vertebrae: 7 of these are known as
cervical, 12 as dorsal, 5 as lumbar, 5 as sacral, and 4 as coccygeal
The average length of the verebral column is about 27 inches.

Each vertebra is made up of a strong anterior portion called the
body, and a posterior called the arch, the latter being composed of
various prominences known as processes or pedicles, the body and
arch joining by the laminae.

The respective vertebrae are very closely bound to each other by
strong ligaments and they are surrounded by massive musdes. The
hollow interior of the spine, houses the spinal cord (or cord), which is a
cable of nerves serving to transmit neural messages to and from the
brain. This cylindric cord is suspended in this spinal canal, begin-
ning above in the medulla at the upper border of the atlas, and ending
below at the lower border of the first lumbar vertebra, and thereafter
it becomes a slender ribbon of gray matter, called the Jilium terminate,
reaching to the second -coccygeal vertebra.

The cord weighs about 28 gm., averages 18 inches long, and hangs
pendulum-like in the spinal canal, occupying only about two-thirds of
the available space therein.

It is covered by three membranes known as the spinal meninges.
The outer investment is the dura, which does not come into contact
with the spinal canal, as the latter has a periosteum of its own. The
central investment is the arachnoid, which is a continuation of that of
the brain forming a sheath for the spinal nerves. The outer surface
of this layer is to some extent connected with the dura, the interven-

575

576 TRAUMATIC SURGEKV

ing portion being known as the subdural space; its inner surface is
separated from the pia by the subarachnoid space, and this is filkd
by the cerebrospinal fluid. The inner investment, the pia, is inti-
mately attached to the cord, forming its neurilemma and also send-
ing a process into the anterior fissure.

The size of the cord is quite uniform throughout except for two
areas known respectively as the cervical enlargement (at the junctiofi
of the cervical and dorsal portions) and the lumbar enlargement (at

Pig. 539. — Spinal cord, showing the location and length (m inches) of the rtspectivc
portions

the junction of the dorsal and lumbar portions). These enlarged
areas correspond to the places where the cord distributes and re-
ceives nerves from the upper and lower extremities respectively

(Fig. 539).

spinal Nerves. — ^Passing laterally from the cord to the interver-
tebral foramina are 31 pairs of spinal nerves; 8 of these are from the
cervical, 12 from the dorsal, 5 from the lumbar, 5 from the sacral,
and I from the coccygeal region. The uppermost nerve is placed
between the occiput and the axis; the lowermost, between the first
and second portions of the coccyx.

INJURIES OF THE SPINE

577

Each ^inal nerve arises by two roots, an anterior or motor, and
posterior or sensory root. On each of the latter (just prior to uniting
with the former to escape from the spinal canal) is a distinct swelling
known as the spinal ganglion, and the function of this is trophic for
the afferent tracts. After the roots unite they are known as mixed
nerve trunks, and their site of exit does not correspond with their
place of origin, as they traverse the cord vertically before escaping,
as will be seen from the illustration. This vertical route is roost

Fio. S40. — Tracts of the spinal cord Light spaces — niotor(orefferent};darlcBpaces —
sensory (or afFeient) (modified from Butler).

marked in the lumbar and sacral nerves, and here the filtum terminate
is enveloped by a mesh of nerves called the cauda equina (horse's
taU).

If a cut section of the cord is examined it will be seen to be cylin-
dric and broader from side to side than from before backward. It
will show a central canal and be divided into nearly equal halves by a
deep broad anterior fissure (or septum), and a shallow narrow pos-
terior fissure (or septum). Gray matter in an H-form occupies the
interior portion and white matter the external portion. Each prong
of the H is known as a horn, and hence arise the terms anterior horns
or columns, and posterior horns or columns. The lateral projection of
gray matter is known as the lateral horn or column (Fig. 540).

578 traumatic suhgery

Spetal Topography
As indicated, the H-shaped gray substance delimits various
columns or horns, dividing the cord into an anterior, lateral, and ^01-
terior portion. In addition, the cord is further segmented by the
levels at which the various spinal nerves escape, determined by their
relation to the spinous processes; hence there are 31 segments.

Roots Spinous Phociss Exits

.!)■■

ad and jd

ad and 4th

4th

■nd 5th -'

sth

■nd 6th ■•

61h

■nd Tlh "

Tth

and Bth "

Bth

.nd pth ■■

Blh

■nd loth ■■

lOth

■nd iilh "

iith

and nth "

13th

d«Hlind»tl

111

■nd Id lumbu-

nd 3d

nd 4th ■■

4ib

and sth ■•

Slh

lumbar and igt

■>i

and 3d tacnt i

nd 3d ■■

xth

nd 4th ■■
and <th "

I-'iG. 541. — Relation at the spinal segments and of the roots and places of ner\-» '-^^
tnt (0 the spinous processes. Dots indicate points o£ origin. Circles indicate pointi-J*' *
of esit. C = cervical; D - dorsal; L = lumbar; S = sacral {modified from Butler). - *

The seventh cervical vertebra {vertebra prominens) is thedeter-"*-
mining bony landmark in the upper portion; the twelfth dorsal vert-^ '
ebra (indicated by the corresponding rib) denotes the mid-portion -^^^
and the fourth lumbar vertebra (denoted by being on a level wittC -^
the crests of the ilia) is the landmark for the lower portion. Reference ^=^
to Figs. 541-543 will best indicate these relations.

INJURIES Of THE SPINE

579

Practically spealdng, to determine the number of a given nerve-
root at any level, we may in the cervical region add one to the spin-
ous process at the place of exit; in the upper dorsal region we add
two; and add three in the lower dorsal; in the lumbar region we add
four. In children under seven, we add three to the number of the
qjinous process up to the mid-dorsal, and add four below that level
(Chipault).

Flo. S4I-— Spinal segmental localization of the automatic centers and the superficial
and deep reflexes. Superficial reflexes, 0 1; deep reflexes, I (after Butler).

Cord lesions are thus located above the level of their spinal
nerve symptoms.

The total number of anterior root-fibers in a woman of twenty-
rix is 303,265; the posterior root-fibers numbered 504,473 (Stilling).

Each segment of the cord, as stated, consists of a mass of gray
matter smxounded by a series of white tracts from which a pair of
spinal nerves pass out. These segments intercommunicate with
each other and are also connected with the brain by various tracts or

580 TRAUMATIC SURGERY

columns of white matter; hence each segment is a center and also a
means of transmitting Impulses to more or less distant parts. Each
of the 31 segments is composed of symmetric halves, each of which
receives two afferent (sensory) and gives off two efferent (motor)
nerves; the former are in the posterior and the latter in the anterior
portion of the cord. Each segment, therefore, possesses motor func-
tion (anterior roots), sensory function (posterior roots), and various
reflex, vasomotor, and trophic functions.

Fig. 543. — LncalioD o( spinal segmeats conLiolling sensatjoa and motian (aFtei B
based on Jakub (sensory), and Starr, Mills, Sachs, and Dana (motor).

The relation of these spinal segments to sensation and motion has ^
been carefully determined and is as denoted in the diagrams.

The function of the respective tracts and columns is also diagram

matically shown (see Fig. 540).

The blood-supply of the cord is by an anterior and posterior set o^B
vessels, the arterial twigs of which do not anastomose after penetrat — =

Fig. 545. — Cutaneous nerves and their segmental relationsUp.

TRAUMATIC SURGERY

ing the cord. The spinal arteries are, for their sUe, the longest in the
body, and they are not subjected to cardiac impulses and the pres-
sure within them is very slight.

The tnanifeslations of cord lesions are irritative or destructive,
depending upon the site and extent of the injury, and they become
manifest as related to the vertical or horizontal planes of the core

Tia. 546.^ESect of lesions {indicated by circles) of the m
spinal cord: G, lolernal capsule legions and the variation ii
anteroposterior position (modified from Butler).

path in the brain u
symptoms due to theit

Vertical lesions of a motor type vary between paralysis and irritar-
live evidences, as denoted by spasms or rigidity. It is to be recdled
that a segment supplies many muscles, and, therefore, paralysis or
involvement of a single rather than a group of muscles is evidence Aat
the lesion is peripheral or distal and not spinal or central.

INJURIES OF THE SPINE 583

Lemons of the sensory type vary from complete anesthesia to
alterations in sensation. The summit of the anesthesia is ordinarily the
best guide as to ^ level of the lesion, and this anesthetic area is often
surmounted by a ridge, band, or girdle of hyperesthesia (Figs. 544-
S48).

Reflexes are wholly abolished in complete lesions at and below the
level of the damage; but later the reflexes increase.

Corfial/ Itimn

Fig. 547. — Mechanism of the deep reflexes and the two mau) types of paralysis
(spastic and flaccid). Dark circles indicate lesions giving exaggerated reflexes. Light
circles indicate lesions ^viug abolished reflexes (modified from Butler}

The upper level of the abolition of reflexes usually coincides with
the anesthesia, and the determination of both gives adequate infor-
mation as to the level of damage.

Trophic centers for muscle correspond to their motor spinal
centers in the anterior horns, and any destructive lesion of this por-
tion of the gray matter causes atrophy of the supplied muscle group.

584 TRAUMATIC SURGERY

The muscles deriving their nerve-supply above and below the lesioD
are unaffected.

This can be best understood by reference to the annexed table (see
page 585).

Fig. 548. — Spinal coni motor pathways. Indirect patkmay (denoted ) ft*

ffiiucular co-ordinatioD and higher reSex and automatic movementa, runs from cortei
ta pons nuclei, to cerebellum, to lateral fundamental column, via the pedundn, the
fibers ending in the lateral hom. Direct pathway (denoted ) for voluntaiy im-
pulses, runs from cortei, via corona radiata, internal capsule, cms, pons, meduD*,
CTOSsed and direct pyramidal columns, to motor cells of anterior horn. Cranio xnc

motor fibers (denoted ) cross at various levels in cms, pons, and medulli

(modified from Bailey).

The earliest signs of muscle involvement are indicated by a loss
of tone with softening and flabbiness; later, shrinkage and the reac-
tion of degeneration appear. Such isolated changes are best illus-
trated in the extremities and about the main joints. The loss of tone

INJURIES OF THE SPINE 585

in the skin becomes manifest by a change in its texture so that it may-
become glossy and shiny, and later may become dusky, cyanosed, dry,
and scaly. Slight pressure is capable of inducing ulceration and
thus bed-sores are formed; they occur most often over the sacrum, mal-
leoli, heels, buttocks, and other places subjected to posture pressure.
Vasomotor changes may show in the pulse-rale; in dorsal lesions a
rapid pulse is rather constant, but the reverse pertains in cervical
injuries. In the latter, unilateral or more or less symmetric swealing
occasionally occurs. The skin at first may be quite flushed and
warm, but later is cold and Uvid. Changes in temperature usually
indicate septic states. Visceral changes relate chiefly to the bowels
and bladder. If these centers in the lumbar segment are involved,
there is complete incontinence of feces and urine; if the lesion is above
these centers, then voluntary control alone is lost and automatic ac-r
tion allows their function to be unconsciously performed. If this
last condition exists, the anal sphincter can still contract on the
examining finger, but it cannot do so when the center is involved.
Retention of urine and feces may occur, and in the case of the bladder
this may lead to inflammatory changes that may later extend to the
kidneys. Cystitis to some extent is a common sequence, and becomes
a very grave menace unless every precaution is taken during cath-
eterization to prevent infection that speedily may induce septic
kidney and death.

■

HORIZONTAL LOCALIZATION

Some lesions affect the cord in the transverse rather than the
vertical axis, and these may be symmetric or otherwise.
Pyramidal tract lesions cause —

Paralysis: Motor spastic type below the involved level.

Reflexes: Exaggerated, with rigidity and contractures.

Degeneration: Downward.
Posterior columns and horn lesions cause —

Sensation: Disturbed, especially temperature, pain, pressure,
muscle, and joint sensations.

Ataxia: Present.

Reflexes: Absent or much diminished.

Degeneration: Upward.
Posterior root lesions cause —

Sensation : Anesthesia in total involvement ; hyperesthesia and
radiating pain if otherwise.

586 TRAUMATIC SURGERY

Anterior horn and root lesions cause —
Paralysis: Motion abolished in muscles involved and atrophy

occurs.
Reflexes : Abolished and the reaction of degeneration is present
Degeneration: Downward.
Central canal lesions cause —

Sensation : Dissociation with preservation of touch and loss of
painful and thermal sensations.
Half of transverse segment lesions cause —
Paralysis: Motion lost on same side as, and at and below, the
level of damage; slight loss of power on opposite side (usu-
ally).
Sensation: Complete loss on opposite side at and below the

level of damage. (See Fig. 546.)
This is the Brown-Siquard paralysis.
Cauda Equina Lesions. — The cauda is about 10 inches long and
reaches downward from the first lumbar vertebra, and hence any
cord injury in this vicinity is a nerve-root lesion of the descending
roots of the lumbar, sacral, and coccygeal nerves that comprise it
The manifestations are, generally speaking, the same as would be
produced by injury to the lumbar or sacral plexus. The reflexes arc
not increased and visceral control is not affected in true caudal
lesions.

As already indicated, the flexible spinal column with its strong
padding of muscles and ligaments affords almost armored protection
to the contained cord, and the latter itself derives added safety by
floating in cerebrospinal fluid and by being enveloped in its own three
membranes. For this reason unusual localized violence is necessar)'
to produce injury of the cord itself, but lesser degrees of violence may
affect the parts external to it.

EXTRASPINAL TYPES OF INJURY

There are no cord symptoms in this group.

CONTUSIONS

These consist of bruises of the soft parts, or of the erector spitKt
muscle mass due to direct violence, as from blows or falls.

Symptoms. — These do not differ from those of ordinary contu-
sions, except that ecch}Tnosis may be diffuse and rather late in onset
and slow in disappearance. Hematoma formation is rare because the
muscle and fascial planes are so firmly connected. Pain on motion is

INJURIES OF THE SPINE 587

marked enough at times to cause a typical attitude in walking resem-
bling that described in Traumatic Lumbago (see below).

Treatment. — Hot or cold applications are used at first (water,
alcohol, or lead and opium), and later several criss-crossed adhesive
straps are applied. If necessary, the counterirritation of iodin,
turpentine, electricity, the cautery, or vibration may be tried.
"Ironing the back" with an ordinary heated household iron is an
excellent remedy. Anodynes will be needed sometimes, especially
in rheimiatics and where a "lame back" is complained of despite
ordinary external treatment.

SPRAINS AND LACERATED LIGAMENTS

Sprains refer to the sudden wrenching or stretching of ligaments
between the vertebrae, usually those connecting the spinous proc-
esses; if this is extreme, the fibers may be torn and then laceration is
said to exist.

Causes are almost invariably sudden forms of indirect violence
resulting in forward or lateral bending of the spine, as from twists,
falls, crushes, and the like.

Chronic forms are generally postural from occupations demanding
stooping or bending positions; many of these in time show bony
curvature in association.

Symptoms. — ^Local pain on pressure or motion is the main fea-
ture, and this is increased by movements that impose strain in the
region of the stretched or torn ligaments. Usually the mid-portion
of the back presents the maximum tenderness, and at no time is the
pressure pain distant more than a few inches from the spinous proc-
esses. Swelling and discoloration are added signs. Mobility be-
tween spinal segments is never found because the adjacent interlacing
of muscle and fascia is quite sufficient to maintain contour even in the
presence of direct severing of many ligaments. The cervicodorsal,
dorsalumbar, and lumbosacral regions are most commonly affected.
In some instances, radiating pain may be present along the inter-
costal and lateral abdominal regions.

Sprains in the lumbar region are common enough to be denoted by
the term traumatic lumbago; the symptoms resemble spinal ligament
sprain elsewhere except that the back is held rigid and somewhat
arched and the patient assumes this stiff characteristic attitude in
walking, rising, and sitting.

588 TRAUMATIC SURGERY

Treatment. — Rest and anodynes summates this. The former is
best provided by adhesive plaster criss-cross dressings, these to be
applied at once or after the preliminary use of hot fomentations of
alcohol and water, lead and opium, or other embrocations. Codem,
aspirin, salicylates, and other appropriate drugs are given as required,
these last being especially suitable in rheumatics. Later, counter-
irritation from iodin, electricity, vibration, the actual cautery,
ironing with a flat-iron, or massage may be necessary. Hot baths
followed by brisk massage will also aid in "limbering up lame backs."
Very rarely it may be expedient to apply a spinal brace of metal or
leather, or a plaster-of-Paris jacket. This last form of treatment is
most applicable in chronic sprain or rebellious lameness of the back
due to habitual posture or constitutional causes.

"Pain in the back" and "lameness of the back" may arise from so
many conditions that the physician must be on guard for non-trau-
matic causes in those cases that do not promptly respond to treat-
ment that is efficacious in the large majority of acute cases due to
injury. In women it is well to remember that pelvic disorders fre-
quently are a source of pain in the back. Intra-abdominal causes
must not be forgotten, such as gastro-intestinal and kidney ptosis.
Finally, neurasthenia, hysteria, rheumatism, lumbago, neuritis, and a
variety of other causes are to be excluded in persistent cases. See
page 146 also.

In differentiating sites of real from assumed pain, much aid fe
afforded by marking places of alleged tenderness along the spinal
column and later asking the patient to relocate these areas when
similar pressure is made upon them. Traumatic sources of origin arc
likely to be localized to one vertebra or vertebral segment; non-trau-
matic sources are generally so diffused, with intervening normal seg-
ments of such wide separation, that trauma could not be the source
of such an uneven distribution. When previously marked areas can-
not be relocated with reasonable accuracy, the trouble is probably
more mental than physical, especially if there is the added corrobora-
tion of normal gait, rising and sitting ability, and little or no limita-
tion of spinal motion. This is known as the " relocation test."

It has been stated that pressure over a painful area increases the
pulse-rate (Mannkopf's test), but 1 have not found this of much
diagnostic importance in this or any other class of injury.

DISLOCATION OF THE SPINE

(See pages 223-235.)

INJURIES OF THE SPINE 589

FRACTURE OF THE SPINE

Recognizable fracture without some coincident cord damage is
relatively rare and is practically limited to lesions of the arches,
mainly the spinous and transverse processes.

Causes and Varieties. — Direct violence, as from missiles, bullets,
blows, or falls is an imcommon factor.

Indirect violence, due to forced forward or lateral bending with
more or less added muscular violence, is the usual source.

Ordinarily but one vertebra is involved.

When the spinoff process is avulsed, it is usually broken at its
base, and the adjacent portion of the arch may be detached with it.

The amount of separation varies, but it may be extreme and
associated with considerable lateral or downward displacement.
Cleavage at the tip of a spinous process is a not uncommon associate
of sprains, thus becoming an example of sprain-fracture.

The bodies and lamince rarely suffer in the absence of intraspinal
complications, and the diagnosis of any such conditions would be im-
possible without x-ray verification.

Symptoms. — Swelling, dejormity, ecchymosis, local tenderness, false
motion, and crepitus are readily obtainable in typical cases. Back
bending is painful and the adjacent muscles are rigid and tense.
Local and radiating pains may occur. There may be associated in-
jury at the costovertebral angle or elsewhere.

Treatment. — Adhesive plaster strapping will suflSce for the aver-
age case; but if there is undue mobility of the column it is better to
apply a plaster-of-Paris jacket, the spine being arched during its
application. If a broken spinous process is unduly movable or
threatens to protrude through the skin, it can be anchored by a few
kangaroo tendon sutures introduced into the adjacent processes
through a small incision. 1 recently employed this procedure in a
case of dislocation of the first and second lumbar vertebrae with
fracture of the spinous and transverse processes of the first lumbar
vertebra. This patient attempted to conmiit suicide by jumping out
of a window, and her freedom from intraspinal injury appeared
ascribable to an old curvature of the spine that in a way was forcibly
corrected by her accident. She had no cord symptoms whatever.

Results. — Union of a spinous process is by fibrous tissue and is
reasonably firm in three weeks, but some support should be worn for
about two months. The outcome is necessarily good inasmuch as
there is no damage to anything except the bony outcroppings of the
column, and their intraspinal ligamentous and muscular attachments.

590 TRAUMATIC SURGERY

iNTRASPmAL TYPES OF INJT3IIY

There are cord symptoms in this group.
SPINAL HEMORRHAGE

This may be extradural {betnalorachis) or inlradural (kmiiilo-
myelia).

Extradural Hemorrhage; Hematorachis; Eztramedullaiy Henuu'
rhage. — By this is meant an effusion of blood on the outside of the
spinal cord coverings and between them and tlie bone; it corresponds
to that form of cerebral hemorrhage having the same name. It b
relatively rare as compared with the other form of spinal hemorrhage,
but both varieties coexist in severe and usually fatal cases (Fig. 549).

Fig. 549.^ — Spina! hEmorrhage. a. Extradural, or henutorachis, b, inlradural, oi
lomyelia.

Causes. — It is always an associate of fracture or fracture-
tion and does not occur as a separate entity, and hence the e
is the 3>me as that of fracture-dislocation.

It is conceivable that it might also occur from glancing or siqio^
fidal penetrating agencies, such as a bullet or cutting instrument; ol>-
viously such a limitation would be rare. Occasionally it occurs also
from spinal puncture made for diagnostic or therapeutic purposes.

Symptoms. — These are transitory and extremely difficult to recog-
nize in the absence of direct inspection by laminectomy, and then an
associated hematomyelia is the condition for which the operation s
usually performed. It requires considerable extradural pressure to
affect the cord, and obviously a very severe injury would be required
to produce bleeding enough to compress the cord outside its dunl
sheath; hence any such injury is almost invariably of the fracture

INJURIES OF THE SPINE 59 1

location or allied type in which hematomyelia coexists and is the
cause of symptoms. Practically speaking, the diagnosis of hemator-
achis is clinically impossible without laminectomy, but it can often
be assumed to exist in injuries capable of causing hematomyelia.

Hematomyelia; Intradural Hemorrhage; Intramedullary Hemor-
rhi^e. — ^By this is meant hemorrhage occurring within the spinal cord
coverings, affecting the cord substance itself.

There are two forms: (a) Primary focal hematomyelia, without
bony injury, and (b) secondary hematomyelia, with bony injury.

The pathology in each form is practically the same, in that the
anterior and posterior horns are the usual sites of involvement. The
gray matter ofTers less resistance than the white to the spread of the
blood, and hence the oozing is generally up and down rather than
transversely. The area involved is usually asymmetric and the
greatest area of bleeding is generally in the zone nearest the maximum
of the trauma, the gray matter being chiefly involved. In addition
to the main areas of dissemination, smaller foci of punctate or minute
hemorrhage may occur in the white matter.

The extent of the hemorrhage varies widely: in severe cases (so-
called "spinal apoplexy") the cord may be almost wholly occupied
by clot at the level of the hemorrhage.

The ejfed of the hemorrhage may be wholly mechanical and pro-
duce the damage solely by pressure; in other instances, inflammatory
reaction occurs with subsequent degeneration.

After the bleeding is absorbed, cavities may remain resembling
those seen in syringomyelia, and hence has arisen the term " traumatic
syringomyelia. ' '

(a) Primary Focal Hematomyelia. — There are but two locations
in which this occurs, namely, the cervicodorsal, and very rarely in
the lower lumbar region.

It is generally due to some forcible sudden temporary bending
of the spine, either forward (flexion) or backward (extension),
with an immediate springing back into place of the temporarily dis-
placed vertebrae. Under these transitory conditions the exact cause
of the bleeding is not known, but it is thought to be due to (i) a tear-
ing of the blood-vessels incident to the stretching of the cord; (2)
direct bruising of the vessels at the time the cord is temporarily im-
pinged upon.

Whatever the cause, the main feature of this variety is the ab-
sence of any demonstrable change in the bony make-up of the spine
and a rather prompt recession of symptoms.

592

TRAt'MAlIC SURGERY

CaHJcs.^While the lesion is much rarer than fracture-dislocation,
yet ordinarily the symptoms at first suggest bony injury.

Diving, falls on the head or neck, twisting or jamming of the bend
forward or backward, and allied forms of violence are the usual fac-
tors. By some, a temporary dislocation is supposed to always occur.
Direct penetration of the cord, as by a bullet or weapon, is also
causative.

Presumably the same bending and penetrating factors might cause
involvement in the lumbar region, but occurrence here is a clinical
rarity when imassociated with bony injury.

Symplams.— These depend on the extent of the bleeding and its
site; but, as stated, invasion is ordinarily of the horns of the gray
matter and the parts immediately adjacent. The clinical picture
is relatively constant and the essential elements are: (a) Motor para-
lysis which soon recedes; (b) sensory paralysis for pain or tempera-
ture (or both) and retention of sense of touch — the so-called
"dissociation anesthesia."

Of course, with signs of "internal injury," there may be object-
ive evidences of "external injury" in the form of contusions, ecchy-
mosis, wounds, swelling, local tenderness, pain on motion, rigidity,
and other indications of local damage about the bead, neck, and
interscapular regions.

(a) Motor paralysis almost invariably occurs immediately on
receipt of the injury, and in very few instances is there any "latent"
or "free" interval.

As stated, the cervical region is most commonly affected, and for
that reason the upper extremity becomes involved, chiefly the muscle of
the hand and forearm, those of the upper arm being less often affected.

Inasmuch as the spinal nuclei of the brachial plexus are generally
afTected in this type, complete recoverj' is improbable, as some
destructive damage, usually occurs. This may involve but a single
muscle eventually, but muscle groups at first generally suffer.

Hemorrhage great enough to affect the lower extremity may be
and often is completely recovered from because the lesion is not
destructive and the sj-mptoms usually arise from edema and pressure
on the pyramidal tracts. The earliest sign is flaccid paralysis, and
this may involve all four extremities, or two, or be limited to one
extremity, all depending upon the site and extent of the bleeding.

The lesion, if small, may cause no marked changes in the rejiexes,
or they may at first be exaggerated or lost. Later ihey become exag-
gerated, and in the lower extremit}- ankle clonus also appears.

INJURIES OF THE SPINE 593

Later the flaccidity gives way to rigidity, and when this spastic
state appears the motion of the part begins to return. The lower
extremity recovers before the upper, and even in marked cases power
enough may return in a few weeks to permit walking. Atrophy to
some extent is likely to remain in the arms, special muscles being
selected, while those adjacent are apparently normal or nearly so in
tone and action.

In the cervical cases pupillary signs are constantly present be-
cause of the involvement of the ciliospinal centers, and bilateral con-
traction of the pupil is present when the lesion is transverse; in uni-
lateral lesions the pupillary signs are on the side of the lesion.

(6) Sensory paralysis in typical cases is manifested by the reten-
tion of the sense of touch and loss of the sense of pain (analgesia),
heat, and cold (thermo-anesthesia). With very extensive clots
there may be loss of sense of touch also, but this is very exceptional.
Distorted sensations, as of numbness, pins and needles, crawling,
and actual attacks of shooting pain, may also occur. Many cases
are wholly free of pain; in others motion or pressure over the region
involved causes much suffering.

Visceral symptoms affecting the bladder and rectum may also
occur and there may be retention or incontinence at first. Later,
control is regained, and the rectum usually responds first. Improve-
ment in the bladder and rectum may begin in a few days and is usu-
ally progressive.

General symploms, such as priapism, cyanosis of extremities, and
tympanites, may also occur, but these are atypical. Bed-sores
practically never occur.

Brown-Sequard type is that in which there is a motor paralysis in
one arm and leg, and loss of pain and temperature sense and preserva-
tion of touch (dissociation anesthesia) in the other arm and leg. The
analgesia is generally less marked than the anesthesia and is usually
the first to be regained.

This form of anesthesia is rather common and is typical of spinal
cord hemorrhage.

Diagnosis. — ^The main differentiation is to be made as between
hemorrhage alone and bony injury; in other words, are the intra-
spinal evidences of pressure due to blood, laceration, or bone?

Typical cases of hematomyelia are characterized by:

(i) The sudden onset of marked flaccid paralysis in four, two, or
one of the limbs, with sensory changes in the paralyzed limbs of the
above-named dissociation type.

594 TRAUMATIC SURGERY

(2) The symptoms begin to show recession in a few days, visceral
control often returning first, and later spasticity replaces flacddity.

(3) The intraspinal evidences are often more marked than the
extraspinal, and objective bony lesions are generally lacking.

Any case in which progression occurs after the fi^rst week is gener-
ally one in which primary focal hematomyelia is but an element and
not the sole initiating causative factor.

Hysteria are sometimes hard to differentiate, but in this condition
the history and type of patient and the existence of other signs
(stigmata notably) is of determining value. Of course, the two may
coexist; here again the history and examination offer main reliance.

Progressive muscular atrophy could only be confounded in ver\'
exceptional instances, as in this the condition is one of progression over
very many years, and not of recession within a short time after a dis-
abling injury. The necessity of differentiating this disease arises
most often after recovery from some injury alleged to be a "localized
spinal hemorrhage, " and from which the atrophic condition is said
to have started. Main reliance is to be placed upon the duration
and extent of the manifestions, notably upon the place of their
beginning as related to the spinal lesion.

Ulnar and brachial palsies offer the greatest confusion, and the
question of occupation and possible toxic influences (notably lead
and arsenic) need careful consideration. It is to be recalled that
sometimes the disease in question may have existed for years until
some general examination brings it to view.

Treatment. — ^Associated injury and shock are suitably treated.
Ge^ieral measures are of prime importance, and the transport of the
patient must be made carefully so that added damage to the parts
may not occur.

In the absence of a water- or air-bed, the mattress must be ex-
ceedingly soft and the sheets kept free of creases so that no pressure
occurs. In old persons, or where respiratory embarrassment
threatens, the head of the bed is elevated a foot or more. So far as pos-
sible the patient is very carefully turned from side to side or held thus
by props placed under the side of the mattress. Aseptic catheter-
ization three times daily is enough at first, later twice a day is sufficient.
Some surgeons advise allowing the bladder to empty itself by overflow,
but 1 do not approve of this and regard it as unclean and unsafe
unless it is impossible to obtain or train an attendant. If the urine
becomes cloudy or purulent, irrigation of the bladder with boric
solution is valuable. This is rarely needed more than once daDy.

INJURIES OF THE SPINE 59$

Urotropin in s-grain doses every four hours should be a routine meas-
ure. Occasionally lo grains of benzoate oj soda may be added to this
dose if urinary alkalinity pertains. The bowels are emptied by a lax-
ative or enema daily or every other day. Tympanites is controlled by
salol, massage of the colon, or turpentine stupes or enemata.

Local measures relate to the application of adhesive straps over
any painful spots on the spine or perhaps the use of a light plastcr-
of-Paris jacket. No operative or intraspinal manipulation is indi-
cated, and the use of the aspirating needle for diagnostic or other
purposes is strongly inadvisable.

Treatment later is along the line of encouraging tone to paralyzed
muscles, and at this time gymnastics, massage, and electricity are of
great importance, but obviously these should not be used until reces-
sion is well under way. 1 have found much benefit from the use of
improvised elastic or metal springs ("health exercisers") attached to
the foot or head of the bed in such a way that the patient may force
the inactive limb to do work against resistance. Isolated paral-
yses are treated by special motions to re-educate their diminished or
abolished functions. Strychnin at this stage is very valuable.
Tendon transplantation may bring surgical relief when all else fails.

Results. — Cases that begin to show improvement within the first
week generally recover sufficiently to use the lower extremities, and
often the upper extremities, to a greater or lesser degree. Visceral
return in recoverable cases is usually prompt and lasting. Atrophy
and loss of power in isolated muscles of the upper extremity usually
persist in marked cases and sensory changes also pertain to some
degree in these same areas.

The earlier the improvement the better the outlook.

SPINAL CONCUSSION

Some forty years ago this term was proposed and for a time had a
vogue, but at present this diagnosis is nearly obsolete because of
better knowledge as to the underlying causes of symptoms formerly
designated by this title, and also because the term "concussion" is a
misnomer as applied to the spinal contents, inasmuch as we now know
they cannot be "concussed" in the same sense that "concussion of
the brain" occurs.

The condition was at one time supposed to occur chiefly as an in-
cident of railway collisions in which "the spine was jarred," and
hence the term "railway spine" came into a sort of surgical usage,
chiefly, however, in litigated cases.

596 TRAUMATIC SURGERY

There never was any adequate clinical or pathologic basis for
this verbal entity, as most of the cases were in reality either sprains
of the spinal ligaments or hematomyelia.

Erichsen in 187 1 and again in 1875 sponsored the term and origin-
ally reported some 52 cases, the analyses of which today would cause
them to be classified in grades of severity extending from fracture-
dislocations of the spine to hysteroneurasthenia. As stated, surgical
nomenclature no longer lists the term, and it survives only as a
memory among well informed physicians, and even the laity, legal
or otherwise, are forgetting it.

Once when the expression was used in court, the unimpressed
judge stripped it of any seriousness by asking the physician-witness,
"What is the difTerence between a 'railroad spine' and a 'steamboat
spine'?''

There is no form of physical or psychic trauma typical of railway
accidents, inasmuch as the same injuries and nervous manifestations
may arise from a great variety of other causes, all of which may be
grouped under the term of ''industrial accidents."

As Bailey has well stated, "there is no logical basis for the term
'spinal concussion' from the standpoint of etiology, symptomatolog}',
or pathology. Cases having objective symptoms of spinal injur}'' are
now otherwise classified, those presenting a more or less well-authen-
ticated history of violence in the spinal region with subjective symp-
toms are classified usually as neuroses. "

INJURIES OF THE SPINAL CORD

Traumata of the cord itself arc in the nature of contusions ir^ ^
lacerations.

CONTUSIONS OF THE CORD

A cord is said to be contused when it has been bruised, dented, 0

otherwise impinged upon without accompanying laceration of fibe -^^n

Causes. — Sharp bending of the spine (either forward or bat-a^ d
ward), heavy blows over the spinous processes, and the alrea— ^E3d
enumerated factors capable of producing fracture-dislocation.

It occurs most commonly in the cervicodorsal and dorsolumh^^ba
regions.

Symptoms. — Practically the signs of hematomyelia exist, ^« — ^^
the external evidences of bony injury added. These are the caseF ■=^ in
which paralysis of varj^ing degrees appears, with corresponding ab --"o/i-
tion of sensation, reflexes, and visceral control.

INJURIES OF THE SPINE S97

The site and extent of involvement determines the nature of the
symptoms; but no definite statement can be made as to the amount
of bruising imtil the coexisting hemorrhage subsides, and this usually
takes a week. If, after this lapse, no improvement occurs, structural
damage to the cord substance may be presumed, either in the nature
of simple bruising or laceration, or both. If temperature is present
and there are no septic foci to account for it, a myelitis may be
assumed to exist.

Persistence of symptoms after temporary recession may indicate
localized edema, cyst formation, or localized serous meningitis.

Treatment. — ^A waiting policy is advisable if pressure from bone
can be excluded and if there is doubt as to the presence of blood-
clot- After a week or so, in the presence of ascending symptoms,
laminectomy is advisable so that decompression may avert degener-
ation from any edema, cystic formation, or myelitis.

Hemilaminectomy may suffice in some cases, but the procedure
affording the quickest, most adequate access in my experience is the
following:

Patient wholly prone or partially so with pillows under one shoul-
der and edge of chest and abdomen; ether anesthesia or mixed anes-
thesia intranasally. Tincture of iodin applied to the dry back in the
operative field. Incision 6 to 8 inches long just lateral to the ridges
of the spinous processes, this reaching to the depth of bone beneath.
Retract the muscles outward and clear the arches by periosteal ele-
vator. Pack this wound with gauze pads wrung out in hot saline
solution. Clear the opposite half of the arch in the same way and
similarly pack the wound thus made. The bleeding is generally
excessive, but this sort of pressure eventually will give a dry field.
With a rongeur gnaw away any available spinous process down to its
base and then remove the latter with a smaller beaked tongue rongeur,
and thus the spinal meninges are brought into view. Repeat this pro-
cess along the laminae until the cord is exposed to the extent desired
(Fig. 550). Normally it should be bulging and pearly gray, but
it may be quite dusky and toneless. A bent probe or director may
be inserted up and down the canal in a search for bony obstruction or
clot. A ridge, mottling, or change of contour may denote the site
of greatest damage and the dura may or may not be intact. Cere-
brospinal fluid may appear at once or gush out during the manipula-
tion, as if under tension or confined.

It is generally advisable to open the dura, and it is accordingly
caught at each margin by mouse-tooth forceps (as in opening the peri-

598 TRADMATIC SURGERY

toneum), nicked, and the iacision is then extended by small sdssocs
to the desired extent. The edges of the dura may be held apart by
stitches placed on either side, and these are then held by clamps at the
edge of the wound (Fig. 550, b).

Fm. 550.— Laminectomy : ii, Removal of spinous processes and lamime; b, duraslil
and retraclcd by sutures; r, dura sutured by running stitcb; three r
]>assed through muscle, fascia, and skin.

Clots may be found or damage may be evident by indentatioD,
flattening, or even pulpification. If the cord is edematous, it has
been advised to make small vertical incisions upon or punctures of it
in many spots with a needle. Personally 1 have never done this and
know nothing of the efficacy or wisdom of it, and prefer to rely upon
the decompression afforded by the other steps of the operation.

The dura is carefully closed by fine siUt or catgut, and Ikis dosiHt
must never be omilled even in t!w presence of oozing cord substatux. The
muscles arc sutured by catgut or kangaroo tendon and a separate
layer of sutures coapts the fascia. The skin is dosed by silk or silk-
worm-gut and no absorbable suture must be used therein, as it fre-
quently breaks and thus allows the wound to gape on the tenth day

INJURIES OF THE SPINE 599

or later. A few retention stitches tied over a roll of gauze or rubber
tubing act especially well in long wounds. .

Drainage should not be used. If for any reason it is employed,
folded rubber tissue or a few strands of twisted catgut or silkworm-
gut are introduced down to the level of the sutured dura, but under
no condition, should it go deeper. All possible blood should be
squeezed from the wound and a heavy gauze and cotton dressing
applied with adhesive straps snugly covering all. There is no need of
a plaster-of-Paris jacket unless redislocation or aggravation of bony
deformity is feared. The dressing is changed on the tenth day unless
there is indication for earlier removal of it. The stitches are removed
then and a gauze and adhesive plaster dressing reapplied.

Results. — Practically those of hematomyelia or laceration of the
cord.

Laceration of the Cord

This sort of damage varies in extent, but for practical purposes
may be grouped as {a) slight; (6) moderate; {c) severe (crushing,
pulpification, severing).

Causes. — Ordinarily the factors producing fracture-dislocation
are at fault, as bony injury almost always coexists. This type of
damage hence represents the severer forms of spinal violence, such as
crushing, sharp bending, and heavy blows in a stooping posture.
Another group depends upon actual penetration, usually from stab
wounds and the presence of foreign bodies (as bullets).

(a) Slight Lacerations. — The dura may or may not be torn and the
extent of the damage is limited to a portion of a vertical or transverse
segment. The posterior portion of the dorsolumbar cord is generally
the part aflfected, and in no instance of this group is more than one-
lourth of the cord diameter involved.

Symptoms. — Differentiation from localized spinal hemorrhage or
"bony pressure cannot be made unless the history, lapse of time-
xadiographs, or operations give corroborative evidence.

Any localized motor and sensory paralysis persisting more than a
"week without improvement justifies this presumptive diagnosis,
sissuming that the violence and the history are adequate. The most
typical cases are those in which a bullet or missile has cut or nicked
^ well-defined margin of the cord, or localized bony spiculae impinge,
^ind in such instances the symptoms are more easily determinable.

(i) Moderate Lacerations. — These are cases in which the motor,
sensory, reflex, trophic, and visceral involvement is of such a grade

6oo

TRAUMATIC SURGERY

that cord function is abolished at and below the level of the Ibioh.
Usually extensive penetration or fracture-dislocation exists, and ordi-
narily the damage is unequally bilateral.

This is the tj-pe common to most of the severe spinal injuries anti
the paralysis (usually of the lower extremities) is immediate, showing
little or no recession, but on the contrary often progressing. The
dura is generally involved. Cases of this sort promptly develop bed-
sores unless great care is given, and the bowel and bladder function is
wholly abolished.

Many of these patients die within the first few days of (i) shock;
(i) associated injuries; (j) pneumonia; (4) delirium tremens, or (5)
failing kidneys. Those surviving the first week may live from three
to six months and then die of sepsis from ascending urinarj- infection
or bed-sores. Some few apparently succumb to a progressing myeli-
tis and general malnutrition.

In my experience very few patients surviving the first week die
from spinal injury per se, the majority of deaths being due to sepsk
and pneumonia. The mortality in operated cases willlaterbestated.

(c) Severe Lacerations.— These arc the cases of so-called "com-
plete crushing," "severing of the cord," or " pulpification of the
cord." They represent the maximum of intraspinal injurj-, and
fracture-dislocation or gross penetrations are practically the sole
causes. Not only are the spinal arches often broken, but the verte-
bral bodies as well, and there is always dislocation or impingement
enough to produce distinct angulation of the compressed and much
damaged cord. The meninges generally are torn, and through the
rent, cord substance may extrude. If the dura is untom, opening of
it at operation or autopsy discloses pulpification and often the gray
matter is found disintegrated. The cord is very rarely completely
severed, but often it is held together by very few strands laterally
and it is virtually amputated.

In the absence of direct inspection it is impossible to clinically
differentiate this form and the preceding.

The lease of life in unoperated cases is similar to the preceding,
and the outlook is exceedingly grave even with prompt recognition
and early operation. Most cases die, and those that live arc more or
less bed-ridden.

General Diagnosis of Cord Laceratioa.— 7*/^ degree of laceration
cannot be estimated accurately except by operative inspection.

Assuming a history of injury to the spine of a crushing or bending
type associated with immediate motor-sensory paralysis, aboUtioa oi

INJURIES OF THE SPINE • 6oi

reflexes, lost bowel and bladder control, the physician will be early
called upon to determine the following: (i) Is there bony injury?
(2) Is the cord lacerated? (3) Is operation indicated? (4) What is
the probable outcome as to life and restoration of function?

(i) Is there bony injury? Fracture-dislocation can be reliably
presumed in the presence of bony deformity, localized ecchymosis,
tenderness, false motion, ancj crepitus.

In the cervical region, bony injury is more likely to be dislocation
alone, and then reliance is placed on the attitude of the head and
upper extremities and the visible malalignment of the spinous proc-
esses of the neck, and of the cervical bodies palpable through the
pharynx.

x-Ray examination is exceedingly helpful, but with extensive
paralysis it generally is but corroborative.

(2) Is the cord lacerated? If there is recession of motor-sensory
paralysis within the first two days, the cord is probably damaged to
some extent. Stationary or progressive symptoms after the first
week render this opinion stronger, especially in the presence of frac-
ture-dislocation or demonstrable penetration by a bullet or cutting
instrument. As stated, the degree of laceration cannot be ade-
quately determined until the cord is exposed, and a presumptive
diagnosis is often found wholly wrong at operation or autopsy. The
extent of the cord damage is inferentially greatest when bony injury
is greatest, but, fortunately, this rule is not absolute. The converse
is unfortimately equally true, as an apparently moderate degree of
bony injury does not by any means denote moderate cord laceration.

(3) Is operation indicated? This depends upon several main fac-
tors, of which may be mentioned: {a) General condition of the pa-
tient as to physique, age, occupation, and associated injuries. (6)
Extent of apparent cord damage, (c) Operative facilities.

(a) General condition of patient is the main element and no opera-
tive relief should be offered unless the physique is adequate. The
aged and alcoholics are the poorest surgical risks; young healthy
adults offer the best prospects. Manifestly, shock and coincident
injuries are often contra-indications. Bed-sores or other infective
zones near the operative field offer great hazards.

Generally speaking, it is better to wait a few days before under-
taking laminectomy even in recognizable cases (penetrations excepted) .

(6) Extent of Damage, — Personally, it is my opinion that every case
of Ulceration will ndt be harmed by laminectomy. Many of them 1 am
aware apparently recover without operation; but it is well to remem-

602- TRAUMATIC SURGERY

ber that in these so-called "lacerations" the diagnosis was at best in-
ferential and dependent very largely upon the belief that marked
bony angulation of necessity predicates some degree of cord lacera-
tion. That viewpoint does not appear to be at all conclusive.

No case is too extensive to be given an operative chance, as most
cases of this severe type are doomed without it at all events; per se,
the operation does not add great hazards, and in the average case it
requires about forty minutes for completion. Minor degrees of lac-
erations are often much benefited by operation, as the decompression
prevents localized serous meningitis (hydromyelia), edema, cj'st
formation, and organization of clots.

The removal of many spinous processes does not in any way
imperil the bony framework, as the main support is imposed upon
and derived from the vertebral bodies. After laminectgmy the gap
left by the removal of the arches becomes filled by a cartilaginous
mass, and in some cases a new bony arch is said to form (Gushing).

(c) Operative Facilities. — Asepsis is an essential to success and the
surgeon should have experience in this class of spinal work before
undertaking it.

In a general way it may be stated that operation is the treatment
of choice in those cases of intraspinal injury in which improvement
does not begin within the first week. The earlier the operation, the
better the outlook, but even after the lapse of years improvement
has occurred in cords released from bony pressure and the angulation
due to distortion of the spinal column.

(4) What is the probable outcome as to life and function? Early
fatalities occur within the first few days, and cases that live a week
generally die from septic complications and not from the injury per se;
hence the prognosis becomes one of maintaining asepsis. Septic
cases die within the first sLx months as a rule. Patients living a year
enter the chronic invalid class and die of intercurrent affections more
or less dissociated from the initial injury. Functional return depends
largely upon the initial extent of injury and the treatment. Oper-
ated cases do better than those unoperated, and even if the outcome
is unfavorable the patient and the physician have the assurance that
every effort was made to relieve demonstrable pressure and restore the
cord more or less to the normal.

Mild degrees of laceration may go on to complete restoration of
function, but the moderate and severe grades usually result in perma-
nent loss of function of varying degrees.

Regeneration of the cord after lacerations is held by many to be

INJURIES OF THE SPINE 603

anatomically and physiologically impossible because there is no
neurilemma; but despite this, there is abimdant clinical proof that
restoration does occur, to some degrees at least, even in a cord com-
pletely torn across. Stewart and Harte's case is an instance of
proved regeneration after deliberate suturing of the severed ends of an
injured cord.^ Fowler's case is another, and thatof Haynes (bullet
wound of liver and cord) falls into the same grouping, although the
degree of laceration was less. This last named case is personally
known to me because 1 sutured the wound in the liver and subse-
quently had the opportunity of assisting Dr. Irving S. Haynes at the
laminectomy and cord suturing. Later this girl was presented at the
Academy of Medicine and she was then able to walk, and at the
present writing is earning her living as a housemaid. She was totally
paraplegic from a .32-caliber bullet wound penetrating the right
upper abdomen and liver, entering the spine at the lower dorsal
levels traversing an intervertebral disk. The cord was perforated
almost at the center but there remained some intact fibers laterally.

This case and others are reported in detail in the literature.

The reasons for recovery after destruction of cord substance are
not well determined, but apparently rest upon a combination of the
following factors:

(a) Bridging of the gap by new formed nerve or connective tissue
that in time conveys proper impulses.

(6) Vicarious action on the part of adjacent undamaged segments.

(d) Nerve-root spontaneous anastomosis.

Suggestive literature as to this is mentioned in editorial comment
of the Jour. Amer. Med. Assoc, February 27, 191 5, p. 746. A. W.
Mayo Robson {British Medical Journal, Dec. 17, 191 7) reports a
remarkable case of cord suture after almost complete severance in a
patient on whom he had previously performed laminectomy suc-
cessfully for the relief of tubercular paraplegia.

Whatever the reason, 1 am firmly of the opinion that some sort of
recovery is possible if we can keep the patient alive long enough.

In this connection, I had under my care in 1913 a heavily built
man (aged forty-eight) who had been caught between a moving
elevator and the floor in such a way as to sustain a fracture-disloca-
tion in the dorsolumbar region, with fractures of several ribs in

^This patient is still alive although no regeneration has occurred. She earns
her livelihood knitting. sweaters.

-^^"L t no SURGERY

motor-sensory paralysis downward

.._. . -r: rr ^"^i of the umbilicus, with abolition of

T fJTC^ I mi bladder also.

. _- M, iTizji" •▼ere made and in about ten days con-

_ :': T trrtinn laminectomy, at which the writer had

-^v-j.^..r L I>r. Irving S. Haynes, in whose Harlem

rr rj.zent had been admitted. The cord was

... ::.T-^ ^c portions of it extruded and escaped when the

- -r:* . Tcicfce this the membranes were sutured and the

. ^ :• - -. :o; iS^.'^pt for a small submuscular drain. Primary

. ^ rt:*;. iZii :ie first notable effect was healing of the bed-

^ _. -^ 4yp«:*jr«i on the buttocks and heels. Later the

... -. — r-^c•i ro the Red Cross Hospital and active massage

.. -. ^j.^:::eau were given for several months. Subsequently

.,^ _ -.i-iivic -nccions were practised, and the patient was soon

V. t: tiriicti tn a wheeled chair, and has now learned to get

w. - -: -• :uic walker. He has a certain amount of sensor}-

. ....* . ^rn^irkAble \'isible and palpable increase in the mus-

^ i ::t- \;*^fr extremities, together with a reappearance of

^^,.^.;^ ..^j inkle clonus. He has a certain sensation when his

.V -- -T ..xc: ^> empty and his bladder empties by sp>ontaneous

^ Lt^ »*. *i* :«rv£v?t IS that further improvement will occur despite

, • 't;;.-^ ^•"-i*-*^ ^^^^ ^^^rd injury that apparently indicated an early

* >:> 7d:iont is still alive fOct., 1920).

CORD INFLAMMATION

- •v-: o: the coverings (meningitis) never occurs in the

^ ._- ' .v:vn, and hence trauma is only responsible when

..^- -v:v. without has occurred. It is exceedingly rare

^c"^^ .. • ^''''^- involvement of the cord substance itself, and thus

. •■v>.> .*: myelitis or meningomyelitis is usually made.

' , v^kT known of a case of **traumatic spinal meningitis"

, ^ 'v .. *.". rxulity an example of "traumatic myelitis," and no

. ^ ..,"^. :^^ mv notice in which minor grades of injur)' (falls,

, ^,^ were causative. It is exceedingly common to have a

., ..- ^.' svMUO more or less recent injury to the back or spine,

._i.\ all of these are coincidental and in nowise causative.

^^. vWiVuxl that a similar history is usually volunteered or

X- •■"'. crx'l^rospinal meningitis also, but in each instance the

^••^ :> :u^l much closer than a history of a preceding blow on

, sx':"x •*. wouM be to a later developing tj'phoid.

••>*

\ ■ -

INJURIES OF THE SPINE 605

Myelitis is inflammation of the cord substance, and it occurs as a
complication of many intraspinal injuries associated with contusion
and laceration of the cord.

Fracture-dislocation and penetrating wounds (bullets and stabs)
are the common causes. Hematomyelia is an exceedingly rare origin.

The condition has been previously described in connection with
fracture-dislocation and contusions and lacerations of the cord.

It does not occur from ordinary injury to the back or spine,
and in the absence of a considerable injuring force is usually part of a
cerebrospinal inflammation of germ origin.

It is to be remembered that there are numerous causes of cord
inflammation independent of injury, and these may induce sudden
onset of paralysis ("acute myelitis") or cause symptoms to appear
gradually ("chronic myelitis'^-

FRACTURE-DISLOCATION OF THE SPINE

As previously stated, dislocation without fracture is exceedingly
rare, but the reverse is not uncommon.

Dislocations have already been spoken of (see pages 223-235).

Frequency and Varieties. — This is a relatively rare form of
injury, and in my list there were 22 cases in the list of 5008
fractures, a percentage of .44. The cervical and dorsal regions are
about equally often involved; lumbar involvement is about one-half as
frequent as cither of the two preceding. Cervical types are far more
commonly fatal, and above the level of the fourth cervical, death
is usually prompt. The fifth and sixth cervical, the twelfth (last)
dorsal, and the first lumbar vertebrae are more often broken than all
the others.

Clinically speaking, most spinal injuries occur in the cervico-
dorsal or dorsolumbar regions.

The bodies of the vertebrae are broken in about two-thirds of all
the cases, and the fracturing line may be vertical or transverse or
more or less asymmetric, and in one or more planes. Crushing of the
vertebral body is not uncommon, and it is broken in over one-half
the cervical, seven-eighths of dorsal, and practically all lumbar
fractures. In the cervical and upper dorsal region, simultaneous
fracture of two or more vertebrae is the rule; but in the lower dorsal
and especially in the lumbar sections a single vertebra is generally
affected.

The arches are usually involved to some extent with the bodies,
the rule being to have involvement of the arch corresponding or

6o6

TR,A.L-MATIC SUEGERY

adjacent to the fractured body, the transverse processes, pedides, and
lamlnir. being the parts usually affected. The arches are affected in
about one-half the cervical and in one-eighth of dorsal and lumbar

fractures.

cal vertebra \a fiactu

Fracture of the spinous process in association with other fracn
f the vertebra occurs in about one-half the cervical cases.

Fig. 5S2. — Fracture dislocation of the !

/i-aj

nitli impingement ol the SfHnal o

DislocatWH may be absent in fractures of the cer\-ical region,
but is practically alwaj's present in other regions. The extent of the
displacenicnt varies, depending upon the manner of the inji^^l
but ordinarily the upper vertebra is displaced forward so that it|

INJURIES OF THE SPINE 607

distort, contuse, or lacerate the cord. There may be also more or
less rotation or lateral displacement of the bodies; either of these
deformations tend to malalign the spinal column and narrow the
spinal canal and thus interfere with cord function.

The intervertebral ligaments and di5^5 are commensurately affected,
and the latter may even be crushed or squeezed* out of position.

Causes. — Muscular violence is the rarest element and is responsible
only in the cervical regions as a rule. Sudden twists or jerks of the
head may fracture the arches and exceptionally produce fracture-
dislocation. Diving accidents occasionally are partially due to efforts
to avoid striking the bottom by pulling the head backward, with the
additional damage following direct contact.

Direct violence from heavy blows on the neck or back, forcible
crushing, and allied forms of violence generally damage the arches
and may produce intraspinal involvement from hemorrhage or im-
pinging of a bony fragment.

Indirect violence is the usual factor, such as from sudden severe
forward bendings, twists, and archings of the spine from a variety of
causes. Of these may be mentioned falls, heavy blows while in a bent
or crouching position, jamming in narrow spaces, and in fact any
severe motions tending to cause the spine to suddenly assume a
"jack-knife" attitude. Aboard ship many cases arise from falls from
rigging or into holds; railway cases are generally from falls and coup-
ling cars; mine accidents from cave-ins; in building operations from
blows of falling material or jamming forces; diving and football are
the common causes among the sports; trapeze and acrobatic stunts
furnish another group.

Slight degrees of violence do not produce fracture-dislocation, and
the grade of needed violence is greatest in the lower portions of the
spinal column where the parts are strongest and least flexible (Figs.

551, 552).

Symptoms. — Cervical Region. — Between 25 and 35 per cent, of
spinal lesions affect this level.

Atlas and axis involvement are clinical curiosities, as death is
nearly always instantaneous; accurate classification of these cases,
after a provisional diagnosis of "broken neck" or "fractured base, of
skull," is usually made by the pathologist.

Midcervical involvement also results in prompt death on account of
diaphragmatic paralysis from phrenic nerve invasion as it passes out
between the third and fourth vertebrae. Pupillary signs may also
exist.

I'ic. 553, 554.^Fraclure of sixth cerWcal vertebra; note postural deformity.
Patient hurt ^hleen months previously white diving. No symptoms now aside bom

stiffness of neck, deformity, numbness and trophic disturbances of left |
eitremity. The markings Indicate spinou? processes and outlines of scapubc.

INJURIES OF THE SPINE

609

Lower cervical involvement includes those below the fourth vertebra,
and the typical symptoms relate chiefly to involvement of the brachial
.^plexus (composed of the fifth, sixth, seventh, and eighth cervical and
ret dorsal nerves).

The phrenic nerve may here also be involved at the time of the
cident, or become so later, and thus result in the sudden death
xurring so often 10 spinal injuries.

Obviously, the extent of injury will determine the symptoms and
B part the outcome, and thus all grades and manifestations are met

Fill, 5s6- — Dorsal verlebr.i;, lateral

with. Local signs may show by an altered position of the head
(flexed, rotated, extended) ; swelling or external evidence of malalign-
ment over the region of the spinous processes (Fig. 556); local
ecchymosis; rigidity or spasm of the neck muscles; pain on motion of
the head and upper extremities. Crepitus and false motion may be
present. Palpation through the mouth may give valuable informa-
tion, and sometimes pharyngeal swelling and ecchymosis may be
visible (see Fig. 551).

FiOG. S57, 558.— Fraclure-dialocation of the (I-Il) lumbu vertebn: in a pMIieot
gbowing marked old spinal cur\-Hture. There were no intraspinal symptoms in (hi&
case. This patient also broke her leg in the Eame accident (see Fig. 476).

INJURIES or THE SPINE Oil

The deformity tj-pical of some cervical lesions is shown in the
Idiagrams. (Fig. 200, page 227.)

Neural signs are those of motor flaccid paralysis at the level of
and below the lesion, this usually being complete or nearly so. Respi-
ration is generally affected to some degree, especially expiration. In
some cases the paralysis may not reach higher than the middle of the
body at first, but within a few days it reaches the height of the lesion.
There may be considerable asymmetry so that one arm is more in-
volved than the other. The paralysis of the lower limbs is spastic in
invasions of this region. Priapism occurs oftener in cervical involve-
ment than in any other segment.

Fig. SS9- — Fracture-dislocalioD of the first and second lumbar vertebtie.

Sensory signs correspond to but are lower than that of muscle
loss, and generally anesthesia extends as high as the nipples; in the
arms there may be various root pains with paresthetic feelings,
and it is not uncommon for the level of anesthesia to rise after the first
day, but it rarely reaches as high as the lesion.

Muscle spasms occasionally occur. Dissociation anesthesia is
pathognomonic of hematomyelia and thus rarely occurs in typical
fracture-dislocation.

Visceral and trophic signs are generally complete in marked cases.

Upper dorsal invoh'ement is usually regarded as including the upper
ten bones of this segment.

6ia TRAUaiATIC SURGERY

Local signs include visible deformity (usually kyphosis) over tte
spinous processes involved, perhaps with regional swelling, ecchy-
mosis, and malalignment. Local tenderness, rigidity, or spa^n
muscle may be present; crepitus and false motion are occasEoi
Sometimes a palpable gap marks the site of trouble.

Neural signs are indicated by paralysis of motion at and below
level of the lesion; all grades are present depending upon the amount
of cord damage.

chy.

Sensory signs are indicated by anesthesia corresponding usually*
the motor loss, with an area of hyperesthesia just about the level of
the lesion; this hypercsthetic zone is the best single index of the height
of the damage in any case.

Visceral and trophic signs are generally present, and the rectum
and bladder are nearly always involved, even if the lesion is incomplete
and at first apparently insignificant (Figs. 557-562).

Lower two dorsal and upper tu<o lumbar invohements are very com-
mon and the term "dorsolum bar"' is given to this group; over one-
half the cases are in this zone.

Local signs are similar l-o the preceding.

Neural signs are manifested by motor paralysis (complete I

INJURIES OF THE SFIKE

6l4 TEAllIATrC SURGERY

incomplele) at and below the level of the lesion; the extent of paraly-
sis may take some hours to become fully manifest.

Sensory sigtts may not appear at once, but when present corre-
spond to the motor distribution. Anesthesia is generally in the form
of an irregular girdle that may reach as high as the umbilicus or
more often to the level of the superior iliac spines.

Visceral and trophic signs often are late in onset, but usually
coexist.

Fig. 563. — Fracture- dislocalioD of the second and third lumbar veftebrsc.

Lower three lumbar involvements (Fig. 563) often give few signs of a
strictly neural sort because the cord ends at the lower pari of the
second lumbar vertebra, and thereafter the conus medullarts and
Cauda equina only can be impinged upon.

Local signs are few and asymmetry is unusual; hence evidences of
bony invasion are with difficulty determined in the abscence of x-ray
examination.

Motor signs may be present as an affection of the muscles of
locomotion, but both limbs are rarely affected alike.

Sensory signs are generaUy in the form of more or less saddle-
shaped anesthetic areas in the [jeri-anal, gluteal, or perineal regions,^

Visceral and trophic signs may or may not exist.

Behavior oj the reflexes in all forms depends on the level of the les

INJURIES OF THE SPINE 6x5

That of the knee is absent or diminished in lesions of the second,
third, and fourth lumbar segments; above this level they are absent
at once, below they may be intact. Loss of the knee-jerks is not of
itself an index of complete laceration of the cord, as it may persist
even in total severance. The earlier it returns, the better the out-
look, and when exaggerated the cord damage is incomplete.

Ankle-clonus and exaggerated knee-jerks usually coexist.

The plantar reflex is absent in lesions of the upper three sacral
segments; above this level the Babinski reflex is also present.

Superficial reflexes are unreliable, but are generally lost in com-
plete lesions.

Variation in symptoms ordinarily occurs within the first three or
four days.

Retrogression is a good indication that part of the damage, at
least, is from hematomyelia.

Accession is an unfavorable sign indicative of myelitis, especially
if fever exists.

Diagnostic Factors. — About one-quarter of all cases are in the
cervicodorsal and about one-half in the dorsolumbar region. Above
the fourth cervical most cases are rapidly fatal, and the prognosis
becomes increasingly better from this level downward.

Bony involvement is determinable by the ordinary fracture-disloca-
tion signs, such as:

(a) Deformity: Spinous process malalignment, swelling, posture.

(b) Discoloration: Bruising, ecchymosis.

{d) X'Ray examination: Postero-anterior and lateral views should
be made when possible.

Care must be exercised in excluding an old deformity, such as
kyphosis or lordosis.

Cord involvement is determined by: (i) Motor paralysis: Partial or
complete, asymmetric or symmetric. Extensors usually more
involved than flexors, and all grades are encountered, from weakness
to abject flaccidity. Spasticity after flaccidity is common.

The "motor level" is generally that of the lesion, but may be
below it; if above it, myelitis probably exists.

Recession is a sign of hemorrhage and of good import.

(2) Sensory Paralysis. — Rarely symmetric or complete, and usu-
ally some distance below the zone affected, because the sensory
nerves run downward some distance before leaving the spinal canal.

6i8

TRAITIATIC SXJKGERV

(A) General Treatment. — Trattsport should be as carefully made as
possible, preferably with the patient lying flat on the back or face.
Any forced bending or change of position is to be verj' carefully
guarded against, notably any sudden motions of the spine.

Bed. — The mattress should be filled with air or water when
possible, otherwise, it should be extremely smooth and so arranged
that pressure is kept off the sacrum, heels, knees, and malleoli.
Automobile inner tubes filled with air or water are valuable
extemporized aids.

Bladder should be emptied at least night and morning by catheter,
and the asepsis must be perfect, and when possible one person should
be assigned to this duty. The boiled catheter should be soft rubber
for each sex and suitably lubricated with sterile oil, glycerin, or
other emollient. The meatus is first sponged with a weak antiseptic
solution (as bichlorid i : io,ooo), and the attendant will be reasonably
sure of cleanliness if sterile gloves (cotton or rubber) are worn. The
uretlira must be traversed very gently and force is decidedly harmful.
Urotropin should be given every four hours in 5-grain doses for a
month; thereafter it may be reduced in frequency if conditions permit.
If the urme becomes alkaline, ammoniacal, foul, thick, muddy, or
purulent, the bladder should be gently washed once or more daily
with boric acid, salt, or weak permanganate solution. Sod. ben-
zoate in ten grain doses should then be added to the urotropin.

In many cases the bladder may be trusted to spontaneously
empty itself into a urinal constantly left between the patient 's legs;
but my personal preference is for catheterization for the first week
at least, assuming that it can be done reliably. If this is impossible,
then spontaneous urination is less dangerous than faulty catheter-
ization. It has been stated that a suprapubic or perineal opening
into the bladder woidd allow the best form of drainage, but this is
rarely called for and has inherent dangers. The external parts
must be kept very dry.

The aseptic control oj llie bladder is probably the most essenliat
element in Ireattnent.

Bowels are emptied daily by enema or a mi]d laxative, and by a
process of training they may be made to respond at a set time usually.
Tj-mpanltes is an annoying feature at times; aromatic spirits of
ammonia, or Hoffmann's anodjue {y-'i teaspoonful of either in Vj
glass very hot water) will usually control it. A few drams of turpen-
tine or an ounce of powdered alum to a quart of enema solution also
act well. Much care must be taken to pre^'ent perianal irritation.

INJURIES OF THE SPINE 619

Skin is to be kept from pressure by air or cotton doughnut-
shaped "rings," and alcohol or alum solution sponging is to be freely
employed. Frequent changing of position is an excellent preventive
of bed-sores. The legs will have a tendency to flop sidewise, and
pillows or other padded supports must be used to keep pressure off
the outer margins of the knees and ankles. The heels are kept off

Fig. 564. — Extension in fracture-dislocation of spine.

the bed by "rings" through which the os calcis protrudes, or by a
soft roll of cotton placed just above the tendo Achilles. Suspending
the limbs in a Thomas splint or some overhead-frame device (as in
fractures) is an added safeguard.

Fig. 565. — Plaster-of-Paris dressing in cervical spina] injury; a. Dorsal Bexion of head;
b, ventral flexion of head.

No prolonged pressure of any sort can be permitted, and the ingen-
uity of the attendant will many times be called upon to devise new
ways of preventing added pressure necrosis.

Bed-sores once formed from decubitus are washed with a weak
antiseptic solution daily, and if sluggish are stimulated by iodin,
silver, or the curet. Balsam of Peru (pure or in 10 per cent, solution

620 TRAUMATIC SURGERY

in castor oil) may also be poured over them and a gauze dressing
applied. When granulation is under way, scarlet red ointment
makes a good dressing occasionally (see Treatment of Ulcers, p. 41).

Exposure of the wounds to sunlight and the open air is probably
the best element of treatment next to freedom from pressure. Odor-
ous sores are benefited by a solution of permanganate of potash, or
iodin (i dram to i pint), or creolin (i : 100).

(B) Local Treatment {Bone and Cord). — Non-operative. — Naturally
much depends upon the site and extent of the lesion and whether or
not there are associated injuries. If the treatment is to be non-
operative, and if there is deformity of the spine (judged by obvious
symptoms or radiograph) it is proper to consider the advisability of
correcting it.

Kyphos and lateral rotation are the usual malalignments, and the
former is usually amenable to correction by (i) direct pressure aided
by (2) backward flexion (extension), or (3) suspension by a pulley
fastened to the chin (Fig. 564), or (4) opposed by traction at head
and feet with the patient prone and the head in an apparatus like
a "jury-mast." See also p. 223, '^Spine Dislocation."

When it has been corrected, a plaster-of -Paris jacket is appb'ed
with plentiful padding over the deformity (Fig. 565). Sometimes
efforts of this sort increase the symtoms, and if so, immediate opera-
tion should be done.

If there is demonstrable fracturing of the arch, much pressure or
manipulation is likely to be very dangerous. If the bodies are much
crushed, little or no impression will be made on the deformity by
external force.

Operative Treatment. — This laminectomy procedure has already
been described under Contusion of the Cord (see page 596).

If the cord is found to be lacerated, the fragments are coapted
by fine silk sutures introduced sufficiently far from the edges to per-
mit their meeting when traction is applied. If the gap is too wide
to be bridged, or if the laceration has caused pulpification, it is ad-
visable to use the posterior root above and stitch it to the root below
so that they form a bridge. If the roots are not strong enough, a
strand of the erector spina? shining fascia can be taken from the edge
of the wound and implanted to bridge the gap. An intercostal or
other nerve may be used for a similar purpose.

In the presence of exceedingly great mutilation, the advisability
of amputating and then suturing each end of the damaged cord must
ie entertained. This has been done on a few occasions apparently

INJURIES OF THE SPINE ' 62 1

with some success; but in the vast majority of cases the procedure is
umiecessary and needlessly hazardous.

Muscles are kept under control by suitable devices so that contrac-
tures do not occur, notably drop foot and bent knees.

Massage, electricity , vibration, ^^ health eocercisers,^^ and other gym-
nastic methods are all very valuable and their use can begin after the
first week. Deep breathing and dumb-bell exercises are useful in
preventing hypostatic«pulmonary changes.

PENETRATING WOUNDS OF THE SPINE

The conditions here are practically those of compound fracture
and the treatment differs only in so far that it generally is modified
by associated injuries, usually those to the lung, liver, stomach, or
intestines. Very many of these cases were seen in the War and for
the most part they ended most unfavorably.

Bullet Wounds. — If conditions permit, and the bullet is located
with sufficient accuracy (by the history, symptoms, or radiograph),
it should be removed at once.

All grades of cord laceration are encountered, most of which are
due to the bullet, with occasionally the added damage from bony
spiculae. Very exceptionally the bullet may not penetrate the dura,
and then the symptoms are wholly due to pressure from it alone or in
association with extravasated blood. It has been stated that a
spent bullet has reached the spinal canal and dropped into it by its
own weight, to be later removed by operation at a distance from its
place of entrance; this seems remotely possible.

Stab Wounds. — Sharp-pointed objects, like daggers, knives, bay-
onets, hat-pins, glass, and other spiked missiles, occasionally pene-
trate an intervertebral disk, causing laceration of the cord of varying
degrees.

These cases are of importance from the standpoint of rarity more
than because of their symptoms or treatment, as the latter have al-
ready been discussed in connection with the lesions usually associated.

Spinal Cysts and Serous Meningitis. — Occasionally pressure
effects are produced by a more or less circimiscribed collection of
cerebrospinal fluid following various sorts of intraspinal trauma,
notably hematomyelia, contusions, and fracture-dislocations. In
the majority of instances the entertained diagnosis has been localized
pressure from blood or bone, and less often intraspinal tumor has
been assumed to exist.

622 TRAUMATIC SURGERY

At operation (or autopsy) a collection of cerebrospinal fluid under
tension has sometimes been released, and in some cases this is seen to
be confined in a more or less cyst-like wall. Occasionally these
cystic cavities are quite nxmierous and not imlike those found in
syringomyelia.

The distinguishing feature of all these cases has been a history of
intraspinal injury with recession of symptoms for a certain period,
and then a stationary stage, with perhaps later a period of accession.
In all there are definite evidences of localized intraspinal pressure
manifested by sensory and motor signs not xmlike timior manifes-
tations. Many of these give x-rzy corroborative signs.

These cases are to be distinguished from syringomyelia with
which they are related clinically, but not etiologically. Some of
these cases because of radiating pain are diagnosed as rheumatism,
sciatica, or neuritis until the xmderlying true cause is demonstrated.

CHAPTER XIII

INJURIES OF THE CHEST

Anatomy. — The bony cage constituting the thorax is made up of
the cartilaginous sternum in front, the twelve ribs on each lateral
margin, and the dorsal spinal column posteriorally. This architec-
ture combines strength and elasticity with ample protection, and
doubtless accounts for the freedom from intrathoracic as compared
with intracranial or intra-abdominal injuries. The muscular and
ligamentous arrangement affords added support and protection to
the subjacent parts and also to the blood-vessels ramifying near the
surface.

The intercostal vessels run in a groove on the under surface of
each rib, and thus are well protected and are almost never involved
in fractures.

The internal mammary vessels are on the posterior surface of the
sternum; injury of these is also extremely rare except from perforat-
ing injury.

The pleura lines the inner surface of the ribs and invests the limgs.
The lower limits of this serous pleural sac are shown in Fig. 292, a, 6,
and this distribution is important in showing what relation if any
exists between a broken rib and a pleurisy, it being well recognized
that early traumatic pleurisy is localized to the site of injury.

The lungs occupy the entire right half of the thorax with their
three lobes (upper, middle, and lower; or superior, middle, and in-
ferior), and most of the left half with their two lobes (upper and
lower ; or superior and inferior) . They are very rarely involved in indi-
rect violence causing contusion of the chest, and rather uncommonly
affected even by direct violence, as by rib puncture.. Perforations
of the lung from bullet, stab, or other wounds are generally less ser-
ious than the anatomic and immediate physical conditions indicate.

Traumatic pneumonia, like traumatic pleurisy, begins at the site
of injury and usually appears within two or three days, and may
becomes manifest within twelve hours; it is always of the lobar type
and generally runs a rapid course.

The bronchi generally are only involved as a part of injury to

adjacent organs.

623

624 TRAUMATIC SURGERY

Heart involvement is always the outgrowth of direct violence^
usually from stab and less often from bullet wounds. War injuries
demonstrated that the heart muscle and cavities could tolerate a
foreign body for a relatively long period.

This organ is so surroimded by the limg that injury to it is rela-
tively impossible without first damaging the intervening structures;
likewise, it is further protected because of its motility in a dangling
position.

Mediastinum injury is of surgical significance only because it is
sometimes associated with injuries involving the adjacent contents
of the thorax.

Thoracic duct injuries are exceedingly rare alone, and are of im-
portance because of the coexisting damage to nearby parts.

Esophagus injury is commoner from within than without, and any
external damage is generally a part of fatal penetration of neighbor-
ing structures.

As in cranial and abdominal injury, the measure of damage is the
extent of involvement of the thoracic contents, and thus injury may
affect the —

(i) Chest wall alone — extrathoracic injury.

(2) Chest contents — intrathoracic injury.

CHEST WALL OR EXTRATHORACIC INJURY

This may be in the nature of contusions, muscle ruptures, wounds,
fractures, and dislocations.

Contusions are generally from blows, falls, squeezing, jamming,
and allied causes, such as may result from fights, contact with mov-
ing objects, and railroad and vehicle accidents.

Symptoms. — Shock of varying extent occurs and the patient is gen-
erally "knocked out'', and may even become cyanotic in an inten'al
during which respiration is temporarily abolished or interfered with.
Thereafter local pain is felt and respiration is shallow or abdominal
for a varying period.

Swelling and ecchymosis soon appear; if the latter is early in onset,
i t may be inferred that only the superficial parts have received the
'Drunt of the force. Hemlaomas may form, but the texture of the
muscles is less favorable for their development than in the abdominal
wall. Pain on ^notion and pressure is present and is increased by
deep respiration; but the absence of crepitus, point-pressure paiD)
and false motion excludes fractured rib.

INJURIES OF THE CHEST 625

Treatment. — This requires the external applications (ice or heat),
and in some cases the use of adhesive straps, as in fractured ribs.
Hematomas uniformly respond to pressure.

The course is to.ward rapid recovery, although the discoloration
and pain on usage may persist for several weeks.

Ruptured muscles sometimes are the outgrowth of the same
causes producing contusions, but more commonly result from violent
eflforts, such as coughing, sneezing, lifting, throwing, or wrestling.
They are rather uncommon, tearing or rupturing of the sternal at-
tachment of the pectorals, and the digitations of the serratus magnus
and the latissimus being most common.

Symptoms are like those of contusion, but occasionally a gap or
depression in the muscle is apparent to sight and touch.

Treatment. — This is mobilization by adhesive straps. 1 have never
known a case where suture was needed.

The course is toward perfect recovery.

Wounds are of all types and are inflicted by knives, cutting in-
struments, glass, spikes, nails, and various other more or less sharp
materials. Bullet wounds are quite prone to richochet about the
chest from a rebound ofif the rib or sternum. 1 have seen several
cases where a .32 or larger calibered bullet at close range has struck
the lateral chest wall, caromed against a rib, and passed half-way
around the chest, to appear subcutaneously almost at the level of
entrance. Such deflected bullets rarely fail to lodge in the soft
tissues, as their force is mainly spent at the time of initial impact.
A ridge of swelling or line of ecchymosis often marks their path
around the chest.

Symptoms are those of any other wound, and bleeding is usually
moderate unless an intercostal, internal mammary, or main branch
from the axilla is cut.

Treatment. — Primarily this should aim at the removal of any
foreign body, especially glass and metal fragments or pieces of cloth-
ing. Disinfection by iodin is to be practised (as outlined in the
treatment of wounds), and the bleeding is controlled by pressure or
ligature. If necessary, the original wound must be enlarged enough
to bring into view any spurting or oozing vessel otherwise uncon-
trollable. All such wounds should be drained for a few days. Bul-
lets lodged subcutaneously are best left alone for three or four days
or even longer, and they are then removed under local anesthesia
after reaction has subsided. If infection of a wound occurs, the

626 TRAUMATIC SURGERY

customary treatment is given. The patient should be kept off the
back, so that hypostatic pneumonia may be prevented.

The course is generally favorable and the prognosis is that of
infection.

INJURIES OF THE FEMALE BKEAST

Contusions. — These are exceedingly common, and there are few
women who have not at some time been subjected to such an acci-
dent.

Causes are blows or falls, and contact with moving or stationar}'
objects, notabl}' articles of furniture and the edges of doors and
similar projections. The violence is rarely received at the summit of
the breast, but ordinarily at the outer lower margin.

Symptoms are pain, nausea, and sometimes decided evidences of
syncope or shock.

Locally, swelling and redness are very promptly apparent, and
usually within a day discoloration and induration follow. The area
involved is generally sharply circumscribed to sight and touch, and
pain is marked at first and is notably increased by motion and palpa-
tion. Fever is an occasional accompaniment. Superficial bruising
is generally more diffused and signs of hematoma do not then appear.
Localized point tenderness, fluctuation, brawniness, axillary gland
involvement, and fever indicate abscess formation; such a sequel is
commonest in nursing women or those who have borne children, and
where fissured nipples have existed. I have, however, known axil-
lary adenitis to occur and subside without abscess formation. After
local signs disappear, an area of induration may remain, and this is
generally relatively hard, mobile, and painless. Still later, the in-
durated area may soften, undergo cystic formation, be absorbed, or
persist. The ordinary case begins to show signs of subsidence
within a week, and the discoloration disappears in a few weeks, and
all indications are usually gone in a month or six weeks, and examina-
tion then discloses nothing aside from slight local pain on firm pres-
sure, but of which the patient may be imaware even if tightly laced.

Treatment. — This demands absolute rest, freedom from pressure,
and the external use of cold lotions. Under no circimistances is rub-
bing, massage, cupping, or similar interference warranted; such inter-
vention is likely to do great damage. The breast should be suitably
supported in a properly padded sling and held at an elevated angle of
comfort. If an abscess forms, incision and drainage are indicated,
the opening being made in a line radiating from the nipple toward

INJURIES OF THE CHEST 627

the chest, like the spokes of a wheel. It should be liberal at first, so
that painful repetition will be prevented; a Bier suction cup is a very
efficient aid, as by its use a smaller incision is adequate. Drainage
should be of gauze packing for the first few dressings, so that contrac-
tion will be prevented. Cysts are watched, and aspirated or excised
if they fail to spontaneously resolve.

The course of the vast majority is toward recovery, and the inci-
dent is usually forgotten until after a lapse of some months or years a
tumor of the breast appears and the original or another injury is
promptly accused. The vast majority of the laity and a great many
physicians still correlate a tumor of the breast and an injury despite
the fact that such a relationship is exceedingly rare and rather
improbable in the light of modem ideas as to tumor formation in
general. If any injury is to bear a causal relation to a subsequently
developing breast tumor, malignant or otherwise, the following fac-
tors must pertain:

(i) The tumor must involve that part of the breast originally
injured.

(2) The breast must have been previously sound and uninjured
and preferably known to be so by recent examination.

(3) The interval between the injury and the development of
the tiunor must have been filled with symptoms showing rational
progress toward a neoplasrn.

(4) A reasonable time must have elapsed, usually not more than
six or nine months, before the tumor was apparent; and the nearer
the accident to the time of tumor development, the greater the proba-
bility of relationship.

(5) The size, symptoms, and especially the pathologic type of the
tumor should be such as to be reasonably sure that the injury was
more productive than another more usual and ordinary source of
origin.

(6) No signs of tumor formation must exist elsewhere.

How far an injury may accelerate a tumor already present is diffi-
ctdt to decide; answer to this would be largely predicted oh the his-
tory of the patient and the tumor, the manner of the accident, and
how close the tumor was to the place struck, and what symptoms
immediately and subsequently followed. As is well known, many of
these tumors are independently subject to periods of quiescence,
remission, and accession; for this reason very careful analysis of all
the facts must be made before an accident is looked upon as the sole
aggravating element. The operative or pathologic examination

628 TRAUMATIC SURGERY

would be exceedingly important, and. if there are any areas of hemor-
rhage apparently of external origin, either outside or inside the timior,
such evidences might prove corroborative. It is my experience that
the majority of patients seeking advice for a tumor of the breast
assert that the breast had been injured at a more or less distant
period, but except in one instance I have never been able to satisfy
myself that an accident appeared wholly responsible for the tumor.
This was in a forty-five-year-old married woman who was of unusual
physique and who never had any lactation troubles and whose
family and previous history were negative. Some few months be-
fore I examined her she had fallen from the platform of a steam rail-
way coach striking her right breast against the last step in her des-
cent. She sustained sundry injuries, notably a fracture of her
ankle, and a localized painful swelling of the outer margin of her
breast. This last soon became ecchymotic, and when the discolora-
tion disappeared a small lutop remained and gradually increased in
size until it became so large and painful that she sought additional
surgical advice regarding it. It appeared that about four or five
weeks before her accident she had some pain in the vidm'ty of her
opposite breast, and her family physician then took occasion to
examine both breasts and found them normal. The tumorous
breast was removed about nine months after the accident and the
growth proved to be carcinomatous.

INJURY OF THE MALE BREAST

This requires no special mention to differentiate it from contu-
sions of the rest of the chest wall.

Chest Contents or Intrathoracic Injury

This may be the outcome of non-penetrating or penetrating inju-
ries, and the effects obviously depend on the part affected; hence dis-
cussion will include injury of the pleura, lung and bronchus, heart and
pericardium, mediastinal contents (esophagus, thoracic duct vessels).

INJURY OF THE PLEURA

Causes. — From contusions capable of produdng so-called "con-
cussion of the chest'' or '^commotio thoraci," pleurisy may rarely
follow at the site of the impact. It is an unusual occurrence in the
absence of penetration of the pleura through the chest wall or from a
broken rib ; of all causes the latter is the commonest, and next in
frequency is intercostal penetration from stab and bullet wounds,
with or without penetration.

INJURIES OF THE CHEST 629

Symptoms. — With or without penetration the signs usually ap-
pear within the first day, and if delayed beyond three days (in the ab-
sence of wound infection) the traumatic origin is to be doubted. The
onset of traumatic pleurisy is with localized pain, difficult and there-
fore shallow and rapid or "cog-wheel" breathing, slow and interrup-
ted speech, cough, fever, and sometimes a chill. Locally will be
found crepitus at the end of inspiration, with altered voice or tactile
fremitus. If fluid is present (serum, blood, or pus) the added signs
will be dulness or flatness on percussion, and diminished or absent
breathing and voice sounds.

The ordinary form is a localized dry (fibrinous) pleurisy, and the
wet (serofibrinous) or pleurisy with effusion is a rare sequel. The
hemorrhagic form is generally associated with injury of the lung,
and then there often is a combined pneumothorax.

Subcutaneous emphysema is a usual accompaniment when lacera-
tion of the pleura occurs, and it may invade the entire chest and even
extend to the abdomen, neck, and face.

Treatment. — This is appropriate for the initiating cause, and
where possible the chest should receive the support and rest afforded
by adhesive straps. Hot applications provide relief from pain when
the straps are inefl&cient or inapplicable, and sedatives are used for the
cough when required. In penetrations from without, probing or
other interference is most unwise, as nothing is to be gained by search-
ing for an embedded and perhaps hidden foreign body or a path of
laceration. If later irritative signs indicate that a foreign body is
mischievous, interference may be considered when proper x-ray
localization is made.

The development of h^-postatic pneumonia is best prevented by
keeping the patient off the back. Alcoholics need stimulants and
sedatives from the outset to prevent delirium tremens.

The course is generally short and the active signs generally sub-
side within a week.

The lacerations due to penetration generally heal kindly and the
gradual expansion of the lung soon restores the vacuum by driving
out the escaped air. For a variable time some pain will be locally
noted on deep breathing, exertion, and climatic changes, but these
regularly disappear. Adhesions of a lasting character very rarely
form, and 1 have known of no case in which they affected respiratory
capacity noticeably. I have never observed a case of chronic or
tubercular pleurisy to arise from injury.

630 TRAUMATIC SURGERY

rajUHY OF THE LUNG

Causes. — Contusions of severe character, notably those resulting
from sudden localized blows, may rarely damage the limg close to the
site of impact, in the absence of penetration of the chest wall or rib
fracture. Such an occurrence may result in pneumonia or IcLceraiian,
and the same sequelae may arise from penetrating causes from with-
out, notably from bullet and stab accidents.

Sjrmptoms of pneumonia coexist with those of pleurisy ordinarily
(traumatic pleuropneumonia), together with bloody sputimi, sharper
pain, chill, and elevations of pulse, temperature, and respiration; the
pulse averages about 120, the respirations 30, temperature 104° F.
The physical signs indicative of consolidation also exist, such as dul-
iless or flatness on percussion, bronchial breathing, and crepitant
riles. If much air escapes, variable subcutaneous emphysema ap-
pears and the evident pneumothorax presents metallic tinkling and the
various other auscultatory signs. When blood is effused the percus-
sion sound is dulled and breath and voice sounds are less audible.
With pneumonia and laceration there will be the combined evidences
of hemopneumothorax. Bloody sputum is always an indication of
some pneumonia or laceration, or both. The onset of the foregoing
symptoms is very prompt, and in the majority of cases they appear
within the first day and are exceedingly rarely delayed beyond the
third day.

In penetrations from without the external wound rarely bleeds
much unless a main blood-vessel has been damaged or an extensive
gaping wound allows the audible exit of frothy blood at each
expiration.

Collapse of the lung promptly occurs when the thorax is pene-
trated, and thus the viscus rarely comes into view.

Bullets frequently penetrate the entire chest wall from before
backward, or the reverse, and at the place of exit are often subcu-
taneously visible or palpable. In such an event, blood issues at the
place of entrance, and emphysema is evident at the site of exit.

So-called rare cases of ** fracture of the lung" or "rupture of the
lung" without external wound are instances of intrathoracic lacera-
tion, and these may be very extensive and result in "pulmonary
apoplexy" and prompt death. Cases of less extent present signs of
hemothorax or pneumohemothorax and generally recover.

Treatment. — This designs to interfere as little as possible, and
hence developments are awaited. No good ordinarily can come of

INJURIES OF THE CHEST 63 1

seeking immediately to check a pulmonary hemorrhage or remove a
foreign body, but on the contrary much added damage may be im-
posed. If an embedded splinter or missile projects from the chest
wall it may be imprudent to immediately remove it if it is acting as an
effective tampon; however, it should be extracted if the reverse
pertains, and, of course, it is subsequently removed when conditions
permit or demand. Saw-mill accidents are of this type, and em-
bedded sword-like pieces of wood have been forcibly removed by
spectators, with the result that immediate fatal hemorrhage ensued.

Wounds are iodin treated and loosely sutured or packed, and
they are always drained.

If respiration is embarrassed because of the hemothorax it is
proper to aspirate the blood through a needle introduced, pref-
erably, in the seventh or eighth intercostal space in the axillary
or scapular line; this procedure may be repeated if necessary.

The pneumonia is treated by such therapeutic means as would
be employed ordinarily. These patients seem desperately ill, but
very many of them recover surprisingly well considering the nature
of the original injury and the apparent damage to the limg itself.
Alcoholics are bad risks and every attention is given to prevent
delirium tremens; it ordinarily appears within the first four days
after this or any other form of injury. The patient should be
frequently rolled gently from side to side to prevent hypostatic
changes, and this is done despite the location of the wound. Rest,
food, and systemic support are the cardinal needs. Unlike
ordinary surgical pneumonia, these cases do not act well out-of-doors
until convalescence is under way.

The removal of an embedded bullet or other foreign body should
not be undertaken at an early stage imless there is some explicit
indication, and this arises very rarely. * Localization by frequent a;- ray
examination is a necessary preliminary, and no foreign body should
be sought unless it inevitably is the source of symptoms. War
experience has abundantly shown that the thoracic cavity can be
entered without any "negative pressure" apparatus. This procedure
of **laparotomizing" the chest is not often called for in civil traumatic
surgery. The method of choice is to exsect 3 to 4 inches of the fifth rib
in the anterior .axillary line. A pair of "rib-spreader retractors"
then widely separate the intercostal spaces. The pleura is then
dissected freely and incised enough to give adequate exposure. The
lung now collapses to the size of about two fists. It is caught by a
sponge holding forceps and drawn through the opening in the chest.

632 TRAUMATIC SURGERY

The foreign body is located, cut down upon and extracted. If
any bleeding occurs, the lung is stitched with catgut. The pleural
cavity is now mopped clean with a compress moistened in salt
solution or ether. The pleura is sutured with catgut and the muscle-
fascia layer Ukewise. The skin and subcutaneous fascia is coapted
by interrupted silkworm gut sutures. No drainage is used. If subse-
quent effusion occurs, it is removed by aspiration, repeated as often as
respiratory embarrassment demands.

Removal of an intrapulmonary foreign body by forcep>s intro-
duced through an intercostal stab wound under the fluoroscope is
some times remarkably dramatic and successful. I saw de la Villion do
this in France and in certain cases the method might be used in
civil life.

The limg however seems to acquire a tolerance to the invader and
no interference is indicated in the absence of definite signs.

Persisting sinus, cough, or abscess of the lung may justify interfer-
ence, and operation should then be guardedly undertaken. Per-
sistent pressure or irritation from any source except unfavorably
placed foreign bodies is almost unknown, as the lung soon accom-
modates itself to alien invasion; for this reason fractured ribs with
lung involvement practically never require operative interference on
the theory that callus or a bony ^linter is acting as an irritant.

The course in the recoverable cases indicates signs of improve-
ment after the third day, and patients surviving imtil then generally
recover. The convalescence from that time is proportionate to the
inital extent and source of injury, and it is generally rapid when wound
infection is absent. After the patient is up and about there will be
local pain and soreness on deep breathing and motion and during
weather changes, but all of these eventually disappear.

Traumatic tuberculosis is said to occasionally occur, but I have
never seen a case in which injury was the demonstrable cause. I
recall about a half-dozen cases in which it was claimed to be the
outcome of various accidents, but in every instance other more usual
and adequate factors were evident. It must be an exceedingly rare
sequel of chest injury to have been alleged in so small a number of
litigated cases in an experience totaling knowledge of about 50,000
claims of personal injury. I have never seen or heard of a case in
private, dispensary, or hospital practice.

For any connection to be established it must appear that: (i) The
patient was free from tuberculous signs before the accident; (2) th(
injury was to the chest and of a sufficient degree to at least induce

INJURIES OF THE CHEST 633

traumatic pleurisy or pneumonia, or both, at the site of the violence;
(3) the interval between the injury and the development of tuber-
culosis must be filled by symptoms showing progress toward the
fully developed disease; (4) there must be no preceding or succeeding
cause that might be regarded as equally or even more liable to induce
the affection.

It is, of course, certain that the tubercle bacillus is the actual
inducing or direct cause, and that any injury is but an indirect or
predisposing source for the malady.

Bronchus injury from without is exceedingly rare and is generally
an accompaniment of fatal lung injury, ordinarily of the penetrating
type.

INJURY OF THE HEART AND PERICARDIUM

This organ is so well surrounded by lung that injury to it is prac-
tically always accompanied by signs of pleural and pulmonary,
damage. According to Latham, for practical purposes the uncovered
part of the heart may be said to lie within a circle 2 inches in diameter
on the middle of a line between the nipple and the lower left end of
the sternum.

Cardiac damage from chest wall or non-penetrating injury is
an exceedingly rare injury, as any violence great enough to reach the
heart from impaction on the chest wall would almost of necessity
induce bony, pleuritic, and pulmonary complications in the form of
fracture, pleurisy, pneumom'a, or lacerations. Blows directly over
the precordial area are capable of inducing symptoms of cardiorespira-
tory collapse and shock of all grades, and the treaivicni and prognosis
is that of shock. Crushing injuries may lead to rupture of the heart
and pericardium in conjunction with other fatal lesions.

There are no well-authenticated cases of traumatic endocarditis
arising solely from violence to the chest wall; and in those cases in
which murmurs and other evidences appear after injury, the condition
is probably one of disturbed compensation.

The same is true of traumatic pericarditis , and all such cases must
be scrutinized unusually closely before injury is regarded as the pro-
ducing cause. This is especially true in the presence of infectious,
rheumatic, arteriosclerotic, nephritic, or other more usual producing
or associated sources of origin.

Penetrating injury that demands surgical treatment occurs usually
from stabbing or shooting accidents, the former being commonest,
because the latter are so frequently immediately fatal.

634 TRAUMATIC SURGERY

There are numerous successful cases of heart suture for wounds,
and in a tabulation of 218 operative cases of injuries of this nature
Frazier states {Progressive Medicine, March, 1913) that the mortality
was 55.5 per cent.; the mortality is probably much higher than this,
as fatal cases are infrequently reported. The War has furnished
numerous instances of this sort either by the chest-open-method or
that of de la Villion (forceps extraction).

Autopsy findings seem to indicate that the right ventricle is most
often penetrated; but in the operative cases the left ventricle has been
affected in 55 of 125 cases reported by Rehn (with recovery in 45 per
cent.), and the right ventricle in 50 cases (with recovery in 32 per
cent.). The auricles were about equally affected; the left showed 2
recovering cases, the right, 4 recovering cases.

Symptoms. — These depend in great part upon the nature and site
of the penetration. If the depth and degree of the wound is slight
(as from a needle or a hat-pin) there may be no immediate serious
symptoms, and, indeed, no suspicions of a penetrating wound may be
aroused. The intermediate cases (like those from thin knives or
sharp-pointed tools or missiles) and the palpably evident cases
(as from bullets, stilettos, carving-knives, ice-picks, or prong-shaped
missiles) quite regularly give signs corresponding to the following:
The patient is in a state of shock and usually unconscious. The wound
ordinarily does not bleed much unless it involves a vessel or is in
direct line with that in the heart, and then projectile systolic bleeding
is evident. The respiration is embarrassed, and dyspnea, cyanosis,
and lividity may then exist, although these are usually signs of
intrapericardial pressure. The pulse lacks volume and usually is
rapid, feeble, and irregular; the left-sided radial pulse may be
imperceptible or less forcible than the opposite. Pallor may appear
as one of the signs of intrathoracic bleeding.

Auscultation shows muffled, unusual, or distant heart sounds; if the
pleura and lung are also involved, hemothorax signs may also exist;
occasionally it is said that the blood can be heard to spurt at each
cardiac systole. Crepitation and emphysema signs may appear.

Percussion gives evidences of hemopericardium if the pericardial
sac is untorn or plugged, and with this there will be signs of cardiac
compression, such as cyanosis and lividity. Abdominal rigidity
sometimes occurs when the abdomen itself is uninvolved.

Main reliance is placed upon the (i) location and source of the
wound; (2) the character of the pulse and heart soimds; (3) signs of
hemopericardium.

INJURIES OF THE CHEST 635

Treatment. — Probing, or any exploration, without preparation for
opening the thorax, if necessary, will do great damage and may lead
to instant death or infection. In cases where developments are being
watched, the treatment is for shock, except that cardiac stimulants
obviously are not employed.

In case of reasonable doubt it is safer to explore the original wound
along an intercostal space, and if the bleeding is found to be from the
heart, this incision may be made part of the main thoracotomy; if
possible, the fifth, sixth, or seventh costal cartilages should be
included in this incision (Fig. $66).

Fig. 566. — Enposure and suture of heart and pericardii

After the pericardium has been reached, it is opened along the
desired line and the blood rapidly removed so that the bounding heart
may be inspected. In cases with spurting of blood a finger is placed
over the wound during systole, and then a silk threaded fine full-
curved needle ties the edges of the wound in diastole, and from this
suture the organ is "dangled like a jumping fish" until all the wound is
closed by interrupted stitches deeply passed. In those cases of
massive bleeding it may be necessary to manually compress the heart
until the source of bleeding is located. Another effective method is
to compress the venas cavse at their entrance into the auricle for a few
seconds (Rehn's method). After all the blood has been removed the
pericardium is loosely sutured by interrupted stitches, but it should
not be drained unless gross evidences of infection are apparent; if
drainage is required, a folded strip of rubber tissue or tlun rubber
tubing is used. Interrupted sutures join the bony, muscular, and
skin layers, and drainage by rubber tubing or tissue is provided, so

INJURIES OF THE CHEST 637

The course is dependent upon the progress during the first few
days, as cases surviving that long ordinarily recover, even if pericar-
ditis, pneumonia, pneumothorax, and some sepsis follow as later
complications.

Foreign Bodies in the Heart or Pericardium. — These are ordinarily
bullets, needles, or fragments of metal or glass. Occasionally
they may remain encysted, and some freak cases are recorded in which
a marvelous tolerance seems to have existed. The majority of such
cases end eventually in death either from direct involvement of the
heart or projection of the invader into the circulation, leading to
hemorrhage, embolism, or thrombosis. Radioscopy is a valuable
aid in determining the exact location of such foreign bodies and the
advisability of removing them.

ESOPHAGUS mjURY

This is rare as an isolated event from external violence, stabbing
and shooting accidents furnishing the few instances of damage from
without.

Symptoms are not distinctive and the signs are generally such as
follow hemorrhage or injury to the thoracic viscera coincidentally
involved. Bloody vomitus may occasionally be suggestive. Esopha-
goscopic examination would be helpful.

Treatment. — This is wholly for the associated injuries, and the aim
is to stop bleeding and prevent or minimize infection. Thoracotomy
for esophageal injury must, of necessity, be rarely advisable. Stric-
ture due to initial damage, or that dependent on infection, is treated
in the usual manner.

THORACIC DUCT INJURY

This is exceedingly rare and the diagnosis is usually made by the
escape of chylous fluid (white and viscid) along the track of a bullet or
stab woimd. Emaciation promptly follows from inanition.

Treatment. — Primarily this is given for the associated injuries,
and when the chylous fistula appears, efforts are made to block it by
cauterizing or cureting. Thoracotomy ordinarily would be a last
resort.

CHAPTER XIV

INJURIES OF THE ABDOMEN

These can be discussed in relation to accidents resulting in dam-
age to the (i) abdominal wall, (2) abdominal contents.

Abdominal Wall, external, Non-penetrating, or Extra-
abdominal Injuries

These arise ahnost always from direct violence, notably from blows,
jammings, kicks, falls, missiles, vehicles, or falling objects.

Less commonly indirect violence is the cause, as from stretching,
wrenching, or similar twisting forces applied at a distance.

The effects depend mainly on:

(a) The individual: Obviously a fat or protuberant abdomen may
be less aflfected than one less well padded.

(b) Manner of accident: The broader the surface affected, the less
likely the localizing effects.

{c) Place of impact: The nearer to the solar plexus the force is
received, the greater the systemic effect.

The chief injuries of this region are contusions, sprains, woimds,
and ruptured muscles.

CONTUSIONS

These may be localized or diffused, depending upon the causation.

Symptoms. — If severe, there is ordinarily abdominal shock, with
difficult breathing, pallor, pain, and vomiting, with associated coma
in the severer forms; the patient, in a word, is "knocked ouL" On
reviving, the remaining signs may be costal respiration and pain,
increased on pressure and motion; later, discoloration follows the
original pink or red area of impact. Local effusion of blood may be
circumscribed, and thus form a hematoma that may be subcutaneous,
intramuscular, or just outside the peritoneum; the first is the conmioii
form. These collections of blood at first are soft and fluctuant, but
later may become quite hard and simulate tiunors. Not infrequently
they become infected and end as abscesses. I recall such a termina-
tion in a patient on whom 1 operated for a suspected appendiceal
abscess.

638

INJURIES OF THE ABDOMEN 639

The differential diagnosis as between extra- and intra-abdominal
injury in some cases is exceedingly difficult, and the main reliance is
to be placed upon the association of symptoms, and the information
gained by the presence or absence of blood in the vomitus, stools, or
urine. Persistent or localized pain with rigidity of the abdominal
wall and increased pulse-rate are exceedingly suggestive of visceral
injury if the inflicting force has been adequate. Tympanites and the
obliteration of liver dulness and other percussion changes are less
reliable, as these are often relatively late in onset.

Treatment. — The shock is treated in the ordinary way; if stimula-
tion is needed, it is best given hypodermically until proof is offered
that the gastro-intestinal tract is uninjured. For the same reason
oral or rectal stimulation or catharsis is to be avoided.

(i) Rest in a comfortable position, (2) an ice-bag, and (3) a hypo-
dermic of morphin is the treatment-trinity most often useful. In less
severe manifestations, cold applications or some mild lotion will prove
effective.

Hematomas are usually controlled by pressure until absorbed;
they may occasionally be aspirated under aseptic precautions, and
less rarely incision is justifiable. Interference of this sort should not
be attempted until pain is greatly abated, and until the acute reac-
tion passes. The vast majority of such effusions subside under pres-
sure and massage, not excepting the rather huge collections that so
commonly collect in the inguinal and iliac regions. If an abscess
forms, it will become manifest by local heat, tenderness, and a
brawny feel, and incision and drainage are then required, a guarded
hypodermic thrust having previously located pus. Incision should
be in the line of the imderlying muscle-fibers.

Results. — These cases regularly respond well imless injudicious
treatment causes infection and sinus formation. It is occasionally
asserted that a contusion or hematoma in the inguinal region predis-
poses to hernia, but this of necessity must be quite conjectural and
from an anatomic. standpoint is relatively impossible.

WOUNDS

Bullets, knives, glass, tools, metal and wooden splinters, or spikes
may penetrate varying depths, producing more or less irregular
lacerated woimds.

Symptoms. — Shock and bleeding obviously vary with the nature,
extent, and site of the damage. Wounds in the vertical axis are more
likely to give more symptoms than those in the transverse or muscle

640 TRAUMATIC SURGERY

plane direction of the abdomen. If the rectus muscle is penetrated
along the line of the deep epigastric vessels, hemorrhage is apt to be
profuse; the same to a less extent is true of wounds involving tlie
suprainguinal regions. Bullets may ricochet more or less around
the abdominal wall from an initial impact and rebound from a rib,
iliac crest or pubic rim, and lodge subcutaneously or at a palpable
depth from the surface.

Treatment. — The wound is flooded with iodin and bleeding points
are then ligated, and the wound edges are retracted and search is
made for any foreign body. Probing should be scrupulously avoided,
and if the entire extent of the wound is not exposed on retraction, it
should be enlarged sufficiently to bring all of it into view. Silk,
horsehair, silkworm or catgut sutures are then introduced, and
the lower angle of the wound is drained by a twisted strand of the
suture material or a few folds of gutta-percha (rubber) tissue; no
wound should be tightly sutured and many of them are best treated
if allowed to remain open until the possibilities of infection disappear,
and later, usually after the third day, they can be coaptcd by suture
or adhesive strapping without danger. The primary dressing is best
made of gauze moistened in iodin (i dram to i pint water), or 50 per
cent, alcohol, or other non-irritating antiseptics. Drainage can be
removed by the third day if purulent or serous leakage does not
contra-indicate. If the muscle layers are cut, they should be sub-
jected to debridement (paring) and sutured tier by tier, drainage
entering to the depth of the cavity. So-called "brush bums" or
multiple abrasions or superficial lacerations or denudations do best
with preliminary- iodin sterilization followed by mild antiseptic
dressings or exposure to air and sunlight. All bullet wounds and
others likely to be contaminated by street, garden, or stable dirt
should receive preliminary injections of tetanus antitoxin.

Results are good and directly proportioned to the amount of
initial and subsequent infection; this means that careful sterilization,
coaptation, and drainage are important elements. Ventral hernia is
a rare sequel and is most likely where the fascial and muscle la]
have been extensively torn.

SPRAINS AHD ROPTOKED MUSCLES

These occur usually in association with other injuries more or
adjacent to the abdominal wall, such as to the thighs or hips, and they
also result from direct twists or pulls.

uais I

INJURIES OF THE ABDOMEN 64 1

Symptoms are pain and tenderness on pressure and motion;
diffused ecchymosis generally appears later. .

Ruptured muscle is rare, and when it does occur the rectus is most
often involved, this then giving exaggerated signs of sprain and a
definite depression along the muscle course that may be visible and
generally is palpable. Hematoma or rather extensive ecchymosis
is also present, together with local pain on pressure, motion, or
respiration.

Treatment. — Sprains respond to local anodynes, massage, and
adhesive strapping.

Ruptured muscle is coapted by posture and adhesive straps when
possible; otherwise it is sutured by open operation. Cases that do
not show definite separation require little, if any, treatment.

Results are good and there are ordinarily no after-effects.

Abdominal Contents, Intra-abdominal or Penetrating Injury

These so-called "internal injuries" are relatively frequent and
occur from localized or diffused violence, the effects depending upon
the origin, extent, and site of the impact.

Like injury to the skull and thorax, such accident may or may not
be associated with a wound leading to the surface.

In order of frequency the intestine (chiefly small intestine),
stomach, kidney, liver, spleen, bladder, and pancreas are involved
either separately or in combination.

INTRA-ABDOMINAL INJURY IN GENERAL

(a) Without External Wound. — Causes. — Blows, falls, missiles,
falling or moving objects, jamming, vehicles (notably run-over acci-
dents) are most frequently the sources of origin. With active digestion,
a full bladder, or an enlarged spleen, damage is more likely than when
the reverse pertains. A rigid abdominal wall better protects than
one that is lax or flabby.

Symptoms, — Shock to some extent obtains in all, but this may
be transitory at first and the real import of the accident may not
be apparent until the onset of so-called ** secondary shock" from
hemorrhage.

Vomiting is very frequent and when associated with blood is quite
suggestive of stomach or adjacent intestinal injury.

Pain especially if localized and persistent on motion, respiration,
and pressure, is a valuable sign.

649 TRAUMATIC SURGERY

Rigidity is the most reliable of all signs, and if progressive is prac-
tically pathognomonic.

Respiration is generally shallow and thoracic.

Tympanites is frequently late in onset, and is most valuable when
it obliterates liver dulness and when it is progressive.

Lhilness in flanks is usually indicative of fluid, generally blood or
intestinal contents, and hence is a later sj-mptom,

Bemorrhage is indicated by pallor, thirst, respiratory and pulse
changes, and lowered blood-pressure. Low hemoglobin and high
leukocytosis indicates blood-loss in the absence of infection.

Temperature is generally subnormal at first, later rises, and may
again fall if blood loss continues.

Pulse-rate is increased, and this is a suggestive sign if the rapidity
increases.

Blood in the vomitus, stools, or urine is valuable evidence of gas-
trointestinal and urinary involvement respectively.

Generally speaking, a presumptive diagnosis can be made on
the combination of: Shock, with or without signs of hemorrhage;
rigidity; local pain; thoracic breathing; the facial expression; rapid
pulse.

This class of case generally requires treatment for the onset of peri-
tonitis; the follou-ing class, for the occurrence of hemorrhage.

(b) With Eitemal Wound. — Causes. — Often due to bullets, stabs,
or penetration by spikes, hooks, or more or less pointed objects.

Symptoms resemble the foregoing, except that evidences of inter-
na! bleeding are often the chief manifestations. The actual site of
penetration is, of course, more readily apparent, although in bullet
wounds it may be quite inferential, especially as the hbtorj- is often-
times hard to obtain with accuracy, either because the victim is un-
conscious, unwilling, or fears to incriminate himself or the assaUant.
In the vast majority of cases omentum protrudes and a very large
amount can appear through a small opening due to straining and
coughing.

Perforation of the upper is less serious than the lower abdominal
zone because of the greater virulence of the intestinal contents.

Treatment. — N on- penetrating injury is treated by absolute rest,
an ice-bag, and abstinence from food by mouth; rectal interference
should be interdicted.

This advice applies only to those cases that present no signs or
reasonable inferences of either peritonitis or hemorrhage. The
presence of the former always indicates perforation of some viscus,

INJURIES OF THE ABDOMEN 643

usually the intestine. It has been definitely established that peri-
tonitis from external injury does not occur from without, but from
within, and is of germ and not traumatic origin, unless the gut or
stomach wall has been actually punctured; hence "traumatic
peritonitis" now means perforation.

Laparotomy is indicated if (i) there is doubt as to actual condi-
tions; (2) in the presence of rigidity and persistent pain; (3) with signs
of peritonitis or hemorrhage. To be effective it must be prompt, and
is demanded usually for involvement of the gastro-intestinal tract.

Penetrating injury, whatever its origin, demands immediate
exploration imder aseptic surroundings. For this reason the first-aid
care of such cases is especially important, and the region of the wound
should be suitably protected and the patient placed in such a position
that gravity will prevent any further visceral prolapse and allow
escaping materials to collect in the pelvis. Before operation the
wound and the parts about it are flooded with iodin and the entrance
of this antiseptic into the abdominal cavity need not be feared. Pre-
liminary preparations are made for intravenous infusion of saline
solution into a vein of the elbow, but this procedure is not commenced
until a failing pulse calls for it. Nitrous oxid followed by ether is the
best anesthetic. The patient's head and shoulders should be ele-
vated, as this posture seems to limit regurgitant vomiting during
anesthesia.

Lines of incision depend somewhat on the site of the perforation,
but they are generally made lateral to the median line at the outer
margin of the rectus, including the original wound if possible. In
cases of doubt the exploratory wound need not exceed 2 inches, and
through this a small moist gauze sponge may be introduced on a
holder to determine the presence of blood or gastro-intestinal con-
tents. If there is no bleeding and if the cavity gives no evidence of
intestinal or bladder contents, then the operative wound is closed
tightly and the original perforation is loosely closed and always
suitably drained. The presence of blood, gas, odor, bubbles, or
suction soimds calls for further exploration, and the operative wound
is then enlarged as liberally as may be necessary.

In cases of known intra-abdominal hemorrhage, preliminary
bandaging of the thighs at the groin and of the arms at the axilla will
reserve a valuable amount of blood to be gradually released into the
circulation after twenty or thirty minutes of such constriction. One
thigh is first released, then an arm on the opposite side, then the
other thigh, and finally the remaining arm. The abdominal cavity

644 TRAUMATIC SURGERY

may be still further temporarily robbed of drculatmg blood bytheuse
of the "Momburg constrictor," which is abroad elastic or other band-
age applied about the abdomen above the umbilicus and pulled taut
enough to produce some lessening of blood flow through the abdomi-
nal aorta. (See Fig. 8.)

Procedures vary after the abdomen has been opened, depending
upon the findings.

Hemorrhage may be excessive and the entire cavity awash with
blood, clotted or unclotted, or both. Here the object b to locate
as quickly as possible the source of the bleeding, disregarding but
marking much less important conditions discovered in the search.
Bullet wounds are common offenders, and the site of trouble may be
in the main vascular supply of a viscus or in the vessels of the mesen-
tery; smaller vessels and those of the omentum commonly cause
lesser amounts of hemorrhage, and not infrequently it is then oozing
or slow in character. In the search for the bleeding area, preliminarj-
manual tension on the aorta or by some pressure device is exceedingly
helpful while the blood is being rapidly removed by large moist
sponges. I have found it helpful to use large sterilized bath sponges
for this purpose, as their flexibility and absorptive qualities exceed
that of gauze for mopping. When at hand, various forms of suction
or aspirating devices (like that of Blake, or Pool and Kenyon) are
\'erj' valuable. Once found, the bleeding area is suitably controlled
by a ligature if vessels are involved, and by sutures, ligatures, or
packing if a \'iscus is the source. The remaining blood is then
speedily removed, but no attempt should be made to obtain an abso-
lutely dry cavity if the patient's condition does not permit. Intra-
venous saline infusion is necessary in all these cases of massive hem-
orrhage, but it should be reserved until the abdomen is opened, and
even longer if possible. The amount to be infused varies, but ordi-
narily the best index is the volume of the pulse, and when this is re-
stored to a fair ratio, the infusion may safely cease. I have not
observ'ed that hypodermics of strychnin, whisky, camphor, ether,
adrenalin, or similar drugs do any good until the heart has some
volume of blood to pump, and then they are frequently of great
value. These patients may be so exsanguinated that little or no
bleeding occurs along the line of the laparotomy incision and the
skin may be blanched, the extremities cold, the pulse almost imper-
ceptible, and the abdomen so full of blood that it flows out of the
operative incision, and yet they often will recover if the source of
bleeding can be found and a sniine infusion introduced, Transfusion

INJURIES OF THE ABDOMEN 64$

IS usually inapplicable as a primary measure, but may be advisable
later. The procedure mentioned under Shock (see page 113) for
introducing dtrated blood may be used here also; if the blood in the
abdominal cavity has not been contaminated, there is no good reason
why it cannot be collected, dtrated, and immediately injected into
the patient.

Closure of the operative wound may be by through-and-through
sutures of silk, horsehair, or silkworm-gut when haste is essential;
otherwise it is by the usual tier or layer suturing, the skin prefer-
ably being apposed by linen, silk, silkworm, or horsehair sutures.
If through and through suturing is used, great care must be taken
not to pinch the intestine; I once lost a patient in an emergency
where this sort of dosure became imperative. The originating
wound is drained and its edges are pared (debridement procedure) if
bruised or damaged. The foot of the bed is elevated 18 inches or
more, hot bottles are placed about the extremities and over the
pericardium and shock is actively combated. In some cases it is a
wise precaution to allow the infusion needle to remain in the vein
for subsequent use if required, although hypodermoclysis or rectal
infusions (drop method or otherwise) usually answer. No rectal
medication is, of course, given if the colon has been involved; other-
wise higher intestinal involvement does not contra-indicate resort
to the so-called '* Murphy drip" or drop method of rectal stimulation.

If mesenteric laceration or vessel damage has been great enough
to affect the vitality of the adjacent intestine, then primary resection
(Murphy button or suture method) may be done; where conditions
do not permit of this, the doubtful loop of intestine may be loosely
stitched along the line of incision, and if it subsequently undergoes
necrosis an artifical anus results and this later can be cared for.

Less severe hemorrhage can be sought for more leisurely and is
controllable by suture or packing.

Contusion of viscera without active bleeding often results in the
formation of bluish or dark-colored areas of subcutaneous bleeding,
notably on the walls of the stomach or intestine from glandng im-
pact. If such areas are not large, and especially if they do not in-
volve the entire lumen, they may remain untreated; if they show a
tendency to later perforate (and this may be delayed several days,
and then occur suddenly and give signs like a perforating ulcer) it is
wiser to resect at once, or to bring the involved segment to the abdo-
minal wall and suture it there and await developments. If areas of
hematoma such as these disappear on pressure, or after hot applica-

646 TRAUMATIC SURGERY

tions are succeeded by a nearly normal color, then more confidence
in their ulLimate vitality may be entertained; in this respect they
resemble the strangulated gut of a hernia.

Perforation or laceration of viscera demands treatment, d<
ing on the viscus and the site and the extent of the opening.

Stomach holes or wounds can be closed by purse-string or infol
suture, with prehminary freshening of the damaged edges. If the
perforation is close to the cardia or pylorus, the danger of subsequent
stenosis may be imminent enough to warrant immediate posterior

foldf^^^^

Fig. s68.— a, Ciemy-Lembert suture
of a punctured intestinal wound; b,
continuous suture of a linear intestinal

Fic. S69, — Suture of a ragged intcstiiul
nound so tlist [lie lumen is not narrou'ed:

a, Diamond -shaped outlining for eiscction;

b, area exseclcd; c, Czcrny-Lembert suturrs
introduced and ready for tying in the bnR

gastro-enterostomy, but ordinarily suture suffices. Perforations
may involve only one wall of the stomach or both; if the latter, access
is best obtained by enlarging the anterior opening sufi&ciently to bring
the hole in the posterior border into view, and it can then be suitably
dealt with after being delivered through the anterior opening. The
mucous membrane will pout and extrude more than the other layers
and will need trimming almost always; but the remaining portions
should only be freshened if bruised or otherwise devitalized heya
repair. The suture line may be reinforced by omentum, fascia*
muscle when practicable.

INJURIES OF THE ABDOMEN 647

Intestinal holes may be of all degrees, from one or many small
punctures to irregular rents (Figs. 568, 569). Circular or overlap-
ping silk or linen sutures are to be used where the lumen is not too
seriously encroached upon; otherwise anastomosis by Murphy
button, end-to-end or lateral suture is to be made. Whenever pos-
sible, a pad of mesentery, omentum, or fat should be used as a patch
over the sutured viscus. If there is any doubt as to the closure it is
a good plan to attach the involved portion of gut to the abdominal
wall so that an external fistula may form if union fails to persist. It
often happens that the perforations are far removed from each other
and this occurs especially in wounds transmitted from side to side,
and before backward. With this in view, each foot of intestine must
be separately investigated before the surgeon is satisfied that all holes
are located. If several are found within a short distance of each
other, and if the lumen is likely to be encroached upon by the neces-
sary multiple suturing, it is safer and quicker to resort to immediate
anastomosis. The same applies if there is perforation and at the
same time wounding of a leaf of the adjacent mesentery. Anasto-
mosis is the usual resort in injury to a main mesenteric vessel, and
then the amount to be resected may reach many feet. Side-to-side
(lateral) or end-to-side anastomosis seems better than union end-to-
end. In these gastro-intestinal perforations, foreign matter should
be removed by sponging and irrigation; and if much had been spilled,
it is safest to make a suprapubic or supra-inguinal drainage open-
ing for rubber tubing or cigarette drainage. Large quantities of food
may often be found in the pelvic or other dependent portions, and
at times some of the menu may prove temporarily confusing. I
recall that tomato soup escaping from a posterior gastric opening
once made me seek for a bleeding point at first; likewise segments
of recently ingested sphagetti simulated bundles of round-worms.

Liver involvement leads to continuous but slow hemorrhage usually,
although in somef cases spontaneous arrest of bleeding may occur,
especially if the wound is in the dome, where it imdergoes pressure
with the formation of a subdiaphragmatic clot. This organ has a
tendency to split or crack in a more or less stellate manner and much
bile usually escapes. In cases associated with extensive injury and
bleeding, Mikulicz packing (Fig. 570) is the best procedure, together
with attempts to forcibly crowd the organ against the diaphragm.
Less severe cases may be deeply and widely stitched by the method
shown in Fig. 571. A hole in the dome or upper surface of the
liver may be inaccessible unless a transdiaphragmatic approach

TRAt'MATIC SURGERY

is made. Sometimes a gauze pack under the viscus may crowd it
against the diaphragm and arrest the bleeding.

Fic. 570. — Mikulicz drainage and packing. Into this tent of gauze sm&ller pieces
at gauEC ate fitted uniil theenlire cavity is fiUed; ihb is sometimes called "thehandket-

chief drain.-

In a friable liver such suturing may fail to hold unless reinfof
as indicated. Various schemes have been tried and several c

mjtTBIES OP THE ABDOMEN 649

have been devised to control portal circulation preparatory to suture,
but these as yet are not very prsictical. Contusions over the liver
occasionally cause soreness and pain on deep breathing and pressure,
with a fine crepitus; these symptoms are supposed to be due to irri-
tation of the surface of the organ resulting in so-called perihepatitis.
Many of these cases more properly fall into the pleurisy class, sub-
diaphragmatic in type ordinarily. They respond quickly to adhe-
sive plaster strapping.

Fig. J71. — Normal site of the kidneys in relation to the ribs and vertebrz.

GaU'bladder involvement is occasional. I recall one case in which
it bad been displaced from position and dangled by its neck, leaving
a bleeding surface to show its former attachment, and there was also
a laceration on the right lobe ol the liver. The patient was a youth
who had struck his right upper abdomen while coasting. I operated
for suspected ruptured liver based on localized pain, some discolora-
tion, marked rigidity, and signs of intra-abdominal bleeding (pallor,
thirst, weak, rapid pulse, and falling blood-pressure) . The prolapsed
viscus was stitched into place, the bleeding ceased, and prompt
recovery followed.

Kidney damage may take the form of contusion, laceration, or per-
foration (Fig. 572). Blood in the urine is a regular symptom, to-
gether with pain, tenderness, and rigidity in the costovertebral region

6SO TRAUMATIC SURGERY

and over tte abdominal surface of the organ. Frequently much
perirenal bleeding occurs, and a mass can be made out on palpation
and occasionally the bulging may be visible. Several cases have been
recorded in which the bleeding has at first been so slighter slow that pal-
patory evidences of it were lacking until distention of the kidney cap-
sule and the perirenal space made it suddenly apparent. A case of
this sort came under my care in which a girl of fourteen sledded
against an iron fence so that her right loin and abdomen struck
forcibly against a post. She was stunned and immediately vomited,
but was soon well enough to watch the others coasting and she did
not go home for two hours. Then, on urinating, blood was noted by
her mother and the family physician was summoned. He found no
evidence of injury and she seemed not to have suffered any damage
to her internal organs. Next day she voided blood frequently, but
otherwise seemed well. On the third day she complained of severe
abdominal pains and an area of ecchymosis was noted above the iliac
crest and she also passed blood at
stool. That night she came to Harlem
Hospital, but no localizing symptoms
wtTe noted by the house surgeon and
her condition was not regarded as
urgent. The following day (the fourth
after the accident) I saw her. and then
the right half of the upper abdomen
was filled by a hard mass, but she was
tittle disturbed by it and had to be
awakened to permit the examination.
That night her condilioa had grown
worse and signs of intra-abdominal
hemorrhage were present. Incision
was made' through the outer side of
the rectus muscle, suspecting intestinal as well as kidney injury,
and immediately a walled-off retroperitoneal massive hemorrhage
was encountered and an extraperitoneal nephrectomy was done.
The kidney had been almost bisected in its transverse diameter and
finally the clot had apparently burst through the orginal lines of
cleavage, thus accounting for the gradual onset and sudden increase
of symptoms. She recovered.

The lumbar approach is alwaj-s preferable, and even when the
organ is extensively damaged, suturing will often control the bleeding
and preserve the organ. If the conditions permit, the surgeon should

lumbar in
the kidney.

INJURIES OF THE ABDOMEN 65 1

first satisfy himself that the opposite kidney functionates before
attacking the damaged organ. In stab and bullet wounds the
method of approach (lumbar or abdominal) will depend upon
associated visceral injury; the organ should be reached through the
back when feasible, otherwise by the extraperitoneal abdominal route
(Fig. 573). Furious and rapidly fatal hemorrhage occurs from
perforations involving the region of the kidney pelvis, and here the
surgeon usually operates, with a tentative diagnosis of intra-abdomi-
nal bleeding, through the outer border of the rectus muscle.

The presence of hematuria and localized pain alone do not
warrant operation, as contusions and small lacerations usually
spontaneously recover. Moderate bleeding can sometimes be
arrested by injections of horse serum, thromboplastin or citrated
blood. I have never known a case of this sort to develop a true
nephritis subsequently.

The indications for operation are progressive signs of hemorrhage,
and, as has been stated, interference may be demanded at once or be
delayed until a mass appears or systemic signs of bleeding present.
In all these cases the use of urotropin or other urinary antiseptics is
advisable.

Spleen injuries ordinarily bleed very promptly and excessively,
especially if the hilum is involved. This is notably true if the organ
has previously been enlarged, as by malaria, anemia, or from spleno-
megaly of any variety. Contusions cannot be diagnosed in the
absence of actual inspection, and then more or less laceration is
generally found. Run-over accidents are very conmion causes of
this injury, and it has been said that wheels passing from right to
left over the upper abdomen more commonly damage the liver,
the spleen being more likely to sufifer when the wheels pass from
left to right. Perforations from bullets and stabs are usually
sources of enough damage to call for splenectomy, inasmuch as it
is exceedingly difficult to suture the injured organ; occasionally
gauze packing checks the bleeding. These patients survive the
removal of the organ splendidly, and apparently no permanent
ill effects follow, as other hemogenetic organs vicariously carry on
splenic functions.

Pancreas injuries are generally associated with those of the
stomach and offer no special diagnostic or treatment differences. A
leaking pancreas is a foe to union of an operative wound, and for that
reason drainage should be more plentifully provided than in any other
organ. It has been stated that the postoperative wound of the late

652 TRAUMATIC SURGERY

President McKinley was extensively necrosed from panaeatic
secretion despite ample drainage.

Bladder contusions are relatively common and occasionally lead
to cystitis after active hematuria ceases. Laceration, rupture, and per-
foration each require suprapubic exposure, and if the woimd is linear
and not too extensive, it is to be closed by purse-string or tier suture,
drainage being made of the suprapubic space. If the wound b
ragged or large, a rubber tube is sewed into the orifice and brought out
through the abdominal wound to provide drainage after the manner of
a suprapubic cystotomy. After a week or less it can be wholly with-
drawn or a small tube inserted. This organ responds well after
injury and it is probably perforated at operations more frequently
than any other hollow viscus.

Generative organs are very rarely affected, due to their protected
position. I recall but one case in which the uterus was damaged, and
that was in advanced pregnancy due to a fall astride a chair. Death
followed from extensive hemorrhage associated with laceration of
the perineum, margins of vagina, cervix, and uterine wall.

Injuries of the Geniials

INJURY OF THE PENIS

Contusions and wounds may occur from blows, falls^ missiles,
bullets, knives, and various other sources. This organ is often the
object of attack in the insane and revengeful. The effects van'
somewhat, depending upon the flaccid or erect condition.

Contusions present the ordinary signs of swelling, pain, much
ecch>Tnosis, and, usually, urethral bleeding. Priapism may be asso-
ciated. Phimosis or paraphimosis may result if the swelling or edema
is excessive. This form of engorgement occasionally occurs in
children or others when the part is constricted, as by a ring or other
encircling band. Negroes are said to gain revenge by a process of
constriction of this sort which they term "point tying," and gangrene
may be induced thereby.

Treatment. — In the minor forms this is by hot or cold lotions, lite
salt solution or lead and opium. In the severer forms, where con-
tusion or rupture of the urethra exists or is suspected, it is wiser to
also introduce a soft-rubber catheter and permit it to remain as long
as necessary.

Phimosis and paraphimosis is relieved by linear incision or dr-
cumcision if reduction cannot be effected by the method shown in

rig. 574.

INJURIES OF THE ABDOMEN

653

Wottnds, especially of the dorsum, bleed freely if deep or if the
dorsal vessels are involved. If the corpore are Involved, much
gaping may occur.

paraphimosis.

t recall a Harlem Hospital patient in which the organ had been
completely amputated at the pubis by a razor in the hands of a
jealous mistress, and the bleeding then almost resulted fatally. Later

Fig S7S —Rupture of the urethra (incom-
plete), showing catheter extending into bladder
from meatus. Urethral wound being closed.

•Fig 576 — Rupture of urethra
(complete) showing suprapubic and
penile catheter introduced

I sutured the urethral orifice to the margin of the skin and subse-
quently the patient voided normally. To restore some semblance of
the former reality, I proposed to transplant the appendix to the
urethral slump and thus obtain a hollow tube to which I might

654 TRAUMATIC SUKCERY

subsequently graft skin and fat. The patient refused this because
he could not be assured of erectile power as well.

Where the urethra has been involved, efforts at first should be
made to introduce a catheter. Failing this, perineal or suprapubic
drainage of the bladder should be provided until conditions permit
repair of the urethra (Figs. 575, 576), Urethroscopic search may be
found valuable. Extensive wounds should not be regarded as an
indication for amputation, as the reparative capacity is very great.

Fracture occurs occasionally from blows or twists when the organ
is erect {as in chordee) , and the symptoms resemble severe contusions
with or without damage to the urethra, with also the presence of a
more or less well-defined sulcus if seen before or after the swelling.
In all instances of intra -urethral damage an end-resuit may be stric-
ture unless dilatation is maintained by the frequent passage of sounds.
Sexual incapacity is not a likely sequence as the vascularity of the
organ is such that it readily recovers from even very considerable
degrees of trauma.

SCROTUM mjUEY

Contusions.^ — ^These may follow from blows, falls, or kicks. Chil-
dren and others frequently sustain injury to this part at play by
landing astride fences or posts.

Symptoms are nauseous or acute pain and swelling, with much
ecchymosis that often extends to the abdomen, perineum, and thighs.
If infection occurs, sloughing and signs of sepsis supervene,

Trealmeni.—TYih need be given to the severer forms only, as the
milder grades spontaneously subside, although the ecchymosb may
last weeks. Lotions, hot or cold, like lead and opium or saline
solution, are applied and the part is kept elevated by a suspensory, or
a T or "triangular" bandage, or by broad straps across the upper
thighs. If abscess, sloughing, or infection threatens, incision in the
line of the rugs is indicated, and then drainage is instituted with
rubber or gutta-percha tissue. The skin of the scrotum does not well
withstand antiseptics, and therefore only mild apphcations must be
used so that no irritating dermatitis may arise.

Wounds may occur from stabs, bullets, missiles, nails and other
more or less pointed objects. Bleeding may be quite copious, and if
the rent is great enough the scrotal contents may extrude or share in
the damage. When the penetration is complete, hematoma of the
cavity may coexist.

INJURIES OF THE ABDOMEN 655

Treatment. — Suture and drainage is indicated and efforts should be
made to coapt in a transverse rather than a vertical direction so that
the normal rugeal lines may be followed. If this is possible, the scar-
ring is often invisible after a short period. Drainage should never be
omitted, and a few strands of catgut or a folded leaf of gutta-percha is
often enough; the drain can ordinarily be removed at the end of
twenty-four or forty-eight hours if by that time there is nothing but
serous oozing.

Associated damage is discussed later.

TUNICA VAGINALIS AND SPERMATIC CORD INJURY

Contusions. — These may occur from any of the forms of violence
previously mentioned, resulting in a collection of blood outside the
tunica vaginalis (hematoma of scrotum) or inside the tunica vaginalis
(hematocele) ; the former is by far the more usual.

Symptoms. — These resemble those of contusion of the scrotal wall
plus a fluctuating, boggy, pear-shaped swelling beneath the testicle,
not involving the latter in the extravaginal forms. The amount of
blood may be very great.

The hematocele varieties generally occur where a hydrocele has
previously existed, and most of them follow direct injury to the
testicle when a hydrocele is being tapped.

The so-called pathologic hematocele is not due to injury, but is a
spontaneous chronic hemorrhagic inflammation of the tunica
vaginalis, generally occurring in rheumatics, arteriosclerotics, and the
aged. With this variety considerable thickening eventually occurs,
and an initial diagnosis is often made of tumor of the testicle.

Treatment. — In the average hematoma, indications are met by
elevation of the scrotum and cold applications or ice-bags for the
first hours; later, elevation and some pressure generally brings about
absorption and cure. In larger effusions, aspiration or perhaps
incision may be required; neither procedure should be undertaken
imtil the acute symptoms subside, or the more usual methods of
relief fail. Hemorrhage is practically always controlable by clot
formation or pressure, without resort to operative search for bleeding
sites.

Undue zeal in treatment will often work harm, as most of the cases
spontaneously recover.

Hematocele generally requires operation to remove the blood;
some cases of long standing require removal of the entire sac.

656 TRAUMATIC SURGERY

HYDROCELE

This is a collection of fluid within the tunica vaginalis. It may
occur as an acute condition, but ordinarily is chronic.

Acute Forms. — Causes. — These are almost alwajrs sequential to
gonorrhea, and may occur as an early or late complication of this
disease. It is less often secondary to typhoid, mumps, and other
infectious diseases. Tuberculosis and syphilis are other sources.
The epididymis or testicle, or both, are usually coinddently involved.

Injury may be causative where the violence has occasioned
orchitis; it is, however, the rarest of all causes.

Fig. 577. — Transillumination of a hydrocele.

Symptoms. — A sudden painful, reddened, fluctuating, hot swelling
appears that is translucent to reflected light from an electric bulb or
pocket flash light (Fig. 577). The onset is usually febrile and there
may be chills, nausea, and vomiting.

Treatment, — Elevation of the scrotum, hot moist dressings, and a
cathartic are prescribed at first. Later, an ice-bag and some pressure
may be used. In excessive swelling, with much pain and tension,
apiration or incision and drainage are best. If pus forms early,
incision and drainage are imperative. Most cases subside quickly.

Chronic forms are by far the commonest, and ordinarily they
exist for years before the active attention of the patient or phy-
sician is called to them.

Symptoms, — Usually there is a history of a slightly painful en-
largement of one-half of the scrotum that finally becomes big enough
to attract attention because of inconvenience. The average patient
suspects he is ruptured. This enlargement, on examination, may or
may not fully fluctuate; and if it does not, a hernia may require
differentiation. The spermatic cord will be found free and it can be

INJURIES OF THE ABDOMEN

6S7

followed up to the enlarged patent external ring. The swelling will be
found translucent to reflected light.

Tumors of the testicle may be hard to differentiate, notably in
very old hydroceles with thick sacs or when the contained fluid is
viscid.

Hydrocele of the cord is generally f oimd in infants and the young,
and the differentiation from hernia is then often more difficult.

Hydrocele bilocularis is relatively rare, and the findings here are
practically those of a series of cysts.

Abdominal and hour-glass hydroceles are rarer forms, and these
may occur at any age, but are common in infants and children.

Pig. 578.—

Aspirating a hydrocele: a, Site of external puncture; h, sac in relation to

testicle.

Injury is the ascribed cause in a large proportion of cases, but is
rarely the true source. Gonorrhea is a frequent factor. TuberculosiSy
syphiliSy typhoid, and other infections are also causative.

Treatment, — In most hydroceles, palliative measures, such as
ointments, iodin, and other applications, generally avail but little,
although for a time the progress may appear to be slow or even show
recession.

Operative measures consist of (i) Aspiration: A hollow needle is
introduced and the fluid drained (as in Fig. 578). Recurrence is the
rule within two or more weeks.

(2) Aspiration and injection: After the fluid has drained away,
from 5 to 30 drops of pure carbolic acid is injected into the cavity
through the canula from which the fluid has escaped. This is done
slowly, and then the canula is withdrawn carefully so that none of
the carbolic gets into the scrotal wall. Then the scrotum is massaged
for five minutes and the patient is sent to bed, an ice-bag is applied,
and the scrotum elevated. Pain is present for several hours and the

658 TRAUMATIC SURGERY

fluid reaccumulates, but subsides in a few weeks. The patient b
allowed to get up a day or two after the injection. Tincture of iodin
is also used in the same manner. In cases of recent origin, where
the sac is not too thick, it is stated that from 70 to 80 per cent, of
patients are cured by this form of treatment.

(3) Incision of the sac: The sac is opened and turned inside out
and sutured about the cord and testicle (Jaboulay's operation). Or
a small split is made at the upper part of the sac and the testicle
squeezed through this, and then the sac is allowed to remain behind
the testicle, no sutures being required (Andrews' "bottle operation")-
Any of the foregoing can be done under local anesthesia.

The injection methods answer well for children and early cases.

INJURY OF THE TESTICLE

Contusions occur from kicks, falls, blows, and other direct forms
of violence; very rarely some great muscular effort or straining is
responsible.

Symptoms. — Nauseous pain and variable degrees of shock are
the initial signs; in some cases vomiting and unconsciousness have
occurred. Soon, swelling and tenderness appear and there is extrava-
sation of blood, visible on the scrotum and usually palpable within
the tunica vaginalis and along the epididynus. In other words, the
combined signs and symptoms of orchitis, contusion of the scrotum,
and hematocele exist.

Treatment. — Elevation and hot applications at first are useful;
later cold and a suspensory bandage may be more agreeable.

If abscess forms (this is rare) indsion and drainage will be needed.

Torsion and dislocation are very rare, and the symptoms and
treatment are similar to contusion of the part.

Wounds may occur from stabs, bullets, or impaling accidents.
Bleeding is likely to be severe, and hematoma of the scrotum or
hematocele may occur.

Treatment, — Cold applications, elevation, and pressure are used
for the ordinary cases, with suitable suture and drainage. If the
bleeding is excessive, the wound of entrance will need exploring so
that the source of hemorrhage may be located.

The outcome of traumatic orchitis is generally favorable, and the
function of the testicle is rarely permanently affected unless abscess
occurs, or there has been excessive formation of fibrous tissue with
considerable alteration in size and consistency.

INJURIES OF THE ABDOMEN 659

INJURY OF THE SEMINAL VESICLES AND PROSTATE

These are so protected that they are never injured except there
has been associated damage, like fracture of the pelvis or severe
lacerations. Infection of the genito-urinary tract is the usual source
of trouble.

INJURY OF THE VAGINA

Contusions from kicks, falls, or missiles result in swelling and
ecchymosis of the labiae, and the ensuing discoloration may extend to
the perineum, abdomen, and thighs. Definite hematoma formation
is common. Dysuria from swelling may be bothersome. Rectal
and urethral bleeding may be associated. Children thus injured are
likely to show excessive edema, and excoriation from urine may pro-
duce troublesome eczematous conditions. Multiparas apparently
withstand this sort of violence better than others.

Treatment. — Cold applications or soothing lotions answer for the
ordinary cases. Hematomas may need incision if external treat-
ment is ineffective after a reasonable time or if an abscess appears.
The ecchymosis may persist for weeks.

Wounds may occur from stabs, impalement, or pointed tools or
missiles. The hymen, torn at intercourse or by other violence,
occasionally bleeds excessively; otherwise the injury is unimportant.

The perineum or vaginal walls may share in the tearing, and I
have seen cases where the wound even extended therefrom beyond
the margins of the cervix, due to a fall astride an object. Bleeding
may be quite marked and there is generally considerable swelling
and discomfort, with marked systemic shock.

Treatment. — Suture and drainage will be needed if the bleeding is
great; usually control by packing will take the place of immediate
suture. Hymen tears require ligation of the spurting vessel that
usually comes readily into view. Injuries to these parts very rarely
result in lasting pelvic disturbance.

CHAPTER XV

INJURIES OF THE NERVES, BLOOD-VESSELS, AND

LYMPH-VESSELS

Injuries of the Nerves

Individual nerve-fibers or trunks may be damaged by a variety
of direct and indirect forms of violence, usually as accompaniments
of other injuries.

Neuritis and PERiirEURiTis

Inflammation of the nerve-fiber (neuritis), or of the nerve-sheath
(perineuritis) may arise from direct injury to the nerve, as from
wounds, blows, falls, and compression; or from indirect injury due to
stretching or traction.

A "traumatic neuritis" is always a "localized" or "simple"
neuritis, and is limited to one set of nerve-fibers or a plexus, and is
never a ** multiple" neuritis or "polyneuritis" which is always toxic
in origin (as from alcohol, lead, rheumatism, fevers, infections,
etc.).

Nerve inflammation from injury is very exceptionally of the
ascending variety, and extension to the spinal cord practically never
occurs from a distant focus; thus myelitis from such an origin is a
clinical rarity.

Symptoms. — The nature, origin,and site of the lesion determines
the manifestations, but in all cases:

(i) Pain is the chief sign, and this is limited to the course and
distribution of the nerve, and in character may be sharp, stinging,
burning, boring, shooting, or numbing.

(2) Tenderness along the course of the nerves is also present.

(3) Swelling, redness, and local Iteat may also occur.

(4) Pain on motion exists.

(5) Diminished or increased sensation appears.

(6) Paresthetic signs may occur, like tingling, "pins and needles,"
and crawling sensations.

Inasmuch as mixed nerves are generally involved in accidents,
motor manifestations are also present, such as:

(7) Weakness or paralysis of muscles innervated by the involved

nerve.

660

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 66l

(8) Twitching or spasms may also occur.

(9) Trophic manifestations are always present in continued or
marked cases, and tiien

(10) Atrophy is the chief feature, and still later contractures may
occur. In advanced cases trophic changes are seen also in the nails y
skin, and hair, so that their texture is markedly altered and the part
looks glossy or thickened and roughened and the surface temperature
is changed.

(11) Ulceration and gangrene appear in some cases and trophic
ulcers form.

(12) The reaction of degeneration is present in cases showing many
objective evidences.

(13) Changes in the reflexes occur in marked cases (Fig. 579).

Fig. 579. — Plantar reflex: a, Normal; b, Babinski.

Manifestiy all grades are encountered, from the transient "pins
and needles" sensation of an ulnar neuritis from striking the "funny
bone, '' to the total wasting of an upper extremity from avulsion of
the brachial plexus.

The commonest clinical forms affect the upper extremity involv-
ing the brachial plexus or some of its branches, notably the musculo-
spiral, median, or ulnar nerves.

In the lower extremity the sciatic, popliteal, peroneal and tibial
nerves are most commonly affected.

Direct damage from wounds causes the most typical cases, to-
gether with those arising from compression by bone (as in dislocations
and fractures), foreign bodies, or external pressure (occupational;
"crutch paralysis;'' or tight bandaging).

In every instance it is important to recognize that trauma produces
localized or regional involvement and that the multiple and gen-
eralized forms are due to constitutional causes. Occasionally sepsis

662 TRAUMATIC SURGERY

may be an inducing cause of a multiple neuritis, but this is clinically
very rare.

The rate of progress from the onset of pain to the development of
atrophy is variable, but is reasonably prompt; traumatic cases are
of the acute type, and within a fortnight there is ordinarily some
obvious difference in size and texture in the involved part, especially
if immobilization has been employed.

Treatment. — This practically resolves itself into removing the
source of trouble. Divided nerves are sutured if possible; pressure is
removed where that element is at fault.

Pain is relieved by external applications of heat or cold or the use
of anodynes. Placing the part at rest by a splint or suitable dressing
and elevation are essentials of treatment.

The more resistant cases are subjected to counterirrikUian by
iodin or other drugs of that class; electricity, vibration, blistering, or
the actual cautery may be tried. In still more resistant cases, forc-
ible stretching, especially in sciatica, is very efficient. The injection
of the nerve-sheath by sterile water or alcohol is also occasionally
needed. Sedatives by mouth should be used cautiously so that no
habit is induced.

Atrophy is overcome by massage and forced use, and these
measures persisted in will prevent or overcome contractures or
deformities.

Constitutional diseases, notably rheumatism, gout, and syphilis, if
coexistent, must be suitably treated.

In persistent cases, and where prompt response does not follow the
use of ordinary measures, resort should be to mercury and the iodids,
even in the presence of a negative luetic history'.

Neuritis of Individual Nerves

Damage to a single nerve or plexus may arise from (a) contusiatif
(b) stretching, (c) laceration.

(a) Contusion of Nerves. — This may occur from blows or falls
and thus produce the effects at once; or the onset may be deferred and
follow slowly increasing or persistent compression^ such as may be
induced by callus, organized exudate, scars, or apparatus like band-
ages, splints, or crutches.

Symptoms, — Mild cases manifest pain, tingling, and numbness
with more or less paresthesia, with perhaps local heat and the ac-
companying signs of contusion. Tenderness on pressure along the
nerve pathway usually coexists.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 663

Moderate cases manifest the above with more or less well-marked
muscular paralysis, the motor signs generally being more marked and
persistent than the sensory. After the paralysis has persisted a week
or more, atrophy usually appears and the shrinkage progressively
becomes more apparent the longer the condition persists, and in time
the atrophy may appear also in the involved or adjacent joints knd
bones. Trophic manifestations are usually absent unless the lesion
has lasted a long time.

Severe cases are exaggerations of the preceding and the reaction of
degeneration is often present, and in effect the symptoms are those of
laceration.

Treatment. — Contusion forms are treated by rest (with or without
well-padded splintage) and anodyne lotions, such as hot or cold lead
and opium, alcohol and water, salt solution, or aluminum acetate
(4 per cent.). After the pain and local tenderness subside, massage
and electricity effectively promote the return of function.

Compression forms demand removal of the originating cause such
as callus, spiculoe, bandages, splints, apparatus, crutches, etc.

In tins connection it is pertitient to again say that no encircling or
constricting dressing or apparatus should ever be applied to an acutely
inflamed or swollen area, notably the forearm and leg. It is particu-
larly unwise to use any encircling dressing under a splint.

Early recognition is the main element of successful treatment. If
callus is at fault, operation should be undertaken ; practically this is
demanded only in musculospiral involvement following fractured
humerus. Very exceptionally nerves may be pinched in scars of the
soft parts, as in amputation stumps or deep adherent scars, and here
also operative release may ht required.

The outcome is usually excellent and perfect if slow restoration of
function is the rule. Compression from callus often offers the poorest
prospect, but even after many months a happy result has often fol-
lowed surgical measures.

(6) Stretching of Nerves, — This form is limited practically to the
region of the shoulder (brachial plexus), neck (cervical plexus), and
hip (sacral plexus), and the manifestations are generally associates of
dislocations or fractures. The main damage is to the sheath of the
nerve and to the peripheral rather than to the central fibers. The
lesions produced, according to Woolsey (Keen's Surgery, Vol. II),
are: (i) Loosening of the sheath; (2) narrowing of the sheath and
constriction of the contained fibers; (3) partial tearing of the blood-
vessels of the sheath, causing ecchymosis; (4) tearing of more or less
of the nerve-fibers, resulting in degeneration.

664 TRAUMATIC SURGERY

Symptoms. — Mild and moderately severe cases are similar to
contusions; severe cases resemble lacerations.

In the case of a stretched sciatic, the opposite nerve may also
be affected at the same time, but ordinarily not to the same extent.
It is to be recalled that nerve stretching is a method of treatment in
sciatic neuritis, and thus neuritis of this plexus rarely if ever follows
indirect violence,

Treatment, — Rest is the main element, the part being so placed
that tension is relieved. External applications (as in contused
nerves) may also be helpful. Later, massage, electricity, and in-
creasing use are advisable.

The outcome is generally excellent unless avulsion has occurred,
and then the prognosis is that of lacerated nerves.

(c) Laceration of Nerves. — This follows wounds and penetrations
from without, but may also be rarely due to fractured ends of bone.
The most typical cases are accompaniments of deep lacerated
wounds.

Mild grades, in which only the sheath of the nerve or some of the
fibers are cut, give symptoms similar to contused or stretched nerves.
The sensory signs are generally least marked because adjacent sen-
sory fibers form so close an anastomosis. In cases seen after the
wound has been partially or wholly closed, and where it is small, or if
swelling or inflammation are present, the onset of nerve disturbance
may not be noted until the local signs become marked enough to pro-
duce atrophy or paralysis.

Moderate grades show aggravated signs of the preceding, with
minor trophic changes; existing hyperesthesia is proof positive of at
least partial severance.

Severe grades indicate total severance of the involved nen/e,
usually with more or less retraction of its ends. The onset of symp-
toms is usually immediate and paralysis is complete as the muscles
are no longer irmervated. Sensory cJtanges are coincident and the
patient generally is aware of the existing anesthesia, and this is asso-
ciated with loss of sense of touch and heat and cold in corresponding
areas.

Atrophy is prompt and contractures a.nd other deformities rapidly
occur unless the part is suitably splinted or provided with apparatus
to prevent the action of unantagonized muscles.

Trophic changes show early, and the part is at first red and swollen,
and later dry, glazed, and cyanotic, and finally ulceration may occur
from pressure or malnutrition.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 66$

Electric irritability diminishes, so that in from two to seven days
muscular contraction torfaradic irritation disappears. Response to
galvanic irritation becomes slight within the first few weeks and is
usually lost after six weeks.

This loss of response to electric excitation constitutes the reaction
of degeneration, and this is made up of a quantitative and a qualitative
form of response. Normally the contraction obtained by closure of
the negative pole is greater than that obtained by closure of the posi-
tive pole; this is expressed by ACC<KCC. In the presence of de-
generation this formula becomes ACC>KCC, or ACC = KCC.
This test is extremely valuable and reliable if properly and carefully
made by a trained observer; otherwise it is the reverse. To be of
proved value the other clinical evidences of wholly deficient innerva-
tion must also exist (i.e., paralysis, atrophy, anesthesia, and trophic
signs).

Fig. 580. — Treatment of a severed nerve by enclosing it in fascia obtained from
an adjacent or distant source (as the fascia lata): a, Fascial envelope prepared; b, nerve
enclosed in fascia.

After the nerve has united, it may be many months (one to
twelve) before electric excitation returns to normal, even in the pres-
ence of restored muscular, sensory, and trophic functions; for this
reason the test is of greater diagnostic than prognostic value. Ordi-
narily faradic precedes galvanic return. "Tinel's sign'' is an index
to recovery and is elicited by gently percussing along the involved
nerve and noting if tingling or formication appear in the cutaneous
area . supplied by this nerve. It only shows when the new axis
cylinder begins to form (4-6 weeks) and is known also as the sign
of distal tingling on percussion and is often denoted as "D. T. P."

Treatment, — Mild grades are treated like contused nerves. When
the fibers are actually separated (moderate and severe grades) they
are best treated by immediate suture (neurorrhaphy), the effort being

666

TRAUMATIC StmCERV

to coapt the shreds by silk or gut sutures so that no tension occurs
after union. With this in view, various operations have been devised
to lengthen the fibers by so stretching or so splitting them that the
anastomosis becomes quite perfect. The line of junction should then
be encased in a blood-vessel or a pad of fat or fascia taken from an
adjacent source, so that added strength and freedom from adhesions
may be gained (Fig. 580). The post-war experience shows that
freshening of the cut edges is a prime requisite, and that extreme care
must be exercised not to rotate the ends as the coaptation should be
as accurate as possible. Some authorities say that the suture line b

Fig. 5S1.— Ner\-c suturitig methods: A, Singli

best protected when covered only by adjacent soft parts. If re-
traction is too great to be overcome by splitting, then a tendril of
another ner\-e or silk or fascia unites and bridges the severed ends and
acts as a trellis. These procedures are suitably indicated by Figs.
581 and 582. Primarj' union is to be sought; but even in the presence
of infection, the ner\'e-ends should be coapted as tar as possible, if
only for identification purposes. When retraction is too great to be
overcome, or where failure of union has occurred, recourse is to (1)
anastomosis with adjacent nerves; (2} interposition of a section of
another nerve, a vein or fascia; (3) resection of bone to shorten the
limb.

Where infection prevents union, secondary suture may I
ployed after the bulbous or sloughed ends have been excised.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 667

66S TRAUMATIC SUHGERY

Functional return after suture is aided by electricity (first gal-
vanic and then faradic). massage, and gradual usage of the part.

The outcome is good if early complete suture can be made. Re-
turn of function is first seen in restoration of sensation and disap-
pearance of atrophy, the motor return often being long delayed, and
it may not fully return for years in advanced cases. Sensory and
trophic improvement may be noted within a few hours, but motion
does not generally show any return short of two weeks.

Horseley advised waiting eighteen months before resorting to sec-
ondary suture after an initial suture with primary union, when im-
provement becomes stationary or retrogression sets in (Keen's
Surgery), ii improvement, however, continues, hope must not be
abandoned, as recovery may require more than two or three years.

War experience showed that early interference awakened dor-
mant infection locked up in the cicatrix; hence early attack in an
area once infected invites failure.

iHjuitK OF Special Nerves

The injuries affecting most of the cranial nerves are included
ordinarily in the symptoms of intracranial injury, notably fractured
base of the skull.

However, some of these nerves are occasionally damaged by ex-
tracranial trauma, notably the fifth, seventh, eighth, ninth, tenth,
and eleventh.

Fifth Cranial Nerve (Trigeminus). — As will be recalled, this
mixed nerve has six branches distributed to the region of the eye-
brow, cheek, and lips, and damage is usually to one of the branches,
generally from a localized blow or wound, and less often from fracture
of the jaw. The supra-orbital branch is oftenest involved, as in
wounds of the eyebrow (Fig. 585).

The symptoms common to all branches are pain or anesthesi
both, corresponding to the distribution of the branch affected.

Treatment. — This is for the associated injury,

Prognosis is usually good, as the part rapidly becomes re-inn^^
vated, as will be recalled on mention of the difficulty in preventing
resumption of function when the nerve is deliberately damaged in as
attempt to cure neuralgia from this source.

Tic douloureux is never traumatic in origin except in 50 f
dental caries or tumor formation may in turn be traced to an iajfl

Seventh Cranial or Facial Nerve. — As already stated, this nerve
is more commonly injured than all others in intracranial injuries,

?d in an 1

INJURIES or NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 669

notably fractured base of the skull. Extracranial causes are blows in
the region of the ear or parotid, wounds, and fracture of the jaw or
malar bone. Operations about the angle of the jaw, neck, and mas-
toid regions are also frequent sources of origin. Peripheral involve-
ment is known as "Bell's palsy." The commonest extracranial
sources of origin are exposure to drafts and changes in temperature,
and from infections, rheumatic or otherw

I. 58s.^Superficial sensory nerve-supply of (ace and scalp: a. Front of face; b, side
of face and scalp; c, back of scalp.

The types depend on the location of the lesion, as the nerve may be
affected within or without the brain. Thus it may have a central or
supranuclear involvement from a lesion of the cortical fibers en route
to the nucleus; this is an associate of apoplexy (hemiplegia), as a
rule, and is not traumatic. Figure 586 indicates the possible sites
of external involvement.

Nuclear involvement is also non-traumatic, and is the outcome of
cerebral hemorrhage, embolism, softening, and some infections (like
poliomyelitis and diphtheria).

670 TRAUiUTIC SURGERY

A Special form of this t^-pe of involvement is known as crossed
paralysis, in which the face is involved on the side of the lesion, and
the arm and leg on the opposite side. Here the lower part of the pons
is involved, as in certain types of fractured skull and intracerebral
hemorrhage.

At the exit from the pons involvement may occur from a variety of
non-traumatic causes, notably tumors and syphilis, but lesions here
always affect other cranial nerves coincidently (Dana).

During the course through the bony canal {aqueduct of Fallo]
involvement may and often does occur from damage to thepetroii5
portion of the temporal bone in fractured skull; otitis media is a very
common originating factor in this zone.

At or after emerging Jrom the stylomastoid foramen it may he
affected by contusions or wounds, and occasionally by fractures or
dislocations of the jaw or other sources of pressure.

Thus it is seen that the central tjpes are often non-traumatic,
the peripheral types are traumatic or due to cold or infecti(

Symptoms. — These depend on the site and extent of the lesion, but
a typical case will very promptly show a flattened, wrinkleless cheek,
drawn to the sound side by the unopposed facial muscles. The eye
cannot be closed and tears may flow freely and a conjunctivitis often
exists. The forehead cannot be wrinkled, or the affected cheek

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 67 1

puflfed out, or the tongue protruded in a straight line. Efforts at
laughing, whistling, or grimacing pull the face toward the good side.

If the temporofacial branch alone is affected, the forehead and eye
only are involved; if the cervicofacial portion, the lips, cheeks, and
platysma are inactive.

In some cases the eighth (auditory) nerve may show associated
involvement as indicated by tinnitus aurium and vertigo; but this
nerve is the only one coinddently affected in peripheral facial
involvement (Bailey). Taste is occasionally affected on the anterior
two-thirds of the tongue on the paralyzed side, but this symptom is
usually unknown to the patient and only exists in deep-seated lesions
within the Fallopian canal where the chorda tympani joins the facial.
Paralysis of the stapedius causing tension of the drum membrane may
also be associated, and this produces hyperacuity of hearing.

Sensation is intact on the face, but may be somewhat altered
behind the ear. In paralysis of long duration stiffness of the side of
the face may occur, and later atrophy and contracture may appear.
Electric excitability is altered and cases of even moderate severity may
show a partial reaction of degeneration. In such cases galvanic
contraction becomes normal within two months, and soon after that
faradic contractility returns, and recovery is generally complete in a
fairly well-developed case in three months. In severer cases the
reaction of degeneration may persist for a year and yet recovery may
occur. Remak, quoted by Starr, refers to a case ot recovery after
three years of paralysis.

Prognosis. — This depends on the site and extent of the lesion.
Complete severance, as from an accidental or operative wound, will
not be followed by recovery unless nerve anastomosis is performed.
Involvement due to a fractured base of the skull is generally recov-
ered from. Cases of partial involvement quite uniformly get well.
The outcome and initial severity are both determined with greatest
accuracy by the electric responses.

Treatment. — This is usually directed to the associated injuries; but
after recovery from these, resort may be had to massage, electricity,
and strychnin. Nerve anastomosis with the hypoglossal or spinal
accessory is reserved for cases of facial severance or where other
forms of treatment have proved ineffective. Cases have been cured
by anastomosis after lasting twenty-nine and one-half years (Elsberg).

Eighth Cranial Nerve (Auditory). — This is rarely involved alone,
but it is often affected in conjunction with the facial nerve.

There are two divisions of this nerve, the cochlear part having to

673 TRATJHATIC SURGERV

do with hearing, and the vestibular part having to do with the main-
tenance of equilibrium.

Causes. — ^Intracerebral injury, like fractured base of the skull or
basal hemorrhage, is practically the only traumatic source. Congen-
ital and acquired causes of deafness are, of course, numerous, and
these must be excluded, especially in those instances in which the
facial nerve is not coincidently involved.

Middle-ear disease and other infections are the usual factors in
deafness.

Symptoms. — Deafness, tinnitus, and vertigo are usually associated
and are of all degrees. Normally, tuning-fork vibrations are heard
longer and better through the air (air conduction) than through
contact with bone (bone conduction). In middle-ear disease

Fir- 587 — Nerve supply of the tonRue.

associated with deafness the vibrations are heard through bone, but
not when in contact with the ear. In auditory nerve deafness the
reverse pertains, so that sounds are best heard when close to the ear,
and here higher-pitched notes are less well heard than low notes, and
hearing is not increased in noisy places as it is in middle-ear disease,
nor does inflation of the eustachian tube cause improvement.

Prognosis. — If the laceration of the drum has healed kindly, the
outlook is better than if otitis has followed or preceded.

The grade of involvement may sometimes be determined with fair
accuracy by tests applied to the coincidently afEected facial nerve.

Fracture of the base of the skull, with deafness that does not
improve as fast as coincident facial palsy, is likely to result in
permanent impairment of hearing to some degree.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 673

Generally speaking, the outiook is not as good as it is for facial in-
volvement. Most cases show improvement within the first few weeks,
and cases lasting beyond six months rarely completely regain hearing.

Ninth (Glossopharyngeal) and Tenth (Pneumogastric) Cranial
Nerves. — These are rarely involved, but if so, they are generally
affected together, ordinarily in fractured base of the skull or in wounds
in the upper part of the neck. In operations for cervical adenitis,
goiter, and other neck lesions they are also occasionally damaged

(Fig. 587).

Symptoms. — The chief of these are anesthesia of the throat,

palatal paralysis, disturbances of taste and salivary function, and

irregularities of pulse and respiration.

There is no case on record of isolated injury to the ninth nerve
alone (Starr).

Division of one pneumogastric may cause little or no permanent
effects on the heart or respiration.

Treatment and Prognosis. — These are related to the associated
injuries.

Eleventh Cranial Nerve (Spinal Accessory). — This has two nuclei,
and the trunk formed by their union divides shortly after its exit
from the skull into two branches, the external supplying the sterno-
mastoid and trapezius; the other enters the trunk of the pneu-
mogastric.

Causes. — Fractured base of the skull and intracranial injuries
(rare); fracture-dislocation of the cervical spine; wounds of the
neck; and sometimes shoulder injuries, like dislocation or fracture.
Operations about the neck are also common sources of origin.

Symptoms. — If the lesion involves the nerve prior to the bifurca-
tion, there will be paralysis of the sternomastoid and trapezius, and
also signs related to the pneumogastric, such as laryngeal paralysis
and anesthesia, palatal paralysis, and difficulty in swallowing, with
alterations in pulse and respiration.

Most of the cases involve the external branch of the nerve, so that
more or less paralysis of the sternomastoid and trapezius exists, the
latter being usually less advanced than the former because partly
innervated by the cervical nerves.

In a typical case the posture is quite characteristic, in that the

head is held forward and tilted toward the involved side, the shoulder

droops and shows atrophic flattening, and the scapula is drawn away

and somewhat rotated; in addition, the arm cannot be elevated

beyond a right angle and lifting power is much decreased.
43

674 TRAUMATIC SURGERY

Treatment. — The initiating and associated conditions are cared for
first, and when possible suture is attempted. Later, massage and
electricity are used, and finally resort may be had to nerve anastomo-
sis when other means fail.

Prognosis. — Partial involvement is followed by recovery quite
uniformly. Complete severance usually means permanent loss of
shoulder function to some degree, and operation offers the only pros-
pect of recovery.

Twelfth Cranial Nerve (Hypoglossal). — This is rarely involved
alone, and cut-throat and stab and bullet wounds are usually the
extracranial traumatic factors. Occasionally it is involved during
operations.

Symptoms. — Motor power is abolished on the side of the tongue
corresponding to the lesion, and it thus deviates toward the paralyzed
side and interferes with speaking and swallowing. Atrophy and
furrows appear and the mouth becomes foul.

Treatment and Prognosis. — Suture is the only successful curative,
procedure; otherwise it is permanent.

Injury of the Brachial Plexus. — The whole plexus or of any of the
nerves composing it may be involved, the lesions being similar to
those found in any other isolated or group of nerves.

Causes. — Of these may be mentioned heavy blows; stab and bullet
wounds; violent twisting motions of the head, neck, and shoulder;
some severe fractures and dislocations of the spine, shoulder, or
clavicle; cicatrices, as from deep wounds or burns; occupational^
crutch, and other pressure sources, and stretching from forced posture
as during anesthesia, this last probably being the commonest cause.

Symptoms. — There are three general types :

(i) Total arm palsies.

(2) Upper arm palsies (Erb-Duchenne type).

(3) Lower arm palsies (Klumpke type).

In all of these the paralysis is the main feature, as the sensory
changes do not correspond to the motor involvement because of the
overlapping segmental cutaneous cord supply and nerve anastomoses
resulting in the so-called ''supplementary sensation."

The usual involvement is of the upper arm type, also called "Erb's
palsy,'' and here there is paralysis of the deltoid, supra- and infraspi-
natus, teres minor, biceps, brachialis anticus, and supinator longus
and brevis. This causes an adduction of the arm and inward
rotation of the shoulder, and the forearm is pronated and extended at
the elbow, so that the arm loses abduction and external rotatory

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 675

power and the forearm cannot be flexed or supinated. Atrophy and
electric changes also occur. In some forms of this type the deltoid,
biceps, brachialis anticus, and supinator longus are alone affected.

All of these muscles may normally be made to contract by
applying an electric current to "Erb's point," which is a spot 2 cm.
in front of the sternomastoid and the same distance above the clavicle.

The lower arm type (Klumpke's palsy) affects the first anterior
dorsal root through which pass the sympathetic fibers for the eye.
Involvement of this sort causes paralysis of the small muscles of the
hand with signs of involvement of the sympathetic, such as con-
tracted pupil, narrowed palpebral fissure, sinking in of the eye, ab-
sent cilio-spinal reflex, and flattening of the face. This type is ex-
tremely rare by itself.

Progftosis. — If the lesion is due to contusion, stretching, or partial
tearing, the outlook is good and perfect recovery is the rule. If
avulsion has occurred, the condition is permanent until restoration is
effected by suture or anastomosis. In severe cases recovery may
take years before it is complete.

Treatment. — This depends upon the extent and site of the lesion,
and usually little can be done at first except to care for the associated
injury. Primary suture is indicated as promptly as the accompany-
ing damage permits. If improvement occurs from the use of massage
and electricity, no operation is indicated until these measures cease to
be effective.

Operation designs to cleanly expose the divided nerve ends and
bring about their junction by suture. Later, massage and electricity
are used.

Circumflex Nerve. — This supplies the teres minor and deltoid;
and in some shoulder injuries, notably dislocations and severe sprains
or contusions, it may be injured. It is rarely hurt in gunshot or
other penetrating wounds (Fig. 588).

Symptoms. — Early loss of the normal rotundity and consequent
flattening of the region of the shoulder-cap due to deltoid atrophy is
the chief sign. This muscle becomes soft and flabby and the arm
cannot be elevated, and may become depressed enough to produce
subglenoid dislocation. Sensory involvement is shown by a tri-
angular area of anesthesia at the upper and outer part of the deltoid;
The abolition of teres minor function is unimportant. Electric
changes occur as in other neural injuries.

Prognosis. — It is important in dislocation and other injuries to
determine whether the nerve was injured before or after treatment

676 TRAUMATIC SURGERY

and this is sometimes quite difficult in the presence of pain and
swelling. In division or extensive damage to the nerve, resumption of
function is not likely to be complete, but in temporary or partial
injury restoration will occur with appropriate treatment.

Treatment. — In the reduction of dislocations great care is needed
so that the nerve will not be (Uimaged by tivorstretchingor actual
laceration.

Fig. 588.— Deltoid atrophy following d

Early massage and the use of electricity and shoulder elevating
gymnastics are the important and recognized measures. In com-
plete laceration or serious damage (as indicated by electric tests) the
propriety of operation for suture or anastomosis is to be considered.

Long or Posterior Thoracic Nerve. — This supplies the serratus
magnus. It is rarely injured alone, but may be involved by contu-
sions or wounds of the neck or shoulder, or forced muscular contrac-
tions. Occasionally it is an occupational paralysis from carrying
weights on the shoulder.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 677

Symptoms. — The scapula becomes unduly prominent ajid assumes
le so-called "winged" appearance, notably at the lower border.
The inner border ol this bone becomes more oblique from above down
and in, and may be tilted upward. Elevation of the arm may be
interfered with so that the patient learns to swing it before seeking to
elevate it. There is a good deal of pain about the neck and shoulder.
Electric changes are present in marked cases.

Prognosis.— Slovi recovery is the rule unless the nerve has been
cut or seriously damaged, as by compression in a scar; in the event of
the latter the outlook is bad.

Treaimcnl.- — This is the same as for circumflex involvement. A
brace or strapping to bind down the scapula is also of value in some
cases.

Suprascapular Nerve. — This is very rarely involved alone, and
when it is, atrophy of the supraspinatus muscle occurs, causing de-
pression of the fossa and some loss
outward rotation of the arm.

Prognosis and treatment are the same
as for the preceding.

Musculospiral Nerve. — This supplies
notably the triceps, brachialis anticus,
the supinators and extensors, and, because
of its long course, it is more often involved
than any other nerve of the brachial plexus,
and, indeed, b one of the most common
of all nerve injuries.

Cow5ej.— Pressure, as from a crutch,
bandage, or during anesthesia or sleep,
is one of the commonest sources; "Sun-
day morning palsy" is the name given to
that form occurring in a patient who falls
asleep with the inner side of the arm hang-
ing over a bench, chair, bed, or other con-
tinuing pressure source. Fracture of the clavicle is an occasional,
and fracture of the arm (notably the middle third) a very common,
source (Fig. 589). Contusions, wounds, and forcible muscle move-
ments may also be factors. Shoulder dislocation is rather a
rare source.

Symptoms. ^—The&e depend on the location of the lesion, the arm
muscles escaping if the injury is below the axilla or upper arm, as
there is a special branch of the nerve for the triceps. Upper involve-

FiG. 5Sg. — Musculospiral
'e included ia the callus
fractured humerus.

678 TRAUMATIC SURGERY

ment abolishes extension at the elbow, and lower involvement affects
the supinators of the forearm and the extensors of the wrist and all
the fingers.

The most familiar and typical symptom is "wrist-drop," 90 that
the hand hangs limp and the patient cannot raise the wrist or first
phalanges (Fig. 590). If, however, the hand is held, the terminal
phalanges can be extended and the fingers separated. The thumb
cannot be abducted or extended. The lost supinator action causes
the hand to pronate when Einy wrist or finger flexion is attempted,
and thus gripping or push and pull power and flexion of the forearm
are lessened. This loss can best be ascertained by placing the inner
side of the forearm on the tabic and asking the patient to raise the
forearm against resistance. Sensory loss is manifested by numbness
and tingling along the outer side of the forearm and the back ^
outer side of the arm.

Fig. 590. — Wrist-drop

Atrophy appears in severe or long-standing cases and is propor-
tionate to the extent of the damage, as also are the electric changes,
but degenerative reaction may not appear even with rather pro-
nounced lesions.

Prognosis. — Most cases of incomplete lesions get well, although it
may take six months or more to attain full recovery.

Where the paralysis is secondary- to the initial injury (as from
treatment, scarring, or callus) operation may be required.

Wrist-drop from other causes (poisons and infections) must not be
confounded.

Treatment. — This is the same as for any other type of neuritis.
Transplantation of tendons at tlie wrist is an excellent procedure and
has the advantage of bringing the operative zone away from the
seat of injury, as in an infected wound or fracture- Where there is
reason to suspect that the nerve has been caught or cut, operation
is imperative.

JUJVRIES OP NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 679

Much success has been obtained by operation even after years of
involvement, and the outlook is more favorable than with any other
nerve of the extremities.

Median ITerve. — This supplies the pronators; the flexor carpi
radialis; flexors of fingers; the thumb abductors, flexors and opposers;
and the two outer lumbricales which flex the flrst phalanx.

Causes. — Ordinarily it is not involved alone except in wounds of
the arm, forearm, and wrist; less often shoulder injuries are respons-
ible. Tight bandaging or splintage is another source.

Symptoms. — Pronator loss causes some outward rotation and
inability to place the forearm palm downward. Wrist and finger
flexion is interfered with by damage to the involved flexors, although
the action of the intact muscles supplied by the ulnar allows some
flexion. The thumb has a tendency to adduct and stay in a position
of extension and cannot be brought to the other finger-tips.

Fig. S91-— Median

e paralysis a Sensory impairment, palm.
impairment dorsal aspect

aspect; 6, sensory

Sensory changes are hmited to areas of varying anesthesia corre-
sponding to the front and back of three and one-half outer fingers, as
shown in Fig 591 Pain m the hand occurs sometimes. Atrophy
may show in the thenar muscles and trophic changes in the skin and
nails may also appear. Electric changes are present as in other allied

Prognosis and treatment are similar to that of other forms of
traumatic neuritis.

Ulnar Nerve. — This supplies the flexor muscles not innervated by
the median; that is, the flexor carpi ulnaris, the ulnar half of the
profundus flexors, the little finger muscles, the interossei, the two
inner lumbricales, and the thumb adductors.

TRAUMATIC SURGERY

Causes. — Next to the musculospiral, the ulnar is involved oftener
than any nerve of the upper extremity. Injuries about the inner
margin of the arm, forearm, and elbow (where the nerve lies in a
groove behind the internal condyle) are very likely to initiate trouble;
hence in this location contusions, wounds, dislocations, fractures,
pressure (occupational or otherwise), and bandages or apparatus are
factors.

A considerable number of cases are due to actual severance (by
metal or glass) of this and other parallel nerves in the vicinity of the
wrist, and in such cases muscles and their tendons are usually in-
volved also.

Symptoms. — Flexor involvement means loss of power in bending
the wrist and two inner fingers, and when completely paralj'zed the
little finger is immovable. Interossei invasion means loss of flexion
of the first and loss of extension of the second and third phalanges.
together with loss of adduction and abduction of the fingers and
adduction of the thumb. These two foregoing conditions produce a
characteristic contraction of the fingers known as the main ett grijfe
of Duchenne, or claw-hand, which is gradual in onset and most aSects
the little and then the ring finger.

e paralysis: a, b, Sensory tmpainnent ili&use; c, d, sensory in
The solid black Mae indicates the normal zone of distiibutic

Atrophy of the hypothenar eminence appears and the interossei
shrink so that the bones and tendons may show prominently.

Sensory changes are indicated by numbness and tingling along the
com^e of the nerve, and occasionally some pain is also present.

Anesthesia is limited to the zone shown in Fig. 592, and is gener-
ally well marked in the little finger, being most prominent when the
nerve is inflamed.

mjDsiES o:f nerves, blood-vessels, and lyufh-vessels 6Si

Prognosis. — Most cases get well if the nerve is not caught or cut,
the outlook being best gaged, here as elsewhere, by electric tests.

F^o. 593. — Sensory nervei of arm and leg: a, Ann, anterior; b, Arm, posteric
anterior; d, leg, posterior.

Treatment. — Primary suture is advisable when possible; otherwise
the treatment is the same as in other types of neuritis. Operation is

682

TBAL*MATIC SURGERY

advisable in chronic cases and where laceration or compression exists.
1 recently operated on a case in which a supracondyloid fracture
of the humerus had so angulated and pressed upon the nerve that it
was flattened like a ribbon for a space of over an inch.

Ulnar nerve dislocation is said to occur occasionally from injuries
to the region of the internal condyle, a neuritis resulting. In a
considerable number of persons the nerve normally does not lie in a
groove, and in others it slips out of it on flexion of the elbow. In this
class of individuals a more or less chronic neuritis often occurs.

Sciatic Nerve. — This, the largest nerve of the body, supplies
with its branches all the muscles below the knee, but because of its
protected position in the thigh it is rarely hurt (Fig, 593, d).

Causes. — Theoretically, injuries in the region of the hip and sacro-
iliac joints should be causative, notably fracture and dislocation of
the femur; but, as a matter of fact, such is not the case, and Stimson
is authority for the statement that cases are only recorded in associa-
tion with hip dislocation or its reduction. Penetrating wounds are
the commonest source of origin.

Symptoms. — In complete paralysis a peculiar gait occurs in which
the hip is moved in a flail-like manner. Atrophy, loss of sensation,
and electric changes promptly appear.

In partial involvement the manifestations usually appear below
the knee and these will later be discussed.

Prognosis and treatment are similar to other forms of neuritis,
and suture is the only efficient form of treatment in marked cases due
to severance.

Sciatica is neuralgia of the sciatic nerve, and is usually due to
non-traumatic causes, of which may be mentioned rheumatism, gout,
exposure to cold, diabetes, infections, alcohoUsm, postural or occupa-
tional pressure, pelvic, urinary, prostatic, or rectal disease, pregnancy,
varicose veins, and various pressure sources.

Traumatic sciatica is usually a pressure neuritis.

Symptoms.— These depend upon the site, extent, and soui
the ailment.

Mild cases manifest pain on pressure and tingling along the 0
of the nerve, with some disturbances of gait or muscle action.

Moderately developed cases are indicated by pain over the sacrum.
buttock, and middle of the back of the thigh, and in severe cases the
pain may extend over the entire nerve distribution. The pain is
increased by pressure and motion, and the gait is so affected that flei-
ion at the hip and knee is limited enough to produce a relativel/

egnancy,

wui^^^l
^ec^^l

INJURIES OF NERVES, BLOOD-VESSELS, AND LVMPH-VESSELS 683

characteristic walk so that there is limping, a stiff form of locomotion,
the toe and leg being rotated and the weight thrown to the opposite
side and this posture is assumed even when standing. The patient is
often able to sharply delimit the course of the pain along the route
of the nerve, and this limitation is a differentiating factor in exclud-
ing rheumatism and other sources or allied trouble.

The pain is paroxysmal or dull and constant, and can be induced
by movements that stretch the nerve, such as walking on stairs or
bending the hip or knee.

Pressure tenderness can be elicited at
"Valleix's tender spots," where the nerve is
relatively palpable, namely, near (i) the pos-
terior iliac spine; (2) the sciatic notch; (3)
middle of thigh; {4) behind the knee; (5)
below the head of the fibula; (6) behind the
external malleolus, (7) on the sole (Fig. 594).

The pain is always deep seated and often
increases at night; changes in temperatOre
modify it and it is worse in damp weather.
Attacks of pain may come on with lightning-
like severity and be limited to the region of
the knee, ankle, or sole. The patient ad-
justs the posture and gait so that pressure is
removed, and thus the weight is placed on
the opposite side and the knee and hip are
supported in a bent position.

If a neuritis is present, the entire course
of the nerve may be tender and thickened,
and herpes may occur. Atrophy and loss of
sensation may exist, notably at the outer
margin of the limb.

Treatment. — The underlying cause must
be relieved and suitable means taken to remove irritation. Ano-
dynes and spHntage and external applications are employed.
Locally, ice and heat are used, and sprays of ethyl chlorid and the
actual cautery are sometimes helpful. Injections of sterile water
and various drugs are sometimes given directly into the nerve or
its sheath, and forcible stretching is also of value, either by sharply
bending the knee and hip or by operative exposure. Dietetic,
hydropathic, and climatic treatment are valuable also.

Prognosis. — Traumatic cases offer a better prospect than those

Fig. 594.

684 TRAUMATIC SUBGERV

due to constitutional causes. The progress may be slow and recOT-
rences are likely unless the initiating causes are kept under control.

External Popliteal or Peroneal Nerve.^The outer branch of the
sciatic winds around beneath the head of the fibula and may become
involved in fractures, dislocations, wounds, or pressure, this last
quite commonly from the constriction of bandages, splints, and
apparatus, notably plaster casts, during treatment of fractures.
Other non-traumatic causes are plentiful. It is the homologue of
the musculospiral of the upper extremity.

Symptoms. — This peroneal palsy induces paralysis of the tibialis
anticus and the long peronei muscles and toe extensors, and hence
adduction with falling of the foot and toes occurs, resulting in "drop-
foot" (Fig. 595). The gait is then quite characteristic and of the
"steppage" type, the foot being raised high so that the toes will not
dangle. Contraction of the tendo Achillis occurs in long-standing
cases and atrophy and loss of sensation appear on the outer side of
the leg and sole. Electric changes may also occur.

Fig. S9S-~~"I'iop-foot" ia peroneal panily^a.

Prognosis and treatment are the same as in other forms of neurftis-
Tenotomy of the tendo Achillis and tendon transplantation may be
needed in marked cases.

Internal Popliteal or Tibial Nerve.- — Because of its deep position
under the knee this other branch of the sciatic may be rarely involved
by the same causative factors named for the peroneal nerve. In
distribution it corresponds to the combined median and ulnar of the
upper extremity.

Symptoms. — These follow from paralysis of the muscles of the
calf and sole. The gait is much impeded and flexion of the ankle
and toes is impaired and the patient cannot rise on the toes. The
outer part of the foot and sole may be painful, numb, or anesthetic.

Prognosis and Irealmenl are like the preceding.

Plantar Nerves. — These are branches of the posterior tibial,
which latter is the continuation of the internal popliteal nerve below
the knee. Isolated injury is rare except from long-continued sources

INJURIES OP NERVES, BLOOD-VESSELS, AND LYUFH-VESSELS 685

of pressure, as from scars and callus. Tight shoes and prolonged
standing are frequent factors.

The internal plantar nerve corresponds to the median distribu-
tion of the hand; the external plantar corresponds to the ulnar pal-
mar distribution (Fig. 596).

Morton's toe is a. pressure neuritis of the second digital branch of
the iaternal plantar nerve as it passes between the great and second
metatarsal bones. It is frequently due to congenital misplacement
of the nerve, and when acquired is often associated with enlargement
of the head of the adjacent metatarsals. It is common in those who

FlO, 596. — Snperfid&l sensory nerve supply of foot; a, Anterolateral surface; b, plantar
surface; c, posterolateral surface; d, anterior surface.

are required to stand or walk a long time, and hence poIicemen>
letter carriers, and others similarly employed are liable to contract it-
It may also affect other digital branches and is often associated with
trouble in the arch of the foot. See p. 506.

Symptoms.— Vain of a steady or paroxysmal type, usually brought
on by walking, occurs along the course of the nerve, and this may be
very severe and associated with cramps in the muscles of the leg and
foot. Walking may be painful or impossible. Snapping of the bones
may also be present.

Prognosis and Treatment. — Proper shoes that support the arch,
separate the bones, and do not constrict the ball of the foot usually
suffice; otherwise resection of the nerve or the head of the metatarsal
may be necessary in severe cases.

686

TR.^,UMATIC SURGERV

INJUMES OF THE BLOOD-VESSELS

iNJUBT OF AhtEHIBS

Wounds and contusions may cause varying manifestations at the
site of the trauma, but clinically all the pathologic conditions occur-
ing in such vessels usually arise from internal causes dependent
upon altered states of the circulating blood.

In this latter class fall the various inflammatory conditions, such
as arteritis, peri-arkritis, arteriosclerosis, and the obstructive group,
variously known as obliterative efi-darlerilis or ihrombo-angittis obliter-
ans. These arterial conditions are the result of disease and not of
injury, and they are mentioned here because so often discovered in a
routine examination called forth by some accident. This is notably
true of arteriosclerosis and the thrombotic tj'pes of circulatory lesions
in which the condition has ordinarily existed for years and the symp-
toms perhaps have been ascribed to various other ailments.

Sometimes the occurrence of gangrene in an extremity at the site
of a trivial injury is often difficult to explain until an examination
discloses arteriosclerotic or obUterative arterial changes. The pre-
liminary signs of these obstructive arterial changes in the lower
extremities are often regarded as rheumatic or neuralgic, inasmuch
as complaint is made of various pains in the legs associated with
lameness or some spasm of the muscles and transient edema. Later,
or in association with the foregoing, complaint may be made of various
kinds of paresthesia, notably "pins and needles." and sensations
referred to as the "feet and legs going to sleep," with more or less
unsteadiness in walking. This group of symptoms was given the
name of "intermittent claudication" by Charcot. This condition
is not at all infrequent in early life, and for some unknown reason
Russian Jews are especially subject to it; it occurs also among users
of tobacco.

In passing, it is to be noted that locomotor ataxia and other
luetic manifestations are to be differentiated, and cardionephritits
and diabetes are also to be excluded. The gangrene occurring
from these sources may affect patches of the extremity, but it pre-
dilects the terminal phalanges, and is ordinarily of the dry or itnile
type and does not assume moisl manifestations unless infection is
present, or blebs have broken down.

Painful sensations in an extremity due to neural lesions or intO^
ference with blood supply are sometimes referred to as " Causalgia."
War experience showed that relief of such pain and the associated
edema, cyanosis, atrophy and disturbed sensation could in some cases

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 687

be relieved by (i) temporary catgut ligation of the main artery of
the limb; or (2) resection of the sheath of the artery, the so-called
"periarterial sympathectomy" of Leriche. (See abstract Military
Surgeon, Feb., 1919, p. 206.)

Treatment^ — This is usually wholly unavailing so far as surgical
removal of the underlying cause is concerned. As a prophylactic
such patients should be cautioned against self-treatment, for even
so slight a condition as a "bark of the shin," that might pass unno-
ticed ordinarily, may be a very serious matter in the presence of
obliterative changes. Inasmuch as the condition is progressive, the
injury is usually but an incident in its development and cannot in
any way be regarded as causative. Massive intravenous injections
of Locke 's solution has apparently benefited some cases.

When gangrene does occur, the question as to the level of ampu-
tation may be quite difficult to decide. A test that has been recom-
mended is to elevate the limb as high as possible and then apply a
constriction at the groin to shut oflf the circulation until the limb is
blanched. The tourniquet is then slowly released, and where the
circulation is deficient from obliterative changes the tissues will regain
their normal tone very slowly, if at all. In this manner the level to
which the blood reaches is shown sufficiently well to determine as to
the probability of obtaining viable amputation flaps. If, when am-
putating, a main blood-vessel is found blocked by a clot, it is prop>er
to remove it by passing a rubber catheter or other instrument into its
lumen; this procedure is known as "arterial catheterization." Am-
putation flaps should be very loosely sutured, and if their vitality is
subsequently impaired the surgeon should wait until a line of demar-
cation brings about spontaneous separation or accurately delimits
the blood-supply. Of course, the presence of active infection may
modify this advice and demand immediate re-amputation at the
requisite level.

Thrombosis and Embolism. — These never occur primarily as the
outcome of an accident except where the vessels have been damaged
either by direct violence or through septic infection.

Embolism of traumatic interest and importance is associated with
fracture, and less rarely with infected wounds. Following fracture,
especially of the long bones, fat embolism occurs occasionally during.
the progress toward repair; obviously it is more likely to appear in the
jfirst three weeks, during the period that osseous material is not abun-
dant. Next in frequency are the cases occurring after healing is well
enough advanced to dispense with the plaster cast or other fixed

TRAUMATIC SURGERY

dressing; thb is in the period from the fourth to the sixth week.
Massage or active sudden usage of the broken limb may be provoca-
tive causes; but many embolic cases apparently have no external or
obvious source of origin. Most of the cases 1 have seen have been in
fractures of the shaft of the femur in men about fifty years of age.

Postoperative embolism is most likely to occur in operations requir-
, ing active interference with the blood-vessels, notably in sepUc condi-
tions. Welch is the authority for the following list of arterial embol-
ism as to frequency of location: pulmonary, renal, splenic, cerebral,
iliac, and others of the lower extremity; retinal, superior mesenteric,
inferior mesenteric, abdominal aorta, and coronarj' of the heart.

Symptoms. — Apparently there are severe, moderate, and mild
cases in order of severity, and obviously the signs will depend some-
what upon the organ involved. It is to be remembered that infeciitm
is an essential prerequisite to embolism from wounds and that throm-
bosis may be a forerunner.

Pulmonary embolism in the severe form causes instant death from
plugging of the pulmonary vessels.

The moderate and mild cases suddenly develop dyspnea, cyanosis,
rapid pulse, an anxious appearance, and may go on to collapse.
These signs disappear completely in a very short time, or they may be
followed by evidences of pulmonary infarction and thus resemble
pneumonia.

Treatment. — This designs to relieve the respiration by oxygen
inhalations; meanwhile the heart is stimulated by drugs like strych-
nin, whisky, or caifein.

Kidney embolism is hard to differentiate from nephritis, and the
diagnosis is generally presumptive and the treatment is that of
nephritis.

Cerebral embolism presents the signs of apoplexy and requires the
same treatment.

AHKURYSMS

es UK I
vidob- 1

Generally speaking, any persisting sacculation, dilation, or widen-
ing of a blood-vessel can be called an ancur^'sm; but from a surgical
standpoint the essentials are (i) that the sac must be directly continu-
ous with the caliber of the arterj-; (2) that the blood-containing sac
must be defined or encysted (Fig. 598).

There are two general classes:

(a) True aneurysm, or aneurysma verum, in which one or all of the
arterial coats make up the sac.

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 689

(6) False aneurysm, or aneurysma spurum, in which extraneous
material goes to form the sac, such as blood-clots or connective-tissue
formation from them ; these are always traumatic in origin.

The preceding are further subdivided by Thoma into five classes:
{a) Congenital; (6) pathologic; {c) traumatic; {d) embolic; {e) cirsoid.
The congenital form is exceedingly rare; the pathologic form is gener-
ally due to some septic particle setting up an endarteritis. Embolic
forms occur in a cavity bathed in germs, as in a tubercular lung.
Cirsoid forms are due to anastomoses between vessels. Traumatic
Jorms fall into the class of false aneurysm and are relatively rare, and
occur usually from direct injury to the vessel, as from woimds due to
bullets, stabs, or other perforations. Some cases ascribed to indi-
rect forms of violence, like muscular efforts or twists or blows are
more properly chargeable to other causes, as most of them give evi-
dences of allied medical disorders, such aS arteriosclerosis or syphilis.

h C d €

Fig. 597. — Types of arteriovenous aneurysm: a, Direct communication between
artery and vein; 6, vein evenly dilated; r, venous sac; d^ connecting fibrous canal; e,
intermediate sac. (From "Review of War Surgery and Medicine,'* September, 1918.)

Occasionally fractures and dislocations initiate false aneurysms;
and in some few instances efforts at reducing dislocations have been
causative.

In some areas effused blood will form a sharply defined hematoma
that may pulsate from the beating of an adjacent artery; such a con-
dition is then known as pulsating hematoma, but it is not to be re-
garded as aneurysmal because there is no definite sac in connection
with the lumen of a vessel. This lesion most commonly occurs in the
region of the femoral, popliteal, and facial arteries. Efforts at pro-
ducing traumatic aneurysm in lower animals are said to fail unless
there has been previously some diseased or damaged state of the
vessel wall (Keen's Surgery),

Arteriovenous Anetuysms. — In these there is a communication

beween an artery and a vein so that they join directly {aneurysmal

varix) or through the intervention of a sac {varicose aneurysm).

Causes, — Injury is the commonest source, and bullet and stab
44

dnssi
Mass;

fracii:

tioiw.
ism as
iliac, a
infcriii'

Syr:
casts ir;
what 11 1 ■
is an f?-.
bosis 111.

Plihi:
pIugginL;

Thi- '
rapid pii
These si.L':
fol!o«-i-<l
pncuniurii

Tri-.ili'
inhalalin:
nia, whi-'

Ki,li:.
diagnosis
nephritic.

sami; iR-.ii'''

(;oiurally«
ing of a liUioil-
standpoint ihf
ous with ilie crtl"
must hv dctinpH
TIktc arc tw
(ii) Trucancii
arterial coats m.i

■ i z^:~. The weapons of modern war-
iiLj-.- -jiis sort of injury now that the
nsK" ttf-i. Venlterquam states that the
asir^ai -ire "a small orifice of entrance
zzr-v ":ut long cur\-ed channel usually
jL-L: iizYCtion; a small perforation in the
wr^ :e me wound and primarj- union of

- Tii=onestform, and it occurs ordinarily
ji'i vein are somewhat separated.

jf,r-tB\ t Aneuiysmal

_j^ ,71* e is many examples, notably in the femoral
_^^ P'tpArily they were caused by machine gun or
-ciJ ic;*ll fragments.

r^imn aneurysm an expansile, more or li-ss

-j,.r 5 wit and usually seen; the adjacent veins

r^i;. ae overlying skin is movable and the veins

~ vujpi»gi^'**t ^"'"^'^'^'•''g" appearance. Pres-

,. sac -'t the tumor, and if so, it quickly regains its

^^ herefrom; this is a pathognomonic sign.

" 4|e character of the palpatory signs, and the

^-isaialler than on the opposite side. A bruit is

' .i^"** W"^ ^^ ™^y ^^ transmitted slightly; it is

"*■ a dr shove the tumor. The patient may com-

.M»i or various symptoms indicative of altered

^pressure.

" .^itA easier because of the existing wound. A

" ijoted as one of the initial signs, and this may

-*iHtk the injury or within a few daj-s c "'"'t*

-ye«*"

lew rare and not well-authcnticated cases in

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 69 1

which several months are said to have elapsed before the tumor ap-
peared. This original swelling may continue to increase in size or
may remain stationary. There may be visible enlargement of the
tributary veins in some superficial locations, and ecchymoses may
also appear. In accessible locations the pathognomonic thrill is pal-
pable and of a purring character, very striking and unusual when ob-
tainable. The bruit is also typical and is likened to the buzz of
machinery, the droning of bees, the whirr of a bird in sudden flight,
or the humming of a top. The thrill and bruit in conjunction
are sufficient for a diagnosis. There may be associated signs of
circulatory embarrassment, as in other aneurysms, especially if a
limb is involved. The patient may also complain of the "roaring'^
or "buzzing" sounds if the tumor is in the neck or head.

Some years ago, at the Surgical Section of the Academy of Medi-
cine, I presented a case of arteriovenous aneurysm of the facial
vessels due to a .32 caliber bullet entering at the angle of the lower
jaw penetrating and furrowing the cheek, and making exit in the mid-
dle line of the upper lip. There was not much bleeding, but a large
hematoma appeared on the cheek and the ecchymosis extended to the
neck. On the third day pulsation over the swelling made me suspi-
cious of an arteriovenous aneurysm, but the bruit was not very
apparent, and I then regarded the condition as a pulsating hematoma.
Next day the bruit appeared in characteristic fashion, and in ten
days only an almond-sized pulsating lump remained and over it the
typical sound was apparent. The patient referred to "a swishing
sound as if a hive of bees buzzed in my ear," but otherwise he had no
subjective symptoms. Pressure over the facial artery as it crossed
the ramus of the jaw stopped the thrill and the bruit, and caused the
hard limip to disappear. Operation after two months demonstrated
no definite sac, and the artery and vein were ligated at the proximal
and distal ends, resulting in cure.

Treatment. — Operation offers the best chance in the traumatic
forms, and this may be performed by any of the accepted methods.

In ordinary aneurysm the suture and reconstruction or oblitera-
tion of the sac (Matas' operation) is a method of choice.

Arteriovenous forms are not operatively treated unless definite
indications exist, and it is best to wait several months when possible,
as some cases spontaneously disappear unaided; in others, firm proxi-
mal pressure appears to cause subsidence (Vanzetti's method). If
S)miptoms demand and the case is suitable, intrasaccular suture or
obliteration may be effective. In others, proximal and distal ligation

6ga TRAUMATIC SURGERY

with cxsection of the sac may be needed. When ligation is made the
method of choice, war experience hcis shown that gangrene is less
likely to follow when the artery and vein are simultaneously ligatcd
in any form of aneurysm. Tuffier's statistics show that gangrene
followed in 40 per cent, of cases when the artery alone was ligated.
but in simultaneous ligation of vein and artery the percentage was
24. In main vessels (like those of upper arm and thigh) anastomosis
or transplantation methods may be necessary.

iBjuRY OF Veins

These vessels are subject to the same sort of injuries as artei _
but because of structural differences they respond somewhat differ-
ently under similar circumstances. The total capacity of the venous
system is stated to be seven times that of the arterial, and for that
reason the entire blood of the body may be found in the veins
death (Stimson).

The valves in veins constitute their chief peculiarity, and these
of greatest importance in lesions of the lower limbs, and play a major
part in various other conditions. These bicuspid valves open toward
the heart and are placed at regular intervals, and are capable of
supporting the intervening column of blood,

Womids involving the lumen of veins produce hemorrhage that is
differentiated from arterial bleeding, in that it is more oozing
darker in character and "wells" rather than "spurts" out.

Phlebitis. — This means an ii\flammation of the walls of
and the process may begin in the lining coat or extend to the lal
from a periphlebitic origin.

Causes. — ^Damage to the endothelial coat is the essential feat'
•and this almost without exception is due to infection of some
Clogging of the vein to some extent is inevitable, and hence the
ing thrombosis is of the thramho phlebitis type. Various diseases,
typhoid, pneumonia, grip, gout, rheumatism, and the exantfat
are frequent sources of origin.

The surgical causes are the outgrowth of contamination of tie
venous stream from some pus focus, the staphylococci and strepto-
cocci being the most common offenders, Examples are found in
sinus and venous involvement in middle-ear disease and the
phlebitis following abdominal operations (notably appcndidl
Pus-containing wounds or ulcers are another source, and by mi
stasis the original focus may infect a far distant site because inft
emboli are carried in the venous channel. In this manner an ii

INJURIES OP NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 693

tion on the foot may be responsible for a similar outbreak on the face;
or the reverse. The common postoperative venous inflammation,
phlegmasia alba dolenSy ordinarily occurs in the left leg because of the
anatomic differences of the iliac vessels on that side of the body; this
condition, however, most commonly manifests itself as a postpuer-
peral incident and is a typical thrombophlebitis.

Phlebitis from injury proceeds invariably from a pus focus due to
the existence of an initial wound in the skin or mucous membrane,
and the condition is generally of the septic or pyogenic variety.

Symptoms. — Following a wound there may be some local evi-
dences of infection (redness, swelling, discharge, heat, and pain), and
gradually or suddenly these signs appear along the track of the vein
and constitutional disturbance becomes prominent, with adenitis,
fever, chills, prostration, sweats, and other evidences of pyogenic
infection. Other less severe cases may manifest only pain and cord-
like or general swelling, with tenderness along the palpable veins. If
a limb is involved, it will be hot, red, swollen, and tender. Areas of
abscess formation will show by local spots of softening, and when
these spontaneously rupture or are incised, the contained pus is thick
and brownish and often odorous. In some cases a series of abscesses
form along the vein like beads on a string. In severe cases metasta-
ses may occur in the liver, lungs, kidneys, or elsewhere.

Treatment. — Attention to aseptic and antiseptic details in wounds
is a valuable preventive.

The two cardinal therapeutic elements are to provide by elevation
(i) rest and (2) diminished venous pressure. If a limb is involved,
the use of some lotion (like lead and opium) or ointment (like ich-
thyol) may prove agreeable, a bulky dressing being provided in addi-
tion. The part is then elevated and supported in a comfortable
position. No active interference should be attempted until pain and
swelling are much abated, and then very gentle massage in an upward
direction can be given at a distance from the infected zone, and at the
same time the adjacent joints may be gently moved. Ordinarily
such manipulation cannot be safely given for several weeks. If
abscess occurs, incision and drainage is indicated.

Septic thrombophlebitis, if accessible, is occasionally successfully
attacked by ligation, or by ligation and incision of the involved
venous segment.

In all cases general treatment is exceedingly important and the
patient needs active systemic support, proper diet, and stimulants.
Out-of-door treatment is exceedingly valuable and most patients will

694 TRAUMATIC SUBCERX

profit if kept there day and night, suitably protected. Various sih-er
salts externaUy and intravenously have been recommended, but 1
have never known them to cure. Vaccine treatment is more promis-
ing and I have seen beneficial results from its use, especially in the
septic types. Autogenous vaccines appear to act best; but the
poly\'alent stock vaccines are often equally active.

Varicose Veins. — This condition means permanent enlargement
or dilatation of the venous channels due to changes in the coats of
the vessel.

The lesion is most typically seen in the lower extremity, especially
the thigh, leg, and scrotum, notably on the left side. The lowermost
part of the bo'dy is most affected because of gravity, weakness or
absence of the valves, pressure from the intra-abdominal contents, the
contraction of the muscles of the calves, and the lack of support for
the internal saphenous and other superficial veins. Some cases are
congenital and in others there appears to be a familial relationship.
According to Da Costa, 20 per cent, of adults have varicose veins in
some part of the body, and 80 per cent, of cases begin before the
twenty-fifth year.

The subject is discussed because it plays such an important part
in 'accidents and not because it is primarily traumatic in origin.

Causes. — Aside from the foregoing mechanical or anatomic
considerations there are certain other factors:

Age. — Two-thirds of the cases occur before the fortieth year^f

Sex.— Men are more affected than women, pregnant '
excepted. Garters cause some cases.

Occw/'a/ion.— Standing, walking, or straining are often pro
tive, and for these reasons waiters, clerks, laborers, postmen, f
men, and others similarly employed are often affected.

Pregnancy and tumors are important producing elements.

Diseases, like constipation, liver, kidney, and intestinal trouble^
that interfere with portal circulation are often causative; arterio-
sclerosis is a potent cause, and a similar change in the veins (phlebo-
sclerosis) may be equally responsible.

A single or isolated injury, like a contusion, wrench, sprain, or
wound, is never causative unless some phlebitis has been set up result-
ing in venous stasis, thrombosis, or consequent dilatation. Ob\-iously
such a sequence would not at first affect more than a single venous
channel and those closely tributary to it.

Long-standing cases are associated with lesions in the adjacent
vascular and neural vessels so that arteriosclerosis and changes in the

n origin.
anatomic

t wol^^l

INJURIES OP NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 695

nerves and their sheaths occur (interstitial or perineural fibrosis).
The skin often becomes leathery, shrimken, and adherent, so that
lymphatic circulation is interfered with and edema appears (elephan-
tiasis phlebectatica). Eczema is common. These changes may also
affect the bones and lead to osteoporosis.

The essential pathologic change in vein occurs in the media and
the phlebosclerosis lengthens and hardens the vessel, and in this and
other respects arteriosclerosis is paralleled.

Hemorrhoids, varicoceles, and enlarged veins of the lower extremi-
ties are the commonest varieties.

Symptoms, — These may be limited to the presence of a more or less
tortuous vein that becomes more prominent when the part is placed
in a dependent position or when the return circulation is impeded.
The accompanying veins or those tributary to the main tnmk may
also share in the enlargement. If the process is extensive or if it has
lasted a long time, edematous and nutritional signs appear, notably in
the lower extremity. Here there may then exist considerable
swellinjg, so that at night or after standihg a ridge may appear at the
shoe top; in some cases the swelling may be great enough to require
special foot-gear or bandages, or even interfere with walking.
Eczematous areas may form, with or without a break in the skin, and
the integument may become leather-like in color and texture. A
brownish-black or blue mottling may also appear, and a yellowish or
copperish pigmentation sometimes occurs. Pain is a frequent
accompaniment, and this may be diffuse or limited to the course of
the main vein or involve an adjacent nerve trunk or its filaments.
Neuralgia of main nerves is not uncommon, and in the lower limb
the sciatic nerve is often involved from edema or actual varices of
peri- or intraneural origin. Sensations of weight and various
paresthesias are sometimes complained of, so that the patient says
the "leg goes to sleep," or has "pins and needles in it," or it becomes
unduly cold or warm. Rupture of a dilated vein with varying
degrees of hemorrhage may occur spontaneously or follow slight
injury; this is especially common when the veins are beaded,
knobbed, or knotted, notably in those near the shin. Subcutaneous
rupture may cause considerable ecchymosis or hematoma formation,
and when the leakage is in the deeper muscles, notably in the calf,
sharp, severe, disabling pain may occur. These are the so-called
*'coup de fouet" or "whip-lash" cases that so closely resemble the
tearing of muscle-fibers or tendons, notably injury of the plantaris.
Varicose ulcers are exceedingly common and may follow minor

6c)6 TRAUMATIC SURGERY

bruises or abrasions, especially when the latter are infected by
improper treatment. They are commonest along the shin where
the blood-supply at best is limited.

Periostitis and osleitis may coexist from an original injur)
develop secondarily from local infection.

Leg ulcers {ulcer cruris) may occur from so slight a cause as scratC
ing, or a pimple, and nearly all of them due to skin breakage follow
superficial wounds, such as a "bark of the shin," The vast majority
have been self-treated for a variable time, and when they come to the
surgeon are usually much infected. Eczematous areas are often the
starting-point, and nearlyall of them showa surrounding area of inter-
trigo from exuding pus. In old cases there is often an area of dry,
scaly, cracked, pigmented skin in proximity. In the alcoholic, rheu-
matic, gouty, arteriosclerotic, tubercular, and syphilitic the manifes-
tations, are usually greater and the course more protracted. Many
are in areas previously ulcerous, eczematous, or otherwise devitalized.
These cases form a very large percentage of dispensary patients and
are commonest in persons over forty-five, especially women. Ancient
cases may be quite extensive, with calloused insensitive margins
and considerable edema that may amount almost to elephantiasis.
Lymphangitis and cellulitis are occasional accompaniments.

Diagnosis of long-standing valvular venous insufficiency is made
by the Trendelenburg lest, as follows: The patient lies down and the
legis raised high until all the veins empty or collapse. A finger is then
pressed over the saphenous opening and kept there while the patient
stands up. Then the finger is removed, and if the main vein fills
from above downward, the valves are incompetent, as normally the
vein should fill from below upward.

Efforts at straining or coughing or a tapping on the upper part of
a dilated vein will often cause a palpable wave of fluctuation when the
valves are incompetent.

Treatment. — Those predisposed should be encouraged to seek occu-
pations that minimize standing, walking, or muscular efforts. Al
every opportunity the leg should be elevated, and at night much good
will follow raising the foot of the bed or mattress. Proper footwear
and hose supporters should be provided. Habits and diseases should
be suitably treated. Some form of elastic stocking will be helpful
but these are expensive and soon stretch and become odorous from
use and perspiration. I find linen mesh bandages a valuable substi-
tute; these are cheap, washable, durable, and elastic enough to
accommodate the dailychanges in the circumference of a Hmb. Thty

I INJURIES OF NERVES. BLOOD-VESSELS, AND LYMPH-VESSELS 697

need not be worn at night. Any support of this sort should be
applied from the ankle to the knee, and above the latter also if
occasion demands.

Hemorrhage responds to pressure ordinarily, and care ig needed
to guard against infection.

Ulcers. — (See pages 63-67.)

Operation is indicated when there is no visceral basis for the
' varicosities and in that class of patient where phlebosclerosis is not
too far advanced. There are numerous types of operations, but
that of multiple linear incisions and exsection of the intervening
segments meets the average indications. Encircling operations
(Schede's and others) are less advisable because of theoccasional occur-
rence of gangrene following the scar contractures. Operative
approach is much easier if the involved leg is hung over the end of
^Ltiie table during the operation.

■ INJURIES OP THE LYMPH-VESSBLS

^B The main surgical interest of these lesions arises in connection
^Kiritb wound infection leading to lymphangitis and lyrnphadenitis.

Thoracic duct injury is so uniformly a part of fatal accidents, like
throat-cuts or bullet wounds, that recognition of it in life is rare. It
is occasionally injured in operations about the neck, and may then
become immediately manifest by the appearance of the characteristic
milky chyle, or this substance may later exude through an external
sinus or collect in the thoracic or abdominal cavity, producing
chylothorax and chylous ascites respectively.

Rapid emaciation, great thirst, difficult respiration, and exhaus-
tion promptly appear, and within a few weeks death is certain
in the presence of a marked lymphorrhea.

If the injury can be recognized early enough, the duct can be
implanted into the internal jugular vein; failing this, it may be tied,
feebly trusting to collateral circulation.

Contusions over lymph regions may very rarely produce a subcu-
taneous lymphorrhagia resembling hematoma, except that the fluid is
proved by aspiration to be yellowish and non-coagulable. Pressure
ordinarily causes their disappearance, other interference being rarely
needed and rather dangerous.

Lymphangitis and L3nnphademtts. — Inflammation of the lymph-
vessels and of their tributary glands is very common, the infection
being commonly of the streptococcic variety introduced through some
break in the skin, although the organisms may rarely gain access

698 TRAUMATIC SURGERY

through the undamaged surface. It more commonly follows small
and rather deep penetrations than open or gaping wounds. Trivial
and perhaps temporarily forgotten wounds on the hands and feet fur-
nish the largest number of cases.

When the smaller network of lymph-vessels is involved, it is
known as reticular lymphangitis; and when it affects the larger
collecting vessels it is called tubular lymphangitis, although both
forms may be combined. Clinically this classification is unimportant.

Symptoms.- — The cardinal signs of inflammation are promptly
present, and with the reticular form, redness, pain, and swelling
may be circumscribed and resemble a dermatitis or erysipelas; or in
the tubular form, red, diffused, palpable, tender streaks lead from the
wound focus parallel to the course of the veins and end in swollen
tender glands (lymphadenitis), and abscesses may here subsequently
appear. These two forms often coexist, and as the bacteria enter
the lymph-vessels, septic thrombi may form, and soon adjacent and
often distant tissues become infected by metastases.

If the condition remains localized, constitutional signs are lacking;
but if the infection is severe or generalized, the classic signs of sepsis
appear, namely, irregular temperature, elevated pulse, chills, sweats.
and prostration. Extreme forms may eventuate in delirium, fol-
lowed by coma and death.

When the deeper lymphatics are alone invaded, pain, tenderness,
and fever may be the only signs until surface brawniness and rigidity
indicate the probable beginning of an abscess.

The swollen glands are likely to remain hard and tender for some
time after the subsidence of acute symptoms.

If the original wound is still open, a purulent or foul sanious dis-
charge may or may not be present ; but with a free vent the occurrence
of lymph infection is less likely- Occasionally lymphadenitis may go
on to abscess formation at a considerable period after the primary
source of infection has healed; this is, of course, more likely in consti-
tutional (tubercular, specific, chancroidal cases) than in traumatic
types of infection.

rrea/men/.— Immediate sterilization of all wounds is the main
prophylactic factor. Early cases are treated by rest, splintage,
elevation, and wet dressings of equal parts of cold water and alcohol,
iodin water (i dram to pint), boric acid, or aluminum acetate. The
wound is given a free vent. Circumscribed or brawny areas not
responding to this treatment are incised, and abscesses are thus
treated as early as recognizable. Beyond this, the management is

INJURIES OF NERVES, BLOOD-VESSELS, AND LYMPH-VESSELS 699

that of septic infection in general. Swollen glands may persist a long
time after active symptoms subside; they require no attention
ordinarily.

Prognosis. — Most cases get well; deep infections and those of
streptococcic variety are more dangerous and may lead to metastases
unless early brought under control.

See also Infections of the Hand, pp. 85-109.

CHAPTER XVI

BURNS; HEAT STROKES; FROST-BITES
BURNS

These may be caused by heat applied by liquids, solids, flames.
and various fonns of radiant heal.

Of the common sources of origin may be mentioned boiling liquid
solutions causing scalds, as from water, oil, steam, or tar. Hot metals
and combustible materials provide another large group, and chemical
and electric contact furnish examples less numerous. Hot-water
bag burns also occasionally occur.

Practically speaking, they should all be regarded and treated as
infected wounds due lo heat.

Varieties. — Commonly, three grades or degrees are described, but
most cases present some of the signs of all types.

First degree burns produce only superficial involvement, charac-
terized by reddening or actual inflammation of the outside layers of
the skin or exposed surface, but there are no blebs and scarring does
not occur. This is known as the stage of hyperemia.

Second degree burns produce skin inflammation and blebs or
vesicles because of deeper involvement. Scarring does not usually
occur, but pigmentation is likely to follow. This is also known as
the stage of vesication.

Third degree burns produce actual destruction of the skin layers
and may even penetrate to the parts beneath, with escharotic or
charring manifestations. Scarring always results. This is also
known as the stage of escharation.

A fourth form, showing extensive manifestations of the preceding,
is sometimes described.

Symptoms. — These depend upon the degree and source of the
burn, and to some extent upon the age and physique of the patient.

Systemic or general signs are those of shock, and evidences of this
promptly appear in bums of all degrees if much of the body surface is
involved. It has been stated that burns involving more than one-
third the surface area of the body are likely to be fatal ; and in children
the susceptibility to fatal shock is three times greater than in adults.'

' Weidenfeld, quoied by Lieber, Bvilr. 2. Klin. Ckir., knd, November,

1 adults.' I

burns; heat stroke; frost-bites

701

There are numerous exceptions, however, to this, and burns of the
head and upper extremity are capable of inducing marked shock often
when relatively small areas are involved. The onset of shock
is prompt and often leads to delirium and coma.

Fever and pulse rise ia quite common (after shock subsidence) and
is independent of any infection in the first few days at least.

Vomiting and diarrliea sometimes occur; blood may appear in the
excreta, and gastroduodenitis or actual signs of duodenal ulcer de-
velop quite often. This last is now .supposed to be due to adrenal
involvement. I recall one case of this sort in which a man inhaled
hot vapor in a superheated steam room of a Turkish bath, and, becom-
ing unconscious, fell against a hot iron radiator, receiving very severe
burns of his back, extremities, and other parts of his body. He had
bloody vomitus and stools at the end of the first week, together with
much epigastric pain, localized tenderness, and rigidity. He subse-
quently recovered despite the added complication of nephritis.

Nephritis may be occasioned, and albumin, and hyalin, granular,
and blood casts may be found as part of an exudative nephritis.
Hematuria occasionally occurs and the urine is usually scanty and
high colored.

These various manifestations of severe burns are the expression
of a toxemia of unknown type, but which apparently has hemolytic
properties. It has been shown that the urine and serum of such a
patient are poisonous and capable of inducing in another similar
symptoms when injected. Death as a direct result of shock or toxe-
mia almost always occurs within sLx days, but in children a fatal
ending may not eventuate until the twelfth or fifteenth day.

Of all burns, my experience is that shock and complications are
greatest in those due to boihng liquids and inflammable materials
(clothing, bedding, and household goods) ; electric burns produce the
least systemic manifestations and the minimum of pain. (See In-
juries Due to Electricity, page 708.)

Burns of mucous membranes from inhaling steam or flame are
likely to be serious, if not fatal.

It is a clinical fact that women and children are more likely to
die from burns than men; this in part may be due to the difference
in clothing as female and children's apparel is quite inflammable.

External or local signs depend on the degree of the burn, and the
location and source of it.

First degree forms cause stinging or burning pain, redness of the
skin, and perhaps some swelling and local heat. Desquamation may

703

TRAUMATIC SURGERY

follow. Sun burns are of this type. Shock may be a factor only if
the bodily extent of the burn is extensive.

Second degree forms are exaggerations of the preceding, plus blebs,
vesicles, or blisters. These occur at once if the burn is localized and
the temperature of the source is high, otherwise they may not appear
for several hours. In size they are variable, and those that do not
spontaneously rupture soon contain pus. If punctured (designedly
or otherwise) the parts under them will be red, angry and painful,
and exude more or less serum. Unless aseptically punctured, pus
quite regularly appears, crusts form, and a more or less eczematous
condition arises. When healing occurs, the part remains dark for a
variable time, but eventually this pigmentation usually blanches
into the normal skin color. Shock to some degree generally appears.

Third degree forms cause actual destructive changes in the deep
layers of the skin and often in the parts beneath. They ordinarily
occur from prolonged contact with materials of very high tempera-
ture, as from molten or other metals. The resulting burn may pro-
duce actual charring, so that the part may be quite black; or the
eschar produced may be gray, yellow, or more or less mottled, and
dry or moist. The superficial appearance may not at first denote
the true depth of the process and this may remain a matter of sur-
mise until sloughing appears. Infection quite regularly occurs and
the process then becomes one not unlike ulceration.

Shock is a regular accompaniment, and other systemic evidences
of toxemia may become apparent by symptoms referable to the gas-
tro-intestinal and urinary systems as already indicated.

Treatment. — Shock and the other complications are treated as if
they had arisen from any other source. It may be stated, however,
that the continuous hot immersion bath is an excellent adjunct, as
this combats the general and local signs in one medium and is espe-
cially indicated when large surfaces of the body have been burned.

Practically speaking, burns are infected wounds and they should
be treated as such.

First degree forms need only a moist cold or hot dressing of salt
solution, boric acid, or other mild lotion. After the surface has been
swabbed with one-half strength iodin, or 3 per cent, picric acid a
10 per cent, solution of alcohol in ice-water is very agreeable. Later,
sterile olive oil or some mild ointment will do much to prevent tie
tight or puckered feeling over the area about to "peel off."

Second degree forms should have the bleb punctured aseptically
at the junction between the sound and unsound skin, the part ha\'ing

burns; heat stroke; frost-bites 703

been first painted with one-half strength tincture of iodin (33^^ per
cent.) or 3 per cent, picric acid. A moist dressing of sterile saline
or boric or sod. bicarbonate (5 per cent.) or magnesium sulphate
(10 per cent.) solution may then be applied and every effort made
to prevent pus formation. If it does occur, the secretion is washed
off and then a pink solution of permanganate of potash or iodin solu-
tion (i dram to i pint of water) may be used as a wet dressing on
gauze. Later, and when granulations begin, a sterile mild ointment
or oil may be used, and balsam of Peru added to this will effectively
aid in healing. Scarlet red ointment is excellent also at this stage,
I dram being used to an ounce of sterile olive oil. The use of carron
oil is to be condemned unless it has been previously sterilized, as the
average combination is often stale and anything but aseptic. Picric
acid in I to 5 per cent, strength has many advocates ; personally I do not
use it except as a primary sterilizing agent.

The posture of the patient is very important and the parts must
be suitably guarded and kept apart to prevent contraction by scar
formation.

The open-air treatment is ideal in a great many of these cases,
and my practice is to make a wire or wooden cage to encircle the part
and over this spread one layer of gauze to keep off dust while the
patient is exposed to the direct sunlight or open air for increasijigly
long periods daily. Usually this part of the treatment begins on the
second or third day. K crusts or sloughs form, they are to be cau-
tiously removed and not roughly pulled away, as thus they may lead
to ulcerations of a deeper type. When the patient is not exposed to
the air, the burned part may be covered by some sterile oily dressing
so that it may readily be removed for the ensuing air exposfe. In the
war we used with much success a "soap solution'* for the gas-burns
coming to our Evacuation Hospital No. iia formations. This solu-
tion is sterile, easily made and will not easily adhere to fresh granula-
tion.^ When the surface is pus free, red, and granulating, healing
may be hastened by autogenous skin-grafting if the area is large.
Personally, I have not had occasion to use grafting in several years
since using open-air and sunlight treatment. Scarlet red ointment
is extremely efficient at this stage. Thiersch grafts are the best,
although flaps or pedicles may act as well. Amniotic and egg mem-

*This is composed of castile soap 20 per cent., vaseline i per cent, Lysol i
per cent., sterile water q. s. 100 per cent. For use this is diluted one-half. In full
strength on crinoline or other wide-meshed gauze, it furnishes an especially good non-
adhering sterile application.

704 TRAUMATIC SURGERY

brane have also been used with some degree of success. On old ulcers
I have successfully used the fresh sac removed at herniotomy.

Third degree forms are treated as in the preceding, every effort
being made to cause early separation of the sloughs. It is unwise,
however, to dislodge eschars by force, as much bleeding and reinfec-
tion is thus occasioned.

Antiseptics of the mercurial and carbolic type are dangerous
because of the possibility of absorption, and thus the less dangerous
antiseptics, like permanganate and iodin, are preferable. Skin-
grafting is very frequently required.

Scarring and contractures are quite likely to lead to deformities
about large joints, the neck or fingers, and, in general, where there is
much need of mobility. The preventive treatment is here most
important, and splints and posture must be as much a part of the
procedure as careful dressings. In burns about the neck, the head
must be so tilted that the chin will not be drawn toward the chest. If
the axillary region is involved the patient must be trained to keep
the arms higher than the shoulders; likewise burns about the elbow,
hands, knee, and foot must be treated with the idea that if contrac-
tures occur the stiffening of the joint will be at such an angle that the
maximum and not the minimum of joint function may persist. The
daily use of passive motion, followed by active motion, will do as much
to limit joint stiffness in burns as it does in fractures and infections.
If necessary, various plastic operations may be performed to restore
contour or function.

Many of the scars remain for a time sensitive to pressure and
weather changes, and they readily crack and may even ulcerate;
eventually, however, these difficulties disappear.

Gastro'inteslinal compHcalions are best treated by careful diet-
ing and the use of such drugs as bismuth, salol, and others of that
class.

Urinary complications require the free use of water; urotropin,
salol, and benzoate of soda may also be indicated. The presence of
albumin is often an incident and does not necessarily indicate gross
or lasting kidney damage even if associated with blood and various
kinds of casts. These manifestations quite regularly disappear just
as they do in any other toxemia.

I have not used the paraffin preparations to any great extent as
an occlusive dressing in an infected area does not appeal to me.
These preparations are of greatest value in burns of minor degree.

^B burns; heat stroke; frost-bites 705

W Heat Stroke; Insolation; thermic Fever

I Two forms arc described: (0 Heal exhaustion; (2) sunstroke.
* Each of these is predisposed to by any set of causes tending to
diminish bodily resistance, and of these may be mentioned fatigue,
poor food, improper hygienic surroundings, and the excessive use of
alcohol, notably beer and whisky. Actual exposure to the sun or
hot weather may be the direct cause, but high temperature under
any method of contact is equally causative. In our climate the
majority of cases occur after a series of hot days, the seizures appear-
ing while the patient is in the open. Another group is represented
by stokers, firemen, and others who work in places of high tempera-
ture and are "overcome by the heat."

f i) Heat exhaustion may occur in or out of doors, and the onset is
usually gradual, with a feeling of great exhaustion, headache, and
dizziness, soon followed by nausea or vomiting that may lead to
actual collapse. The patient looks flushed or pale, the skin is gener-
ally hot and dry, but may be bathed in cold sweat. The pulse is
rapid and feeble and the respirations shallow. Temperature is
rarely over 103° F. and ranges from this to subnormal. The un-
consciousness of the collapse is not profound, and the pupils if dilated
will respond and the patient can be aroused.

{2) Sunstroke usually comes on suddenly and the patient is found
unconscious and in collapse; less often the symptoms of the fore-
going may first appear. Typical and well-marked cases manifest
general or local convulsions of a tonic or clonic type. Such a patient
has usually a flushed or hot skin, with a rapid and bounding pulse
and stertorous respiration; later the cardiac and respiratory signs are
those of collapse. The temperature is over 103° F. and may be so
high in fatal cases that the average thermometer will not register it.
Incontinence of bladder and rectum is common. Delirium fre-
quently occurs if the temperature remains persistently elevated.

Treatment. — The indications are to (i) reduce temperature, (2)
combat collapse, and (3) prevent complications.

(i) Temperature is best controlled by ice-water sponging, spray-
ing, or baths. The usual procedure is to employ cold externally
until the temperature shows a steady but not too sudden decrease,
repeating the sponging, spraying, or bath if a sudden rise appears.
Cold cloths or ice-bags are kept on the head after the patient is put
to bed. A very suddden drop of temperature is a had omen,

(2) Collapse is treated by hypodermics of whisky, strychnin, digi-
talis, caffein, or remedies of that type. If there has been much loss

7o6 TRAUMATIC SURGERY

of bodily fluids and the pulse does not gain in volume by these means,
repeated rectal use of a pint of salt solution and 4 ounces of whisky
may prove effective.

(3) Complications like delirimn tremens, pneumonia, anuria, intes-
tinal hemorrhages, and continued vomiting demand appropriate
treatment; but all of these are to be disregarded until the originating
condition is relieved and the remaining temperature is definitely
known to arise from a complication and not from the initiating or
relapsing heat stroke.

Many of these patients remain for a long time intolerant to high
temperature, and some of them have more or less well-marked e\i-
dences of peripheral neuritis, tachycardia, and impaired respiration.
Subjective symptoms like dizziness, headache, various pains in the
head and body, and special sense defects also may persist for a time.

Prognosis depends upon the individual, the extent and duration
of symptoms, and the opportunities for prompt and adequate treat-
ment. Alcoholics constitute the largest proportion of patients arid
in them the mortality is highest. Patients surviving forty-eight
hours usually get well, but those who have more than two relapses
usually die. Persistent convulsions and delirium are bad features.

FROST-BITES; CONGELATIONS

These may be due to sudden or prolonged exposure to cold and
are usually best shown in involvement of the toes, fingers, nose, and
ears.

Varieties. — Three grades or degrees are described, as in burns.

First degree frost-bites produce redness and more or less superficial
inflammation of the skin. If this is repeated or continuous the
affected part may swell, become livid, and less often desquamate or
ulcerate, meanwhile being itchy or irritating, especially on changes of
temperature; this condition is known as chilblain or pernio.

Second degree frost-bites result in the formation of blebs or blisters,
^nd when these heal under a crust no scar usually remains.

Third degree frost-bites produce more or less deep ulceration and
actual destruction of tissue, and in advanced cases gangrene occurs
with detachment of the involved part.

By many this last manifestation is known as a fourth degree
frost-bite.

In the War Zone, the generic name for. this class of case was
"Trench Foot," often a horribly mutilating infliction due to a com-
bination of impaired circulation, wet and cold.

burns; heat stroke; frost-bites 707

Treatment. — First degree forms require restoration of circulation
by friction and cold applications, such as rubbing the blanched
finger, nose, or ear with snow or ice until the normal color returns,
and meanwhile the progress from a cold to a warm temperature must
be gradual.

^ Chilblains should be protected by adequate clothing. Locally
the use of iodin, lotions like lead and opium, and various ointments
will be of value.

Second degree forms are treated as in the foregoing, and later
blisters are opened aseptically and dressed by some mild antiseptic.

Third degree forms are regarded as infected ulcers and treated
accordingly. If gangrene is present, the line of demarcation should
be awaited if possible, and in the interval the damaged part is kept
dry and elevated, as these measures tend to prevent moist gangrene
and the spread of the process.

In case of general freezing the patient is to be gradually "thawed
out" by being placed in a cold bath in an unheated room, friction
being applied by cold towels. After several hours the bath is to be
gradually raised to the average room temperature (about 70° F.)
and then the patient can be put to bed and further treated as
required.

CHAPTER XVII

INJURIES DUE TO ELECTRICITY; TO COMPRESSED AIR
OR CAISSON DISEASE; INJURY FROM ILLUMI-
NATING GAS

Injuries Due to Electricity

Accidents from this source are relatively common owing to the
wide-spread industrial use of electricity, particulariy as a source of
light and power.

What follows is very largely taken from the author's article of
similar title read in March, 1909, before the Surgical Section of the
New York Academy of Medicine, and subsequently published in the
Journal of the American Medical Association, April 2, 1910, vol. liv,
pp. 1127-1132.

Authoritative information as to the physical eflFects of electricity
is very scanty,^ especially in American literature, but in France,
Great Britain and elsewhere there has been much preliminary ex-
perimentation and subsequent case reportmg by physicians; but in
this country investigation has been limited almost solely to electrical
engineers, and case reports have been few in number.

For an intelligent understanding of the subject it is necessary to
know some of the usual technical terms, and they can be stated thus:

The volt is the unit of pressure. The ampere is the unit of
strength. The ohm is the unit of resistance. The coulomb is the
unit of quantity.

^ In addition to the subsequent numbered references the following may be con-
sulted: F. Batelli, Rev. nUd. de la Suisse romande^ 1902; M. A. Cleaves, ReJ, Handbook
Med, Sc.y iii, 742; Crile and Macleod, Amer, Jour, of Med. Sci., 1905, p. 417; R. H. Cun-
ningham, NciV York Med. Jour., Oct. 21-28, 1899; H. L. Jones, British Med. Jour., 1895,
i, 468; J. H. Lloyd, Med. News, Nov. 24, 1894; Mills and Weisenburg, University of
Pennsylvania Med. Bidl., March and April, 1903; E. A. Spitzka, New York Med. Record,
January 4, 1902; Proc. Amer. Phil. Soc., 1908, Jour. Med. Soc., New Jersey, 1909; H. A.
Ingalls, Remote Effects of Electric Shock, New Mexico M. J. 15: 185 (Feb.) 1916;
E. Kirmisson, Brulures multiples par r61ectricit6; h^moglobinurie; morte rapide i la
suite de convulsions, Bidl. et nUm. Soc. de chir. de Paris 42 : 1887, 1916; W. M. Bayliss,
The Dangers of Electrical Currents, Nature (London) 100: 24, 191 7; C. W. G. Mieremet,
Death from Electric Shock from Incandescent Bulb. Nederlandsch Tijdschr. v. Geneesk.
2: 1951 (Dec. i) 191 7; abstr. J. A. M. A., March 2, 1918, p. 661; E. Tornaghi, Poly-
neuritis Following Electric Shock from Live Wire, Brazil Med. 31 : 175 (May 26) 191 7;
abstr. J. A. M. A., July 28, 191 7, p. 393; D. Lewis, Electric Burn Causing Necrosis of
Skull, Ann. Surg. 67: 149 (Feb.) 1918.

708

INJURIES DUE TO ELECTRICITY 709

But for all practical medical purposes it is enough to remember
that the volt is the unit to express pressure, intensity, or electromotive
force; and that the ampere denotes strength or rate of current flow.
The volt is the impelling force which moves the electricity through
any conductor. The ohm is the unit of resistance and expresses that
quality of the conductor which resists the passage of electricity
through it.

Electricity flowing through any conductor is impelled by the volt-
age applied to the circuit and is opposed by the resistance of the
circuit. In direct current circuits, and in alternating current cir-
cuits when the current and electromotive force are *'in phase," the
rate of current flow is directly proportional to the voltage and in-
versely proportional to the resistance. This rate is measured in
amperes, and its numerical value is found by dividing the volts by
the ohms (I = E/R; ''Ohm's law'')-

Ordinary conductors carry currents of three varieties: Direct
(or continuous), alternating, and interrupted.

The contact may be of four kinds, viz., positive , where the body is
firmly and constantly pressed against the conductor; partial, where
the contact is slight and steady; brushing, where the contact is
slight and for a short interval, and arcing, where the current reaches
the body via a vapor through which the current passes. The
intensity may be (i) low (loo to 300 volts); (2) medium (400 to 600
volts); high (1000 volts and over); this classification being that
adopted by Prevost and Batelli, of Geneva, as the outcome of many
experiments.

The duration of contact may be (i) short, from one to five seconds;
(2) medium, from five to eight seconds; and (3) long, from eight sec-
onds upward.

Mode of receipt is generally by charged (i) wires or rails; (2) metal
apparatus or tools; (3) flashes or arcs which are productive of burns
only.

The average electric pressure in electric lighting is from 100 to
225 volts (direct or alternating), usually about no volts; in over-
head and underground trolley systems, from 500 to 650 volts (direct) ;
suburban lighting circuits, 1000 to 6600 volts (alternating with trans-
formers to reduce the pressure for use); series arc lighting circuits,
20cx> to 6000 (direct or alternating) ; in overhead, long-haul railway
systems, as in the N. Y., N. H. & H. R. R., 11,000 volts (alternating),
or, as in the C. M. & St. P. R. R., 3000 volts (direct). In third
rail systems, like the New York Subway, the voltage is about 650

7IO TRAUMATIC SURGERY

(direct). The highest voltage transmitted by wire in this country is
that generated by the Pacific Light and Power Co., 150,000 volts.
Another system transmits 120,000 volts between Cleveland and
Nashville. The Toronto Power Co. transmits 85,000 volts from
Niagara, and a Connecticut company uses 120,000.

A voltage of from 200 to 500 is usually not dangerous, but the
alternating current is considered to be more dangerous than the
direct, although Jellinek^ believes the reverse. In the electrocution
of criminals from 1300 to 2000 volts are used, the average being 1800
of the alternating type, the amperage being 7 to 9.

The physical effects are mainly determined by the following:

1. Amount and duration of current.

2. Site, type, and area of contact.

3. The individual.

1. Amount and duration of current is the main essential, and the
greater the degree and the longer the duration, the greater the effect.
High voltage, long duration, and positive contact generally predicates
coma, severe systemic shock, burns, and oftentimes death. Medium
intensity, with medium duration and partial contact, generally means
burns of the second or lesser degree, less profound coma and shock
with more or less paresthesia, especially numbness and tingling.
Low intensity, with short duration and brushing contact generally
means burns of the first degree or none, slight, if any, coma, and mod-
erate paresthesia, mainly of the tingling type. Low intensity, with
brief duration and partial contact, generally means absence of bums
or systemic symptoms, paresthesia of the formication type being gen-
erally alone complained of.

Amperage is so variable that it has not been mentioned because
of its uncertainty, but the higher it is, the greater the effect in general:
Jfo ampere is generally regarded as safe; over i ampere is usu-
ally fatal, assuming that the other factors are proportionate.

2. Site, type, and area of contact is less important, pursuant to the
physical law that electricity takes the shortest route between two
electrodes, and this has led to investigation to determine the resist-
ance of various bodily elements to the transmission of electric energy.
This pathway of the current is along the route of least resistance, and
Jellinek states that one path is through, and the other over, the sur-
face of the body. It has been found that the tissues transmit pro-
portionate to the amount of their fluid constituents; the more saline
this is, the better the conductivity. Blood is the best conductor,

^ Archiv. Roentgen Ray, Januar>', 191 3.

INJURIES DUE TO ELECTRICITY 7 II

mainly because of the saline serum. Muscle comes next, nerve tissue
follows, and bone is a poor conductor. Similarly, experiments have
shown that the bodily tissues exert varying resistance to the passage
of electricity, as denoted by the unit of resistance, the ohm. The
average human resistance is icxx) ohms. Dry skin is very resistant,
and one observer (Jolly) says that this is 150 times greater than that
of the underlying tissues. Jellinek states that the average resistance
of the integument varies between 30,000 and 100,000 ohms, and may
reach 1,000,000 ohms for calloused hands. A dry, hard, thick skin
oflFers more resistance than one that is moist, soft, or thin; an acid or
alkaline perspiration reduces the resistance, while an oily skin raises
the resisting power. If a strong alkali be applied to the skin so that
the oily secretions are removed, the resistance is much lowered, so
that the subject experiencing little effect from 100 volts might be
<iistxirbed by 10 volts. Larrat^ says that if muscle is given a standard
resistance of i, then nerve and cartilage can be denoted by 2.5; bone
as 15 to 20; and the skin and epidermis as between 100 and 500.
Electric energy meets greater resistance passing transversely to the
axis of a tissue than when transmitted longitudinally, this being 6 : i
in muscle, 3 : i in nerve-fibers. Turner's experiments indicate that
transmission from hand to hand meets with a resistance of 1375 ohms;
through one hand, 900 ohms; from cheek to cheek, 600 ohms; from
one supramalleolar region to another, 700 ohms; and through the
calf of leg, 350 ohms. Nerves and blood-vessels are the vulnerable
points.

As compared with any metal, the body is a poor conductor, it
being calculated that muscle is 115,000,000 times a poorer conductor
than copper. It has also been estimated that i inch of the sciatic
nerve has eight times the resistance of the Atlantic cable. ^

The greater the area of contact, the greater the effect, especially if
the current traverses vital parts, notably if the heart is in circuit.

3. The individual variation means the personal equation, and it is
strikingly similar to that of drug idiosyncrasy, notably as to sex, age,
physique, occupation, and temperament. Males are less affected
than females; the aged offer less resistance than the young on account
of the constituents of the blood-vessels ; those of rugged and muscular
physique have a greater conductivity than those of the opposite type;
the phlegmatic are subjectively less prone than the neurotic; those

^ Electro th6rapie, quoted by Dawson Turner, Manual of Practical Medical Electricity^
p. 188.

* Beard and Rockwell, p. 168.

712 TRAUMATIC SURGERY

accustomed to electric energy are often less influenced than the
novice. Illness, sleep, and alcoholism render persons less sensitive.^

Variations as to time of day, type of clothing, amount of food in
the stomach, and general well being all seem to exert some influence;
but the given effect cannot always be determined by these factors,
and I have known electric workers to have practically no effects from
contact under circumstances that left no doubt as to high voltage
traversing the system. If the person is prepared for or expects the
shock the effect is better borne.

Physical Effects. — In a general way these are three in number:

1. Deaths.

2. Bums.

3. Nervous symptoms.

Death from electricity is usually sudden, and is best represented by
the execution of criminals, lightning stroke, and unexpKxrted contact
with highly charged materials, the body completing and short-cir-
cuiting two conductors. Under such circumstances there may or
may not be decided external evidence of what has occurred, any such
taking the form of burns of varying degree, areas of lividity or ecchy-
mosis, or simple crimsoning to mark the place of entrance or exit of
the current. It is, however, very unusual for a lethal dose of elec-
tricity to fail to leave some visible evidence at the points of contact
Postmortem, such cases are surprisingly free from gross microscopic
changes, and the most careful search of all the tissues has as yet
failed to give any adequately uniform cause of death. The findings
in general are not unlike those following drowning or suffocation.
The body of Czolgos, assassin of President McKinley, was subjected
to the most minute scrutiny, especially by Spitzka's examination of
the brain and cord, but nothing more than the customary fluidity and
venous stasis of the blood with flaccidity of the heart muscle m'as
found. In a still more recent autopsy of an electrocuted murderer
the same negative findings were recorded. Still later, Spitzka and
Radasch- report finding in the brain of five electrocuted criminals
peculiar circular areas ranging in diameter from 25 to 300 mm. The
authors believe these to indicate the electrolyptic action of the current
liberating gas bubbles. Observers appear to have two main theories
to account for death under such circumstances: one being that the
heart muscle is paralyzed by a tetanic spasm analogous to that ob-
servable in skeletal muscle under high voltage ; and the other theiwy,

^ F. B. Aspinwall, Lancet, 1902, p. 660.
* Amcr. Med, Jour, Set., Sept., 1912.

IN JURIES DUE TO ELECTRICITY 713

that there is a definite cellular destruction, especially of the vital
centers. In connection with this last, it has occurred to me that the
disintegration that seemingly takes place may generate toxic mate-
rials, thus adding a chemical to a mechanical irritation that almost
immediately kills. Death from low tension current is by heart
fibrillation; heart and respiration alike fail from lethal medium
tensions; and respiratory failure is the cause of death in high tension
accidents.^

Burns by electricity differ from those due to extremes of tempera-
ture only in origin, and they may be of the usual first, second, and
third degrees. An electric burn is an index of resistance of the tissue
affected, and always indicates that the full strength of current has not
been received. The character of the burn is sometimes determined
by the type of metal acting as a conductor, and burns by arcs and
flashes from copper conductors sometimes produce less severe burns
than those emanating from iron or steel By contrast with burns
due to flame, or contact with steam, hot solids or liquids, deep electric
bums are apparently less painful, produce less systemic shock, and
heal more quickly. This was once vividly impressed on me in a
Harlem Hospital service, where in adjacent beds lay patients who
sustained irregularly distributed bums of all degrees in an incendiary
fire, and also those who had received ** third rail" bums; the former
had more systemic symptoms, the burns were more intractable to
treatment, and the complaints of pain were greater than in the latter
class of cases. This is probably due to the fact that electric destruc-
tion of tissue is sudden and absolute, as if done by electric cautery.
The contrast is even greater by comparison with bums from hot
liquids, such as boiling water, oil, or tar, and this irrespective of the
surface areas involved. The resultant scarring and contraction
appear about equal, even though electric burns are often more
diffusely distributed over widely separated areas than bums of other
kinds. Many electric bums are characterized by the lack of supr
puration and the smoothness of the resulting scar. If the clothing is
ignited, there is added the element of heat bums to those which may
be the direct result of electric contact. Sometimes metallic particles
are deposited on the skin (as if electroplated), causing a brownish,
dry, stiff, painless burn that leads in a few days to a flaky peeling of
the skin.

Burns resulting from partial or arcing contact often heal slowly

* L. Minot, Des accidents caus6 par Temploi industriel de I'electricit^, etc., Paris,
1908, p. 21, quoting Pr6vost and Batelli.

714 TRAUMATIC SUSGEKV

and show a tendency to slough or to become gangrenous, especially if
the trophic supply is involved. Cases of this type sometimes give
external signs disproportionate to the underlying damage, and the
severer symptoms may be a few days in appearing, and then show as
isolated or confluent areas of a more or less gangrenous type. From
the time of receipt of burns of this kind to the outbreak of severer
manifestations the interval period is always filled by symptoms
indicative of more or less deep-seated damage, in addition to the
superficial evidences.

Fig. S99- — Third dcgi

: burn cxUmliiig Fium miilscapu'a

I have had many opportunities to examine cases of electric in-
juries, and one of the worst of these was the following:

Case i. — History. — S., a laborer, was ivorking in a manhole repairing the "chiniwl
rail" ot one of the surface roads, the current of 550 volta being turned on. la wmt
manner he fell against this charged tail so that his bact contacted at about the lora
scapular level, his feet being grounded on concrete. He remained in that poalins
several minutes and when released was found to have a third degree burti that praclinlly
escharcd his back from midscapular to the lower lumbar region, and it is said thai <^
bum reached far enough to expose the underlying I'iscera. He sufiered profound!;'
from shock and was unconscious, and his recovery nas protracted. Even at this <)■■

INJURIES DUE TO ELECTRICITY 715

(six years later) there is an unhealed area about 3 by 4 inches in the central portion of
the scar, but all except this space cicatrized without skin-grafting in a remarkable way
considering the original extent and severity of the wound.

Subsequent History. — Some years later he was seen and exhibited by me, and at that
time he had a butterfly-shaped scar 13}^ by 11 inches in the involved area, in the lower
portion of which was a supposed lumbar hernia. The scar had contracted enough at
£rst to almost draw the wings of his scapulae together and spinal flexion was impossible;
but by continued self-bending and manipulation of his back he so far recovered as to
be able to resume manual labor. Later he was operated on by me and the supposed
lumbar hernia proved to be retracted bundles of muscle-fiber. The above-mentioned
unhealed areas were covered by autogenous Thiersch grafts, but healing was not yet
complete in January, 1910. He at no time developed a traumatic neurosis (Fig. 599).

Nervous Symptoms, — In the absence of direct destructive or in-
flammatory damage to nerve-fiber and the subsequent development
of a more or less localized neuritis, the nervous effects are almost in-
variably those of the hysteroneurasthenic type, it being rare in my
experience to find either neurosis separately as a consequence of
electric or any other form of trauma. I have never known an organic
disease of the central nervous system to develop from the passage of
electricity through the body, nor does the available literature narrate
more than one instance of this nature. If a direct injury has been
done to nerve-fiber the symptoms will be those corresponding to the
distribution of the affected nerves, and hence no description is needed.

Where direct injury to nerve tissue is absent or minor in extent,
the subsequent development of neurasthenic and hysteric symptoms
is generally psychic in origin or dependent on auto- or heterosugges-
tion, and the signs then presented are usually disproportionate to the
actual physical damage sustained. Such cases rarely present object-
ive evidences of electric contact and occur usually in those predis-
posed because of a neurotic or actually hysteric temperament. The
flash, spark, or arc from charged metallic contacted points occasion-
ally induces this set of nervous symptoms, either with or without
bodily contact. Cases of this and allied sorts are often designated by
the term "electric shock,'' and less frequently as "electric neurosis;"
but the symptoms do not differ in any essential respect from the
ordinary shock or neurosis attributed to any other trauma.

Examination of such a patient develops a wealth of subjective
symptoms and a poverty of objective symptoms, and the average case
will correspond to the following:

Case 4. — History. — Mrs. F. was alighting, during a rain, from a suburban electric
car operated by the overhead trolley system. While she had one foot on the car plat-
form and the other on the metal step, her hand being on the dash-handle, she claims to
have received a "shock," the force of which threw her 'face downward to the ground.
She was stunned but not unconscious, did not vomit, and when assisted to the adjacent

7l6 TRAUMATIC SURGERY

sidewalk was able to discuss the Dcc:ur[i:nce with some sbow of agitation and not a liltle
anger. She walked uoaided to htr humc nearby and saw her doctor some few hoim
later. He gave her lotions for the bruises of the knee, elbow, and hands. Thttt: were
no bums or obvious electric effects, but she did complain of tingling and needle sensa-
tions in the hand that touched the dash-handle and in Ihe foot that contacted with the

When I WW her some fourteen days after the accident she was abed, somewhat
pallid, and had a characteiisticalty tense and drawn expression, and was markedly
irritable in manner and speech, all of the foregoing being said to be foreign to her nonnd
state. There was an obvious rapid tremor of the closed eyelids, about the angles of
the mouth, and of the outstretched fingers and protruded tongue. External e^'idences
of injury were lacking aside from a fading area of bluish discoloration over a palm-sied
area just above the right knee, probably from her fall. No eiidencea of electric con-
tact, or of so-called "electric shock," were prcscnL No paralyses and no anms of
diminished sensation: conjunctival and pharyngeal reflexes absent; marked dernio-
graphia; knee-jerks lively, aU others normal. Romberg sign marked; no Babinski or
allied manifestations. Gait was normal and pulse rapid. There were areas of shiftins
tenderness along the spine, these being very inconstant and readily brought otit by
suggestion, T^vo spots were found in the upper dorsal region consistently lender, but
she leaned back in a chair on these same areas and made no complaint. There was on
contraction of visual fidds and no color distortion.

Here is a typical case of the milJer form of recoverable bysterooeurnathenia, and
she had many symptoms that might as well be stigmatic as symptomatic She rnnvrml
perfectly in a short time.

Contrasted with the former mixed type of functional ner\ous
disturbance, the following case of almost typical hysteric motor
paralysis with milder neurasthenic symptoms is narrated:

Case 5. — Hishiry.—G., an electrician, was admitted to the Harlem Hospital will*
history of having been injured two weeks previously in an out-of-town power-house, Cte
patient slating that while holding a. dead wire in his left hand, some one turned on Vu
current of 1:0 volts and his hands ^nd lingers were burned; immediately Gngenof ibr
left hand contracted; it felt as if an electric current passed through him every timelui
fingers were touched; he claims to have lost all sensation over entire left upper eitrHmt)';
and says that he cannot move his fingers; he has had other electric bums, but was neve
affected in this manner before; the current entered the palm of the left hand, hut ihr
place of exit is unknown.

On examination Ihe left hand presented the pseudo-Dupuytrcn's cootractian ip-
pearance indicated in Fig. 600, palmar fiexion at the metacarpophalangeal joiotiol Il<
inner four fingers being marked, that of the ring and little finger being most pnuniiuiil-
There was no apparent atrophy, nor was there any bum or other sign of trauma. Hf
would not permit the slightest manipulation of the extremity except when his attiBlliX'
was diverted, and then the fingers could be partly extended. He claimKl kw °'
thermal and tactile sensation over vnriable areas from the elbow down; but tb«seduft(<L
especially on suggestion, und followed indefinite nerve distribution. Actj%'e motioBoi
the' wrist was limited; flat of the elbow and shoulder normal. He would not pttw'
passive motion, nor would he consent to electric tests. The examination ns to hitpi''
eral state showed him to be in excellent cotulition except that he was of oeuiotic W
and presented many hysteric stignuta and neurasthenic manifestuttons.

During the fortnight intervening between the accident and his entry to the boipOl
he was under the care of a physician, who had gi'.cn him some internal medicatioD win
local application of iodin, and who is said to have made a diagnosis of "pualyiisiniD

INJURIES DUE TO ELECTRICITY

717

dectric shock." At no time were splints or retentive (onns of apparatus employed.
He would not consent to the proposed anesthetization, nor would lie allow a doisal
splint to be applied, and accordingly he was dismissed from the hospital with a diag-
nosis ol "hj-stcrical paralj'sia of hand." There was unquestionably an element of vol-
untary exaggeration in this inslancf as so often happens in that class of case in which
litigation is pending. When seen a month later he had regained function enough to do
his usual work but still had many subjective complaints.

Fic. 6oo.^Pseudo-Dupuytrcn's contraction as the result of electric bum, showing
•\ marked palmar flexion ot the metacarpophalangeal joints of the inner four fingers.

1^ Occasionally there are cases recorded in which blindness and deaf-
' ness and other special sense defects have been attributed to electric
contact or flashes, but all instances of this sort are of the hysteric
variety, and fall into the class of so-called "fright neuroses." An
example of this sort came to my notice recently in which "blindness"
was said to have been induced in a susceptible woman by the flash
and spark display when an overhead trolley wire was struck by a
metal beam. She was seated in her room some 300 feet away from
the scene of this brilliant display of light and sparks, but within sight
and sound of the occurrence, and she claimed that she experienced the
sensation of a ball of fire dancing before her eyes, and she immediately
became sightless. Examination showed no organic defect of vision;
the case was one of hysteric amaurosis induced by fright in a sus-
ceptible person. Vision returned within a short time.

Other Effects. — Crile' says that high-tension currents produce no
chemical change of importance in the various tissues and organs aside
from the burning at the place of contact, and that the blood is un-
altered. To prove this, a current of 2300 volts (alternating) was
passed through the head of an animal, and during the ensuing month
of observation there was no discoverable Joss of function. The same
observer also says that when atropin is administered before the cur-
' G. W. Crile, article on Surgical Physiology, Keen's Surg., i, jg el seq.; Crile and
DoUey, Jottr. Exper. Med., 1906, vill.

7l8 TRAUMATIC SURGERY

rent is applied the inhibitory effect is almost wholly obviated, except
when the current passes through the heart muscle, and then death
ensues.

Treatment presents no special problems, inasmuch as it is for the
relief of shock, burns, or neuroses. In cases of profoimd injury, and
even where death has apparently occurred, prolonged artificial res-
piration should be maintained, as in drowning cases, with compres-
sion of the chest wall in the precordial region; even digital compres-
sion of the heart itself has been proposed, but never successfully
practised. The pulmotor and lungmotor have proved of value, but
until they can be operated, artificial respiration must be diligently
given. Crilc recommends rhythmic pressure over the heart area, the
tongue being drawn out, as he says that this combines circulatory and
respiratory artificial stimulation.

With the foregoing manual methods the use of various stimulants
of the atropin, strychnin, and adrenalin sort is also advisable.

Burns are treated after the manner indicated for other bums (see
p. 702), and it has been observed that the so-called open m.ethod of
treatment is especially efficacious in this type of bum. Exsection of
the involved area and subsequent suture is also advised for some third
degree forms; 1 have never found this necessary.

Neuroses are best treated by isolation, plus the mental and thera-
peutic means named in discussing neurasthenia and hysteria (see

p. 757).

Prognosis depends on the extent of the im'tial inhibition s)!!!!)-

toms; in patients that survive forty-eight hours the prognosis is that
of the absorption of septic and toxic products from the burned areas,
with the development of cardiac, respiratory, or kidney complica-
tions, and with, occasionally, the presence of fatal gastro-intestinal
disturbances.

The ultimate scarring and contraction from the bums requires no
comment. Neuroses do not ordinarily develop until after the patient
has recovered from the main objective symptoms, and these nervous
manifestations then frequently stand in relationship to a pending
claim, and recovery does not usually ensue until adjustment is
effected.

Conclusions. — It can be stated that there is no special form of
physical effect inherent to electricity, inasmuch as every s>Tnptoni
can be paralleled by other forms of trauma. Likewise there is noth-
ing pathognomonic in electric shock, and the symptoms of it are those
common to other forms of systemic shock, with or without bums or

INJURIES DUE TO COMPRESSED AIR; CAISSON DISEASE 719

neuroses. The duration of symptoms is no more prolonged after
electric than other forms of trauma; nor does there appear to be any-
sound basis for the claim that one electric shock renders the patient
more prone to similar experiences, but, on the contrary, an acquired
immunity seems to be created by repeated applications. Electridty
is well imderstood scientifically and is governed by well-known phys-
ical laws, and there is no good reason for the \aew often expressed
that its effects on the human economy are unusual or peculiar.

Injuries Due to Compressed Am; Caisson Disease

This is an incident of occupation and occurs among those who
work under forced atmospheric pressure in the construction of tun-
nels, bridges, subways, foundations, or other subsurface work carried
on in compressed air locks, chambers, or caissons.

The normal atmospheric pressure is 15 pounds to the square inch,
and workers in compressed air are subjected to an average pressure
ordinarily between 30 and 40 pounds.

Hill states^ that he and his assistants have been subjected to six
and seven atmospheres of pressure without suffering harm or discom-
fort. In subaqueous construction, for every 5 feet below the surface
of the water, about 2 pounds additional pressure is needed. This, at
a depth of 373^^2 f^^t beneath the surface, 15 additional pounds pres-
sure would be required, and this is technically known as "two at-
mospheres." Pressure less than this usually causes no symptoms,
and some work is carried on with a, pressure as high as 55 pounds.*

Physiologically, the condition is supposed to be due to the libera-
tion of the dissolved nitrogen gas from the blood into the tissues
(Hill), the air having been absorbed under pressure by the blood with
coincident increase of blood-pressure. For this reason, if the worker
is gradually subjected to the forced pressure there are ordinarily no
serious symptoms; the same freedom follows if the pressure is gradu-
ally reduced before the workman returns to the surface level.

The majority of cases occur from too rapid decompression when
the worker is suddenly forced to acconunodate himself to a change
from about 35 pounds to the normal 15 pounds. An acut6 dilatation
of the blood-vessels is said to occur under such conditions and the
tissues of the brain and spinal cord are most readily affected, leading
to evidences of pressure, edema, or hemorrhage.

^ Brit. Med. Jour., February, 191 2.

* The author quotes freely from the articles of L. E. Hill, H. H. Pelton, and L. M.
R}raii.

jaO TRAUMATIC SURGEKY

Causes. — As indicated, the essential element is lao rapid variatieH
of pressure, and this ordinarily occurs during the passage from the
lock to the surface. The Latin races are said to be more prone than
others and the novice is more susceptible than the experienced "sand
hog." Cardiac, arterial, pulmonary, nephritic, and alcoholic sub-
jects are bad risks, and those under twenty or over forty-five years
also do not act well.

Symptoms. — The onset is generally immediately after or during
release from pressure; in some cases there may be a delay of a few
hours, but very rarely is there a lapse of more than six hours. The
later the onset, the milder the symptoms.

There are two main tj-pes, the spinal and the cerebral, and the
manifestations vary accordingly.

Spinal Type. — This is the commonest and comprises approxi-
mately 90 per cent, of all cases, varying grades of severity codstin^.

Neuritis Grades. — Here the main symptom is pain in the limbs,
usually in the calf or arm muscles; these may be cramp-like or shoot-
ing in character and occasionally may involve the muscles of the
chest, abdomen, and back. Ordinarily these signs are constant, but
may intermit or become paroxysmal; they are commonly known as
ihe bends.

A respiratory form, with more or less dyspnea, cough, and sense
of suffocation, may occur less often; this is called Ifie chokes.

Itching may coexist, but swelling or discoloration never occurs.
More or less shock generally coexists, so that the pulse is quickened,
perspiration is profuse, and there may be nausea or vomiting.

Paralysis Grades. —This may he a monoplegia, hemiplegia, or para-
plegia; the last is commonest and ordinarily the legs are most affected.
The onset will be sudden or gradual and may or may not be preceded
by pain. Sensation is generally not totally abolished even when
motor control is wholly absent. The sphincters may be involved and
the reflexes may be altered; the reverse may also pertain. Shock
usually coexists. Cases going on to lasting improvement begin to
show recession of symptoms promptly, and in some instances re-
cover>' is brought about at once after recompression.

Hematomyelia, not unlike the ordinary traumatic type seen with
fracture-dislocation of the spine, may occur, and cases that show h'ttle
or no progress in sl\ months generally end fatally from sepsis acquired
from infection of the urinary tract or bed-sores.
never occurs in the spinal type.

UnconsciousiMB

INJURIES DUE TO COMPRESSED AIR; CAISSON DISEASE 72 1

Cerebral Type. — Vertigo Grades. — Ringing or roaring in the ears is
an almost constant occurrence of changed air pressure. Passengers
passing under the East River in the local subway and Long Island
trains experience such sensations; similar experiences mark the
journey to New Jersey in the tubes of the Pennsylvania and Hudson
and Manhattan Railway Systems also. Nausea, staggering, vertigo,
and vomiting may also occur when the pressure changes are greater
and when the compression or decompression is more marked; this
form is commonly known as the staggers.

Coma Grades, — Unconsciousness may be moderate or severe, and
when the latter occurs the outlook is grave.

Delirium may occur and the patient tosses about, endeavoring to
clutch at the affected side of the brain in those cases associated with
hemiplegia or paraplegia. In the semicomatose cases the patient can
sometimes be aroused by irritation and may be able to stand with
assistance, but vision is generally limited to ability to distinguish light
from darkness. Marked shock also exists frequently.

Treatment. — Prophylaxis is important and applicants should be
rigidly examined before being allowed to work in the locks. Cardiac,
arterial, nephritic, respiratory, nasopharyngeal, and otitic defects are
contra-indications to employment. The markedly alcoholic are bad
risks, and the use of such stimulants should be limited as far as possi-
ble. Persons less than twenty or over forty-five years old should not
ordinarily be employed. Men formerly working as "sand hogs"
should not be re-employed without examination, especially if pre-
viously subjected to "bends," "chokes," or "staggers." Very few
"sand hogs" are able to work constantly more than five years, and
during that period re-examination every three months is advisable.
A severe attack interdicts future employment.

Large organizations provide medical attendance in a specially con-
structed "hospital lock" at the scene of the work, and such a "lock"
is thus described by Pel ton: It consists of a horizontal cylinder made
of J-^- to ^-inch boiler iron, a good size being 25 feet long and 7 feet in
diameter. It should be divided into two chambers by a partition in
which is an air-tight door opening inward. The open end of the lock
has a similar door. Both chambers are supplied with outlet and inlet
valves, and then the patient can be visited without changing his
pressure. Heating apparatus should be electric.

Rate of decompression is the main prophylactic factor, and danger
is minimized when this is done gradually and when the men are urged
to drink hot coffee freely, and emerge warmly clad.

722 TRAUMATIC SURGERY

Spinal cases usually respond promptly to recompression; tbat is,
the patient is subjected rapidly to about two-thirds the pressure un-
der which he was working when attacked. The duration of the
recompression depends on its effects, and usually the sjinptoms sub-
side after a few minutes of increased pressure. As soon as possible
the patient is urged to stand or walk, and the circulation is further
stimulated by deep breathing, forced muscle movements, or massage.
The legs and arms are especially urged into action, Hj^podermics of
strychnin, caffein, camphor, or other heart stimulants may also be
employed.

As soon as the symptoms subside, decompression may begin and
the ordinary case is decompressed at the rate of i pound in four min-
utes, thus allowing one hour for 15 pounds pressure. In severer
grades, decompression should be much slower, and as much as ten min-
utes should be allowed for a reduction of i pound of pressure. Mor-
phin may be needed occasionally for the pain.

If the attack occurs after the patient has left the scene of employ-
ment, recompression should be resorted to as promptly as possible;
fortunately, such cases are generally not of severe grade. Patients
suffering only pain go on to recovery spontaneously (Ryan). Exer-
cise and forced activity, especially walking, is urged until the seizure
subsides.

Where paralysis occurs and recompression is not available,
massage, electricity, vibration, and forced movements are advisable;
in many respects the necessity for this sort of activity resembles the
treatment of opium-poisoning. If the sphincters arc involved, suit-
able care must be provided. Cases showing early improvement
■ recover completely as a rule; however, it the paralysis persists after
recompression, it is likely to persist to some degree, and is later fol-
lowed by atrophy and a condition of ataxia or spasticity. The
treatment of these cases is then like that of myelitis or peripheral
neuritis.

Cerebral cases of the "staggers" variety are also recompressed,
but this form of treatment is less valuable than in the preceding vari-
ety. Rest and quiet in a dark room are most beneficial. The attack
gradually wears away, until at the end of a week the patient is on
the way to recovery. Catheterization of the eustachian tubes with
inflation of the middle ear is of service as well (Ryan). Stimulation
is given hypodermically when needed. Artificial respiration, prefer-
ably by the aid of the pulmotor or lungmotor, is valuable. Oxygca
may be of aid after the patient is out of the lock.

INJURY FROM ILLUMINATING GAS 723

Injury from Illuminating Gas

Accidental inhalation of illuminating gas generally occurs from
failure to fully turn off the stop-cocks of chandeliers or gas stoves,
and from leaks in gas pipes or gas mains. Gas is commonly used
as a means of suicide. Employees of gas companies and others
continuously exposed are sometimes subject to so-called "chronic gas
poisoning."

The lethal effects are primarily due to the irrespirable character of
the inhalant.

The carbmt monoxid present in gas is the determining poisonous
element because it has an affinity for the hemoglobin of the blood
three hundred times greater than oxygen. Fortunately the resultant
carbon monoxid hemoglobin is relatively unstable and hence can be
decomposed when oxygen is present in great excess, resulting in the
formation of oxyhemoglobin. Under such conditions it appears that
the carbon monoxid is expired as such and is not converted into car-
bon dioxid as formerly maintained.

Sjrmptoms — Ordinarily three stages are described, depending
upon the {a) amount inspired, and {b) personal susceptibility. Ob-
viously, the more concentrated the gas, the more rapid and severe the
effects. Some individuals have a marked tolerance; others readily
are affected by even slight amounts. The essential cause of symp-
toms is the diminution of oxygen leading to asphyxia.

First Stage. — Period of Excitement or Stimulation. — There will be
evidences of mental excitability with perhaps giddy, irrational or deli-
rious phases. Some dyspnea or respiratory embarassment generally
is apparent. The superficial veins are generally prominent and cyano-
sis ai moderate degree may exist. The pupils are usually quite
widely dilated. Muscular twitching may be marked. The pulse is
slow and high tensioned. Temperature is normal. The breath and
vomitus may be odorous of gas. Complaint is made of headache,
weakness, and nausea, and there may be vomiting. Prostration
and langour may be marked features. Irritation of the throat and
bronchi may cause coughing.

Second Stage. — Period of Unconsciousness or Asphyxia. — The
patient is unconscious, with rapid, stertorous breathing. The pulse is
rapid and weak and the pressure is lowered. Temperature is elevated
and not infrequently may reach 104° F. or more. In profound suffo-
cation, control of the sphincters is lost. In later or more advanced
stages muscular rigidity, especially of the jaws may occur.

724

TRAUMATIC SURGERV

The pinkish or characteristic cherry red blotches on the skin may
appear. Spectroscopic examination will show the presence of carbon
monoxid. The patient gradually shows increasing respirator}' diffi-
culty and Cheyne-Stok.es respiration may ensue just before death.

Third Stage.— Period of Coma. — The patient has practically ceased
to breathe, although the pulse is still perceptible, but cyanosis is
marked. The pinkish or cherry red markings on the skin ordinaril)
are present, and muscular rigidity is marked.

The duration of the various stages is variable, and the passage
from one period to another may not be appreciable: nor does a mild
first stage indicate freedom from danger, as the transition to a graver
condition may be very sudden and without premonition. The aver-
age individual is affected by two minutes' inhalation of moderately
concentrated gas; persons found in the second or unconscious period
are ordinarily dangerously affected. The character of respiration is
the best single index of the degree of poisoning, and if respiration is
fairly well establis/ied the immediale danger is usually passed in an
hour.

Postmortem Findings. — The fingers and toes are rigidly extended
and assume the attitude of tetany. Witliin a few hours the pathog-
nomonic pinkish or cherry red skin blotches appear, if they are not
already present. The internal organs, notably the liver and spleen,
are deeply injected and show areas of minute scattered hemorrhage.
Areas of softening may be found in the brain and spinal cord. The
soluble blood is pink, and carbon monoxid is shown by the spectro-
scope. The Hoppe-Seylcr lest, demonstrating carbon monoxid in the
blood, is performed by doubling its volume with a solution of sodium
hydrate that yields a cherry red color when spread on porcelain;
ordinary blood becomes brown or green under similar dilution.

Blood containing carbon monoxid does not turn scarlet on coming
in contact with the air; normal blood does present that hue from ihe
formation of oxyhemoglobin.

SequeUe. — Most of these are of nervous origin and chiefly relate to
headache, irregularly distributed areas of pain, hyperesthesia, w
anesthesia. Some patients are irrational or slightly delirious, an''
insomnia or tremors may appear. Laryngitis, bronchitis, and
bronchopneumonia may occur. Less often there may be transient
paralysis, glycosuria, and fever. Disturbances of the special senses
(notably sight and hearing) and areas of gangrene are rare <l
rences. Permanent after-effects are exceedingly rare, and t
ceding sequels are generally present only in severer cases.

INJURY FROM ILLUMINATING GAS 725

McCoombs, with icxx) cases in ten years' experience, states:
"There have been individuals poisoned by illuminating gas who have
been suffering at the time from chronic organic involvement of almost
every description; many pregnant women are included in these
statistics, also patients with tuberculosis and several who were in the
midst of typhoid fever. None suffered any permanent bad effects
and no miscarriages have occurred ; the children wh.en bom have been
normal. Sequelae are more likely to occur in those of advanced
years . . . . "

Other Forms of Illuminating Gas. — Water-gas is the sort ordi-
narily now in use for illumination.

Coal-gas, according to Remsen, contains 7.9 per cent, of carbon
monoxid and a much less percentage of ^^illuminants^' (ethylene,
propylene, burylene, ethane, propane, butane) than water-gas.
The latter contained 28.25 per cent, of carbon monoxid (Remsen), or
21.51 per cent, according to Lave.

Oil-gas is principally used to illuminate railway cars and is made
after the "Pintsch process" by heating petroleum tar or shale oils in a
retort to a temperature of 1000° C; it is also used to enrich other
gases of a low illuminating power (Bartley).

Treatment. — The essential need is to displace the carbon monoxid
hemoglobin of the circulating blood by introducing oxygen so that the
normal oxyhemoglobin may reappear.

First stage cases are given fresh air and such stimulants as whisky,
aromatic spirits of ammonia, or others, as may be needed. Patients
feel much better after they have ''belched up the gas," and for that
reason effervescent drinks are used; vichy, seltzer, effervescent
phosphate of soda, and other "fizzing" types of drinks are useful.
Employees and others accustomed to such symptoms usually drink
"weiss beer." If these milder measures do not relieve the nausea,
headache and other symptoms, inhalations of oxygen are used.

Caution is to be given the patient so that relapse or progression
into another stage may be avoided. Most cases complain of nausea,
headache, and weakness for a few days, and, if needed, appropriate
treatment is given for these.

Second Stage, — Artificial respiration in the fresh air is generally
needed until oxygen inhalations can be substituted. Stimulation by
hypodermics of atropin, strychnin, caffein, or whisky are generally
required. If shock is present, external heat is necessary. Massage
of the limbs is useful. Venesection can be used in the plethoric. It
may be combined with the injection of normal salt solution into a

728

TRAUMATIC SURGEfiY

Treatment comprises (i) stimulation and (2) artifidal respiration.

(1) Stimulation is by hypodermics of such cardiac and respiratory
stimulants as were named in the treatment of Submersion. An
excellent emergency stimulant is to dilate the rectum by the fingers;
occasionally v-igorous massage or slapping over the precordial region
is also effective.

Fic. 6or. — Inspiration; pressu:

(2) Artificial respiration is preceded by efforts to remove t
that may overflow from the mouth, and to that end the head b
lowered and the upper abdomen and chest compressed. The patient
is then subjected to the manipulations of artificial respiration, care

Fig. 601. — Expiration; pressure

being exercised to have the head slightly raised and turned sidewise.
The tongue ihust not be allowed to drop over the epiglottis, and to
prevent this a scarf or other pin or a thread may be put through one
side of the tongue so that it always is held forward.

INJURY DUE TO SUFFOCATION; SMOKE INHALATION 729

The "Schafer method of artificial respiration" or ''prone pressure
method/' Figs. 60 1 and 602, is the medium of choice and should be
taught to first-aid teams and others likely to be on the scene of
accidents in which respiration failure is a main symptom.

Irrespective of the method chosen (the Sylvester is the other or
" supine pressure method ") , the rate of the manipulations is such that
respirations of 14 to 18 per minute are carried on. Death must not
be conceded until such efforts have been vainly employed for at least
three-quarters of an hour. Respiration once spontaneously reestab-
lished is likely to continue, but provision must be made for careful
watch over the patient until consciousness is wholly restored.

Mechanical apparatus (lungmotor and pulmotor) is unreliable,
and reliance is best placed on the manual means always available.

A tube introduced into the trachea and attached to a bellows may
provide a useful emergency method of intratracheal insufflation after
the Meltzer-Auer method.

SequelcB like pneumonia, nephritis, or delirium tremens are rela-
tively common, and these usually appear within the first three days,
if at all.

SUFFOCATION; SMOKE INHALATION

When a person is overcome by inspiring smoke, fumes, or irritat-
ing vapors the condition is practically one of unconsciousness with
symptoms not unlike those due to cardiac and respiratory failure
from a variety of other causes, such as gas-poisoning, drowning, or
profound electric shock. Firemen and occupants of burning build-
ings are the usual victims, and all degrees of smoke-prostration are
encountered.

Mild forms are characterized by coughing, lacrimation, and a
mucous nasal discharge, accompanied often by much redness of the
eyes and dryness of the lips and mouth.

Moderate forms manifest the preceding symptoms, with head-
ache, ringing or roaring in the ears, dizziness, nausea, vomiting, and
mild syncopal tendencies.

Severe forms are preceded by initial symptoms of the foregoing
type, with unconsciousness as a terminal manifestation. Such a
person is livid, the face is puffed, the body rigid, and there may be
involuntary defecation or urination.

Treatment is summated by the terms "fresh air," "cardiac and
respiratory stimulants," and "artificial respiration," either manual or
mechanical. The inhalation of fumes from vinegar is a valuable

730 TRAUMATIC SURGERY

adjunct in cases that are recovering, and another favorite remedy
with firemen is birch beer, because the effervescing and "taste-
repeating'' qualities of this drink effectively "take the smoke out of
the system."

In an unusual accident in the local Subway due to a "short
circuit," numerous passengers were overcome by smoke arising from
the burning insulation of feed wires. Most of the patients vomited
and had headache and signs of laryngobronchitis; practically all of tbe
cases recovered within a few days.

Sequelae like pneumonia and gastro-intestinal disturbances are
relatively common in the most severe cases.

In case of death the respiratory tract shows evidences of con-
siderable engorgement and patches of bronchopneumonia.

CHAPTERXIX

INJURY IN RELATION TO ABORTIONS, APPENDICITIS,

VISCERAL PROLAPSE

Abortioks and Miscariuages

These are frequently more or less reliably connected with acci-
dent and injury, and are often the subject of medicolegal importance.
Interruption of pregnancy is generally classified by the terms:
(i) Abortion: Interruption of pregnancy prior to the fourth
month.

(2) Miscarriage: Interruption of pregnancy prior to the eighth
month.

(3) Premature birth: Interruption of pregnancy after the eighth
month and prior to full term, namely, two hundred and eighty days,
or ten lunar or nine calendar months.

Varieties. — An abortion or miscarriage can be —

(a) Complete^ in which the fetus is expelled intact with the mem-
branes unseparated.

(6) Incomplete, in which the fetus and membranes are separated,
more or less of the latter remaining in the uterus; this is the common
variety;

{c) Spontaneous, in which the occurrence is improvoked by drugs,
instnmientation, or other interference.

id) Induced, in which the interruption is brought about designedly
by any of several abortifacients.

{e) Concealed, in which the fetus dies in utero and remains there for
days, weeks, or months; this variety is clincially so rare that it is
negligible.

Frequency.— Obviously, statistics are unreliable as to abortions
and miscarriages in general, but of io,cxx) representative cases of
pregnancy collected by Edgar and cited in his work on Obstetrics, it
appears that 635 were interrupted pregnancies, distributed as follows:

242 were abortions (before fourth month);

175 were miscarriages (before eighth month);

218 were premature births (before tenth month).

731

732 TRAUMATIC SURGERY

Stated in other language, these figures indicate that there was i
abortion in every 41.3 labors; i miscarriage in every 57.1 labors; i
premature birth in every 45.8 labors. This, summed up, means that
for every 15.7 labors there was one interrupted pregnancy of some
form. Most authorities hold that the vast majority of women abort
once or more during their child-bearing period.

Multiparae are most prone to interrupted pregnancies, and Edgar
quotes the following statistics based on the same series of 10,000 cases:

Miscar- Premature Interrupted, Pull
Number of pregnancy. Abortions riages. births. total. term. All.

First 29 22 71 122 2009 2131

Second, third, fourth, fifth. . 120 94 97 311 5202 5513

Beyond fifth 79 49 46 174 2047 2221

Unknown 14 10 4 28 107 135

Total 242 17s 218 635 9365 10,000

There are certain months in which these mishaps are most likely
to occur, and Edgar states the following as to this feature:

Third month 23 . 9 per cent, interrupted before term.

Fourth " 11.18 "

Fifth " .6.93 " " " **

Sixth " 6. IS

Seventh " 9.60 " " ." "

Eighth " 12.63

Ninth " 12.25

Manifestly figures for the first and second month of pregnancy are
not very reliable, because so many women "skip a period" without
being pregnant, and hence the author above quoted begins his
statistics with the third month.

Some women have interruption of pregnancy so often that they
are said to have the **miscarrage habit," and figures indicate that
each subsequent miscarriage occurs a little earlier than the one
preceding.

Causes. — These are numerous, and may be maternal, paternal, or
fetal. Of the great number of possible factors, Edgar gives the
following as the most common: Edometritis; retrodisplacements,
with or without adhesions; syphilis; nephritis; intentional or criminal
interference; low placental attachment.

Relation of Trauma. — There is apparently an individual suscepti-
bility in respect to accidents and injuries as a producing cause,
because some women are unaffected by the gravest injuries and others
claim to abort or miscarry on the receipt of many sorts of trivial psychic

•

ABORTIONS AND MISCARRIAGES 733

or physical violence. My personal observation is that most of the so-
called traumatic cases occur in the early periods of gestation, usually
at the third or fifth months. The majority of them, strange as it
may appear, are not incidental to grave injuries, but, on the contrary,
are quite regularly associated with rather trifling injuries, and not a
few are ascribed wholly to "fright" or "shock." It is exceedingly
rare to have any hospital patient blame the mishap on any other
cause than "strain," "lifting," "falling," or some emotional upset;
and, indeed, this is the history usually given by private patients
as well.

It is a common experience to have a woman deny interference by
an abortionist even though death is imminent from septic infection.
This sort of secrecy on the part of the patient is so well known that
reputable physicians usually call in a confrere before operating
upon a case of interrupted pregnancy so that there may be a witness
to the narrated cause of the ocurrence, and also as to the operative
findings. Certainly it is the experience of most hospital surgeons
that abortions and miscarriages are very rare complications of
actual injury, and that such an alleged sole cause is at least open to
some suspicion.

If an injury is to play any part in the matter, the symptoms should
appear very promptly, and if there is a lapse of more than a few hours,
other factors should be looked for as at least contributory if not
wholly causative. There are some in which symptoms are slight or
sharp at first and then progress or recede; but the usual rule is, as
stated by Edgar, for the whole process to be finished in from twenty-
four to thirty-six hours, irrespective of the asserted cause. In other
words, from the onset of symptoms until the expulsion of the ovum or
fetus there are some symptoms indicating that interruption is
threatened or actually under way.

Symptoms. — In cases of threatened abortion or miscarriage the
initial symptom is abdominal paitiy which is usually of a cramp-like
or colicky variety, and which is associated with some nausea or vomit-
ing, and perhaps also with dizziness or vertigo. Vaginal bleeding may
be of the spotting variety or in quantity sufficient to soil the clothing.
It usually does not last long and is generally associated with the
abdominal pain.

Vaginal examination at this time shows the cervix to be soft, open
at the tip, and blood or clots will be found at the external os; the en-
larged uterus is likely to be tender and perhaps boggy in certain areas.

If due to injury, the onset of these signs is reasonably prompt,

734

TR,\UMAT1C SURGERY

usually witlim a few hours, thus occurring at a time when the ^ects
of the accident are at the maximum; if there is an interval of more
than thirtj' hours after the accident without any signs of interrupted
pregnancy, then the accident can rarely be looked upon, as the sole
producing factor.

In inevilable abortion or miscarriage, the abdominal pain and the
bleeding are more severe and continuous, and there is practically no
cessation of symptoms until the uterus empties itself completely.
Most of these patients bleed so much that an acute anerrua is pro-
duced, and marked shock is often in evidence and fainting may occur.

In the interruptions of early pregnancy the pain and bleeding are
less marked than in later pregnancy, and after the third month the
symptoms simulate those of full term labor.

Any vaginal examination made more than three weeks after a
mishap may fail to show any recent uterine enlargement ; but investiga-
tion prior to that time will give indications either in the vagina,
cervix or uterus, and perhaps also in the breasts.

Differential diagnosis in the early periods must be made between
menslrualioti, ectopic pregnancy, neoplasms (notably poU-poid and
fibroid growths), and adnexal disease. The distinction is best made
by vaginal examination and the external evidences shown by the
breasts and abdominal markings. It is to be remembered also that
the external genitals and the cervix of a pregnant woman present
rather typical manifestations of pregnancy. X-ray examination may
also prove confirmative in some cases.

Treatment. — Threatened forms are treated by absolute rest, eleva-
tion of the foot of the bed, an ice-bag over the abdomen, and sedatives,
such as morphin or other derivatives of opium. Packing the vagina
with gauze or cotton will invite uterine contractions and thus promote
rather than prevent the event.

Inevitable forms require the same treatment, except that packing
the vagina &nds more indications. After expulsion of the ov*um or
fetus, curettage should be done if there is any doubt at all that some of
the conception products are retained. An anesthetic is of ten uncces-
sary, but strict asepsis must be practised, and the uterus should notlc
regarded as really clean until it becomes hard or much smaller.

After-trealmenl consists of a daily saline douche and a stay in bed
of five days or a week. Ergot, piluitrin, and drugs of that class may
sometimes become necessary. The uterus must be put into the
normal forward position and kept there by a pessary or tampon if it
has sagged or becortie tilted backward. Cases improperly treated or

TRAUMATIC APPENDICITIS 735

neglected usually furnish the examples of subinvolution, and these
are often associated with adnexal disease, and this combination may
require curettage and perhaps other operative care. Sepsis and like
inflammatory complications nearly always indicate criminal inter-
ference or imclean personal or surgical attention.

An uninduced imcomplicated abortion or miscarraige should
leave the genital organs in practically a normal condition after a
month.

Traumatic Appendicitis

It is sometimes asserted that an attack of appendicitis is induced
by continued pressure, or a blow, fall, or other violence upon the
abdomen, and such an origin is then made the basis for a claim
against an employer or an insurance company, or a suit is brought
against some defendant.

In other words, this contention is practically limited to medico-
legal exigencies, and it is discussed with that in view and not because
it is clinically even an admitted occasional etiologic factor.

Perhaps half a dozen such claimants have been examined by me,
but I never clinically saw or operated upon a case of traumatic appen-
dicitis and do not know of any form of external violence capable of
inducing it in a healthy appendix. That it may awaken a dormant
appendicitis and produce a recurrent attack, seems remotely possible
in certain forms of circumscribed violence, and in some more or less
constantly inflamed, relatively superficial, or ''ripe" appendices.
That abscess formation or a gangrenous process is aided or abetted by
external violence, I do not believe.

There is only one case on record, so far as I know, that apparently
is a real example of ''traumatic appendicitis,'' and this was reported
by Robert T. Morris as occurring in a physician who swallowed some
glass and within a few days that same fragment of glass was removed
from his appendix. Occasionally foreign bodies, like pins, seeds, and
pits, are found in an appendix, but that they induce the attacks is
exceedingly doubtful.

If external violence is to play any causative part whatever, the
following factors must be in evidence.

(a) The trauma must be over the appendicular region, relatively
circumscribed, and severe enough to give immediate abdominal pain
and external evidences of injury.

(6) The (nisei of symptoms must be reasonably prompt, and from
the receipt of the violence to the development of diagnostic evidences

736 TRAUMATIC SURGERY

of appendicular trouble, the interval must be filled by manifestatiaiu
of some intra-abdominal disturbance.

(c) The attack must be the first that ever occurred, because
recurrent attacks arise so commonly from a variety of causes that
any injury would probably only act as an incident or coincidence.

(d) There must be no preceding history of "indigestion," "bilious-
ness," "colic," or "ptomain poisoning," for any of these may actually
be and often do mean, appendicitis.

(e) At operation the appendix should be found acutely infiamed,
with perhaps some evidences of hematoma on or in it. No adhesions
within or without should exist; and membranes, veils, bands, or lesions
of the adjacent intestines or viscera usually mean chronicity or recur-
rence.

(/) Pathologically, on gross examination, there should be no
fibroid, strictural, or other indications of an ancient process, and
microscopically no changes of a similar sort should be apparent.

From a practical standpoint it seems highly improbable that any
sort of violence could produce a lesion of this deep-seated, movable,
and well-protected tiny piece of intestine and yet do no damage ta
surrounding intestine nearer the source of violence and far more
vulnerable. Further, abdominal injury may affect almost any of the
contained viscera most seriously, but as yet no case of direct injun'
to the appendLx has been authenticated, either as an isolated or
associated lesion.

There is a perfectly good, adequate, and well-established cause for
every case of appendicitis, and it is thus exceedingly hard to rank
trauma as even a remotely possible etiologic element. I have known
patients to have "pain in the appendix region" afte^ diving, straining,
lifting, coughing, climbing and doing a variety of movements thitt
cause the lower abdominal and upper thigh muscles to contract; but
all of these patients previously had symptoms more or less marked
that denoted the possession of a "grumpy" appendix that would
"growl" at many forms of external as well as internal irritation.

Sprengel, quoted by DaCosta, says that there is no recorded case
of scientifically proved traumatic appendicitis. John B. Deaver in
his article on this topic is of the same opinion. Personally, I see no
more relation between a blow on the abdomen and appendicitis than
between a blow on the abdomen and typhoid fever, or a blow on the
neck and tonsillitis.

The worst that abdominal violence can do is apparently to act
very occasionally as an alarm clock for an appendix that was a little

RELATION OF INJURY TO VISCERAL PROLAPSE 737

tardy in re-awakening, but which would probably "get up'' more
promptly at a signal from an overloaded stomach or colon, or from the
immigration of bacteria from a more or less distant focus.

Relation of Injury to Visceral Prolapse

The traumatic origin of herniae and displacement of the kidney,
uterus, and other organs is a matter of frequent medicolegal, casualty,
and compensation law importance. Strictly speaking, visceroptosis,
or the displacement of any organ, is, in a broad sense, a "hernia,'' and
for that reason there are certain determining elements common to all
displacements of abdominal viscera.

In order of frequency, traumatic origin is sometimes claimed for
displacement of the uterus, kidney, or gastro-intestinal organs.

Traumatic Hernia

Inguinal, umbilical, and femoral hernise are often said to have
developed as the sole result of an injury, and this source of origin
is generally accepted by the laity, who, in turn, learned of it from
physicians who as a class formerly entertained similar views as to its
causation.

Inguinal Hernia or Rupture. — It has been stated that i in every
30 males has an inguinal hernia, this having been ascertained by
military, insurance, and other statistics. It is equally well known that
a rupture may for a long time exist unknown to the possessor, and if
any symptoms arise, they are often ascribed to a variety of other
causes until the true origin is demonstrated by examination. In the
examination of recuits for our Army, pre-existing hernia was one of the
commonest findings.

Anatomy. — It will be recalled that the lower abdomen has no
main communication with the outside parts except by way of a canal
leading from the bladder, rectum, and uterus respectively; or by a
spermatic cord or round ligament or vessels escaping from a guarded
abdominal orifice. Structurally, then, there are few places predis-
posed to give way under the strain from within, but of the available
weak spots, the inguinal region is one of the most vulnerable.

Normally, the oval opening of the internal abdominal ring is a

little larger than an ordinary lead pencil, and it lies midway between

the anterior superior spine of tlie ilium and the spine of t/ie pubis. It

leads to' the inguinal canal, which is about 2)^2 inches long, reaching

almost to the pubic spine and ending in the external abdominal ring.

Along this route or canal an inguinal hernia passes if it is of the ordi-
47

738 TRAUMATIC SURGERY

•

nary oblique or indirect variety; if it pushes right through the canal,
without first entering the internal ring, then it is of the vertical or direct
variety. Very strong interlaced and tightly bound muscles and fascia
protect this region and it abounds in blood-vessels and nerves; thus
it is strong and sensitive.

The traumatic theory of origin asserts that some form of extreme
violence (direct, usually, but often indirect) is capable of suddenly
causing these natural barriers to stretch or break, thus allowing the
protusion of gut or omentum, or both.

At one time "trauma,'' used in a very general sense, was supposed
to be the essential cause of hernia, but of late this idea has been prac-
tically abandoned, and the prevailing view is that a hernia is of a
gradual development and that a preformed sac or pouch of peri-
toneum is almost invariably present, or that the protrusion creates a
sac as it advances. There is a strong congenital cause for hernia
and it is well recognized that a marked family tendency to the
condition exists.

It seems strange that a fully formed hernia could be susj>ected of
developing from a single act of trauma in view of the anatomic and
surgical structural formation. The fallacy is brought out very
prominently during the progress of a herniotomy, and no operating
surgeon would maintain that an internal ring could be by one act of
violence suddenly stretched enough to allow a portion of the abdom-
inal contents to escape and then equally suddenly dilate the inguinal
canal, and perhaps traverse it and even reach the scrotum; such an oc-
currence inevitably would lacerate the protruding part and cause mark-
ed shock and probably hemorrhage also. In the hernia operation it is
often quite difficult to introduce an ordinary grooved director (less
than one-half the diameter of a lead pencil) along the already dilated
c?inal from the external to the internal ring; if this is so in an anes-
thetized patient with the parts already stretched by the passage of a
hernia, how much more difficult must it be for a richly sensitized
piece of intestine or omentum to reversely traverse a much more pro-
tected and previously normal route?

Causes. — The sources of origin are usually divided into (a) con-
genital or predisposing, and (6) acquired or exciting.

(a) Congenital or predisposing elements are structural and ana-
tomic and presuppose that the normal barriers (rings, canals, muscles,
fascia, vessels, peritoneum, intestine, or omentum) are abnormal in
formation or inadequate in strength or resistance. As stated, there
is a marked family tendency notably on the male side, and it is well

RELATION OF INJURY TO VISCERAL PROLAPSE 739

known that children are quite prone to present hernise in connection
with hydrocele and other congenital or early acquired defects.

(b) Acquired or exciting elements can all be grouped under the one
essential factor of intra-abdominal strain or pressure, and of these may
be cited:

(i) Occupation calling for effort in which the abdominal muscles
are caused to contract so that the abdominal contents are forced
downward and forward. Lifting, pushing, hauling, bending, and
twisting motions, if persistent, may eventually produce a hernia in
any individual presenting relaxed rings or other abnormal safeguards.
Certain occupations are particularly liable to act as excitants, such as
those of laborers, teamsters, chauffeurs, piano-movers, and others
whose daily work requires a maximum of pushing, pulling, lifting, and
can^'ing. Work that requires prolonged standing or walking may
also be causative.

(2) Caiighingy sneezing, vomiting, and allied acts may be product-
ive because of their persistency or severity, especially if accom-
panied by muscular weakness lowering the resistance of the normal
supports. Whooping-cough, bronchitis, and gastro-intestinal ail-
ments are thus often responsible.

(3) Muscular relaxation due to pregnancy, tumors, ascites, vis-
ceral displacement or operations, are important factors because
atonicity is a very essential element, notably when it becomes more or
less general with the advance of years or is an associate of prolonged
or exhausting disease. The enteroptosis and sagging abdominal wall
of the old person is very familiar, and in women, especially, it is often
found in association with hernia and displacement of pelvic viscera.
Likewise, too much or too little fat may produce muscular weakness
and thus cause hernia.

(4) Trauma is the rarest of all causes and no single or isolated act
of ordinary violence has ever produced a fully formed hernia. Bull
and Coley investigated the alleged relation of injury to hernia, and of
10,000 cases at the Ruptured and Crippled Hospital only 2 stood in a
causal relationship. One of these was a man gored by a bull and the
other was caused by equally direct violence. This question has also
been investigated by Out I en, Sultan, and many others, and the con-
sensus of opinion is against any such long entertained belief. The
writer has never seen a genuine traumatic hernia due to a non-pene-
trating accident, and he knows of no well authenticated cases of acute
rupture, even though the associated injuries were of such a nature as
to greatly damage parts likely to be herniated.

740 TRAUMATIC SURGERY

This inability to show any relationship is very remarkable in \dew
of the fact that nearly all patients give the surgeon a history of injur)'
and look upon the latter as the ascribable cause.

Direct or vertical hernia, in which the protrusion is directly into
the canal without passing first through the internal ring, is naturally
much more likely to be traumatic than the indirect or oblique variety.
In this connection it is very suggestive that if injury was such an
important causative agent, then direct should be much more common
than indirect hernia, but this is not true, as the former occurs only in
from 3 to 5 per cent, of cases.

At one time any sort of violence was looked upon as productive,
but manifestly iftdirect violence can play no part, as the impacting
force would be expended long before the inguinal region was reached.
Falls on the extremities, back, buttocks, and elsewhere were supposed
to "jar the abdominal contents" so that a loop of gut or piece of
omentum would extrude; but at the present time local or direct injur)*
of the abdominal wall or region of the subsequent hernia is the only
sort of injury given consideration as a possible factor.

Of course, any penetrating wound that sufficiently cuts the mus-
cles or other retaining parts is excepted in this discussion, as any
hernia then resulting is practically of the postoperative variety.

Given a case of alleged post- traumatic hernia, the following factors
are to be considered by the examiner in determining what relation, if
any, the accident bears to it:

Uistory of the Case. — The manner of the accident and the immedi-
ate and subsequent symptoms are very important. If the violence
has been ordinary and if the main force of the impact has been distant
from the herniated zone, then, obviously, the relationship cannot be
close. If, however, the impact has been to the abdominal wall or
region of the hernia, then the associated findings need greater con-
sideration. This is especially, true if the abdomen has been squeezed
or jammed (as between a moving and stationary' object, or moving
objects) or where there has been a direct impinging against a rela-
tively small area close to the hernia (as a fall against a sharp projec-
tion, or a blow from a small moving object).

The immediate symptoms should be pain, nausea, and perhaps
also vomiting and bloody stools, together with a considerable degree
of shock; in a word, some of the well-known evidences of internal ab-
dominal injury should be present, for the damage done has been great
enough to produce considerable systemic disturbance. Later should
follow ecchymosis, swelling, and tenderness localized over the region

RELATION OF INJURY tO. VISCERAL PROLAPSE 741

of the hernia. The recognition of an actual rupture may for a few
days be obscured by a hematoma, but the earlier the hernia actually
appears, the greater the possible relationship to the accident. Hema-
toma of the vulva or scrotum are often mistaken for hernia; and it is
well known that both sexes often show sausage-shaped inguinal
swellings after abdominal contusion, and these also are at first hard
to differentiate. After the first few days the exact location, size, and
extent of the protrusion are determinable, but in the interval and
from the very inception of the violence the patient will complain of
pain increased by motion or pressure and perhaps also have pain at
stool or during micturition. The ecchymosis and local pain may
persist a fortnight or more; and if the former has been extensive, it
may also diffuse into contiguous but distant parts, and may even appear
in the middle of the thigh or mid-abdomen and near the iliac crests.

The condition now being definitely determined, the question
arises as to its age, and this can be ordinarily ascertained by the size^
location, and ge^ieral appearance. If small, tender, and at or near the
internal ring, the greater the possibility of recent origin. Likewise,
an irregular, tight, and tender ring, with inability to easily reduce and
reproduce the mass, speak for recency. It is to be remembered in
this connection that in many persons an impulse can be obtained with
a finger-tip in the canal; but the United States Army, Pension and
other official agencies do not regard this of itself as indicative of
hernia. Ancient origin is denoted by absence of ecchymosis and the
large size (bigger than an almond after the lapse of a few weeks);
the laxity and regularity of the ring (admitting more than one finger-
tip); the presence of thickening or other signs of pressure; dermatitis
from tension within or without; the absence of pigment or hair as
from a truss; general thickening of the parts; easy reducibility and
reproduction; freedom from pain on manipulation and the ability of
the patient to accommodate 'his moveqients to the swelling; general
laxity of the involved or adjacent muscles; bilaterality or other
herniae; associated varicocele, hydrocele, or other abnormalities.

Scrotal hernise take a long time to form and are never seen within
a few weeks of any alleged causative factor. The type of contents
within the sac offers little clue, as this may be wholly intestinal or
omental, or both combined.

A previously existing hernia, bruised or otherwise irritated by
injury, may become inflamed and thus in the early stages simulate a
recent hernia; but after a few days the differentiation should present
no difficulties.

742 TRAUMATIC SURGERY

Non- traumatic hernia is often bilateral ; traumatic hernia never is.
Ordinary hernia is usually left-sided; traumatic hernia is near the
seat of injury.

The surgeon may also be sometimes called upon to express an
opinion as to what influence, if any, an accident has had in aggravating
or increasing an already existing hernia. Often when an accident
occurs, or if the patient receives a "strain," self-examination may dis-
close a hernia which naturally enough is charged to the occurrence in
question; or the condition is found by a physician and the same \aew
is entertained even though the "lump" may have long existed un-
known to its possessor. If further analysis indicates that the acci-
dent was not the producing, then it may have been the aggravating
factor. Sudden increase of intra-abdominal pressure can still further
propel a pre-existing hernia along its route; and such forms of pres-
sure may sometimes act sufficiently promptly to bring into immediate
view a mass that eventually would independently appear because of
the more gradual and steady push of factors that had been operative
perhaps since birth.

In this respect the inguinal route can be likened to the parturient
route in which the internal ring represents the internal os; the in-
guinal canal is like the cervical canal; and the external os is like the
external ring. The propelling forces in both act slowly until the
intra-abdominal contents are born, and thus the vis a tergo in preg-
nancy and hernia alike is effective only by a continuing process of
forcible gradual dilatation. This means that a hernia once started
will eventually fully develop unless checked by treatment; but the
rapidity of growth is indeterminable, depending mainly on the age,
physique, and occupation of the individual. In other words, if the
structural conditions arc right and the necessary intra-abdominal
"push " is present, then a hernia can always be said to be "viable" or
"nascent."

Sudden increase in the size of any rupture is not uncommon if the
parts arc lax, and even an attack of sneezing or coughing or simple
straining may be enough if the conditions are ripe. An accident may
act in the same way if it is adequate^ and this element, together with
the extent of increase and the symptoms from it, determine to what
degree, if any, a given injury is responsible for still further propelling
a hernia. The possessor of a hernia may suddenly become aware of
ownership, but in reality the title to it may have been a birthright.
The inguinal region can be compared to a pocket in a pair of pants:
A small hole in the lower end of the pocket may not be noticed if

RELATION OF INJURY TO VISCERAL PROLAPSE 743

only big enough to let a dime escape; but if a quarter and then half
a dollar slips through, then attention is likely to be attracted to the

gap.

The element of adeqtiacy is present if intra-abdominal pressure has
been caused by violence of such an extent that added protrusion could
be reasonably expected to follow.

The increase in size likely to occur is naturally dependent upon the
degree of violence and the type of person, and the site and kind of the
rupture. At best the enlargement cannot be very great and rarely
can it cause an increase of more than one-fourth the original size, and
nearly always the mass has been previously at or beyond the external
ring. Omental are more likely than intestinal contents to sudden
increase in size; and atonic muscles more likely to further relax than
the firm and strong.

Symptoms necessarily exist, and these are usually in the nature of
pain, swelling, tenderness, and ecchymosis. A recently enlarged her-
nia is obviously harder to replace than formerly, and the kind and
degree of manipulation differs from that needed when the rupture was
stationary in site and size.

Irreducible or incarcerated hernias obviously are less likely to be
affected by external causes than reducible or more or less "free"
herniae. Those retained by properly fitting trusses also are not so
subject to changes in size. Poorly fitted trusses often aggravate
conditions because they squeeze or inflame the herniated mass and
push part of it out instead of holding all of it in.

The relation of injury to strangulation of a previous hernia is
sometimes apparent when the accident is of such a nature that intra-
abdominal pressure has been increased and when the strangulation
develops within a very short time (usually immediately) after the
trauma.

HernicBj unsupported, inevitably increase in size and are never
spontaneously cured in working adults.

Umbilical Herniae. — These navel ruptures usually occur in fat per-
sons, especially women. Pregnancy, tumors, ascites, and other
causes for intra-abdominal strain are the usual producing factors.
They may exist a very long time without causing symptoms, and
hence the possessor often knows nothing of their existence. Their
origin is essentially dependent upon structural deficiency and slow
increase of intra-abdominal pressure or strain. Many* of them are
congenital and they are quite common in infancy. They all are of
very slow growth up to a certain period, and then may suddenly

744 TRAL'MATIC SURGERY

undergo quite a marked increase in size as they become subcutaneous.
Usually they are omental in type, but occasionally contain intestine
also. They are prone to be irreducible because adhesions readily
form between the contents and the sac, or the latter attaches itself to
neighboring soft parts. Every operating surgeon is impressed by the
fact of their ancient origin from the very firm attachment they uni-
formly present to the adjacent parts, and by the wide separation and
atrophy they produce in the rectus and other muscles by long con-
tinued pressure. I recently operated on a large strangulated omental
hernia in a woman weighing 380 pounds. The strangulation she
ascribed to "a strain while lifting," but it was ascribable to very old
adhesions.

Injury never is the sole producing factor, and no accident k
responsible for their increase or aggravation unless considerable intra-
abdominal pressure has been occasioned, and under such circum-
stances signs of abdominal shock, local pain, ecchymosis, tenderness,
and rigidity promptly appear.

The relation of injury to strangulalton is the same as in inguinal
forms,

Femoritl hernia occurs much more often in women, and is the out-
growth also of structural defects and prolonged pressure from above
and within. It bears the same relation to injury as the preceding
forms.

Lumbar, obturator, and other rare forms are never looked upon
as traumatic unless there has been actual laceration of muscular fibers
by penetrating wounds.

Postoperative Hemiae.— These are quite common after abdominal
operations, especially where drainage has been used, notably if the
incision has been at or near the midline of the lower abdomen, as
for appendicitis, intestinal, pelvic, or urinarj' lesions. Incisions
that split and do not cut muscles or fascia are least likely to cause
hernia, especially in "clean" cases where no drainage has been used.
The lateral muscle-splitting incisions {like McBurney's "gridiron")
are less prone to hernia than vertical or transverse incisions.

The essential cause for their development is intra-abdominal
pressure acting upon (1) a weak scar due to the operative severing
of the nerve supply to the abdominal muscles; (2) to the relaxed con-
dition of the muscles due to ineffective coaption or prolonged illness;
(3) or imperfect or inadequate operative technic. Most postopera-
tive hernia; occur within the first six months, and (or that reason many
surgeons require the patient to wear an abdominal belt and refrain

KELATION OF INJT.IRV TO VISCERAL PR0L.4PSE

745

from lifting, straining, or otherwise increasing intra-abdominal
tension in that interval. A rupture of this type rarely involves more
than a portion of the scar at first, and. indeed, may appear only
lateral to it near a stitch-hole or a slit in a muscular or fascial
strand. The giving way prematurely of a buried stitch may be the
starting-point, and gradually the process goes on until a bulging
appears on standing or effort. Sudden increase may spontaneously
occur when the hernia is sufficiently developed to appear subcutane-
ously, thus indicating that the inten,-ening barrln-. h:\\f' Ih'Mi
gradually stretched until they no longer posses.s any r- -]■■■:.■.■■.■ . ,

Injury is never the sole initiating element in such a rupture, and
may contribute to it as an exciting agent only when it has caused
intra-abdominal tension adequate enough to induce acute symptoms
allied to abdominal shock.

A patient of mine was caught between a moving subway train
and the platform and received a long wound over the crest of the
ilium, and a hernia through Petit's triangle subsequently developed
in the scar of this wound, thus constituting a true traumatic post-
operative hernia (Fig. 603).

Summary. — For an accident to be related to the subsequent
development of any variety of hernia the following factors are needed:

(i) No previous hernia existed, as determined by definite prior
examination.

746 TRAUMATIC SURGERY'

(2) The parts are anatomically sound.

(3) The injury must have been close to the herniated zone.

(4) The violence must have been adequate.

(5) The symptoms must be of the type seen in abdominal shock
with appropriate local signs (pain, swelling, ecchymosis, etc.).

(6) The hernia must appear very promptly; after two weeks it is
often impossible to say just how long ago it has existed.

(7) No signs of old origin must exist.

(8) No other hernia on the opposite side or elsewhere must be in
evidence, thus ruling out the so-called *' hernia? tendency."

Treatment of Hemise. — No spontaneous cure occurs in adults
and hence only two methods of relief are possible :

(i) Truss.

(2) Operation.

Truss wearing is irksome to the average individual and very few
will long submit to the ordeal, umbilical varieties excepted.

Operation is indicated in all healthy individuals and the chances
of permanent relief are upwards of 92 per cent, in the inguinal and
femoral forms. If for any reason a general anesthetic cannot be
given, the operation can be done under local anesthesia.

In the incarcerated, inflamed or strangulated varieties, operation
should be performed without delay ; in the last named it is imperative.
If the patient is in poor condition, local anesthesia can be used.

In about 85 per cent, of inguinal varieties that I operate upon
there is a visible mass on one side and an impulse on the other side;
therefore in nearly all cases it is a better procedure to do a bilateral
herniotomy because sooner or later it will become necessary, ily
practice is to remove the stitches on the tenth day, allow the patient
out of bed on the twelfth day and to go home on the fourteenth day.
No truss, pad or other support is worn after the patient leaves the
hospital.

Six to eight weeks after operation the patient is allowed to resume
heavy work, light work being permitted in three or four weeks.
Recurrences are most likely within the first three months.

Uterine Displacement

External violence is sometimes looked upon as a source of origin
in displacement of the pelvic viscera.

Backward displacement of the womb {retroversion or retroflex-
ion) is the usual malposition alleged in accident cases, and it may
or may not be claimed to exist with prolapsus also.

RELATIONS OF INJURY TO VISCERAL PROLAPSE 747

Forward displacements {ankversion or anteflexion) are rarely
claimed as the outcome of an accident. Ovarian and tubal dis-
placements are also infrequently alleged.

Anatomy. — ^The pear-sized and shaped uterus is placed in prob-
ably the most protected portion of the body, apparently a provision
on the part of nature to propagate the race. The average virginal
size of the organ is about 3 inches long and 2 inches broad, the wide
upper end tapering to about i inch at the cervix. After pregnancy
some permanent enlargement is the rule. The womb in the virgin
state usually weighs between i}^ and 2 ounces. It lies deep in the
bony box of the pelvis and is protected in front by the strong abdom-
inal wall, the peKds and the bladder, the latter acting as a hydraulic
bumper. Behind it is protected by a large mass of intestines and
the bony bulwark of the lower end of the spinal column and the thick
buttocks. Laterally the flaring wings of the bony pelvis guard it,
together with the intestines. Thus it is practically suspended in the
bottom of a bony box and surrounded on all sides by buffers of a
fluid, semifluid, or gaseous consistency. It is so inaccessible that
when the abdomen is opened, it is necessary to push aside the intes-
tines or bladder in order to view or feel it, and thus uterine operations
are performed with the patient 's hips much higher than the head so
that the intestines may gravitate toward the diaphragm ("Trendel-
enburg position ") .

The normal axis or position of the uterus is one of anteversion, so
that it lies at an angle of between 65 and 85 degrees to the abdominal
wall, this is about the angle that the hand makes to the forearm
when the wrist is bent backward as far as possible. It is maintained
in this position by a variety of factors such as the dynamic force of
intra-abdominal pressure from surrounding contents, the guy-rope
pull of elastic ligaments, and the supporting power of the intact
fasciae and perineum.

Uterine ligaments (or accessory peritoneal folds) are eight in num-
ber, so arranged that they accommodate the organ to the daily changes
of intra-abdominal pressure. The large pair of broad ligaments pass
from either side of the organ like bat- wings and become attached to
the lateral walls and floor of the pelvis, embracing in their folds the
ovaries and fallopian tubes. The two round ligaments pass from the
upper front portion of the organ forward and outward and escape
from the abdomen through the internal abdominal rings.

The two uterosacral ligaments pass backward to the sacnmi. The
two uterovesical ligaments pass laterally and forward.

748 TKAUMATIC SURGERY

Normally, the organ is very movable, and it can be pulled in all
directions quite freely and will resume the normal position as soon as
tension is relieved. However, if the pressure or abnormal displace-
ment is continuous or nearly so, the ligaments become permanently
stretched or lax and then the organ assumes some maljwsition.
This is especiaUy true if the normal supports are weakened from a
variety of long or slowly acting causes, especially those leading to
actual sagging or tearing, like enteroptosis and pregnancy.

Backward Displacement. — In this form the organ is tilted back-
ward so that the fundus (roof) is turned to the rear, constituting
retroversion. If the Junction between the body of the organ and the
cervix forms a kink or angle, then we denominate it as retroflexion
(Fig. 604).

Fic. 604.^ — Utcnne displacemont bhck line iinlicating the normal position of ante-
version: 1, Ri'trovtrsion ; retroflexion {moderate! j retroflexion (marked) and pn>-

Causes. — The rearward position may be entirely normal, as it is
estimated that about 20 per cent, of women are born with the organ
in a backward rather than forward position ; this is sometimes referred
to as congenital retrodis placement and it is entirely compatible with
perfect health and function, and usually is unknown to the possessor
until discovered by examination.

Acquired retrodis placement is the outgrowth of any cause or set
of causes that upset the mechanics of the lower abdomen ; in other
words, the organ will be more or less permanently shifted out of
position if the normal supports are persistently weakened by long-
continued pressure upon or actual tearing of them. Of this group
of causes may be mentioned:

RELATIONS OF INJURY TO VISCERAL PROLAPSE 749

(i) Structural Conditions. — This great group comprises those
architectural faults in the skeleton that sooner or later lead to a
shifting of the contained organs in an effort on the part of the body
to maintain equilibrium and carry on function. These anatomic
defects are often comprised under the term of " enteroptotic female."

(2) Pregnancy, — ^Here the organ increases in size and the ligaments
are stretched; but the process is so gradual that no displacement
occurs unless the outlet is torn at delivery (lacerated perineum) ; or
the organ fails to resume its normal size after the confinement (sub-
involution) ; or where some infection leads to more or less thickening
and rigid inelasticity of the ligaments, perhaps ending in adhesions
that fix the organ in an abnormal position. Repeated pregnancies
bring about the same results, and incidentally weaken the abdominal
wall, allowing it to become flabby and atonic with subsequent relaxation
or displacement of some or all of the contained viscera. Severe
labors or those attended by complications at the delivery, or later,
are manifestly prime causative elements. Patients who remain abed
too short or to long a period after confinement often thus acquire
malposition that inevitably gets worse unless recognized and corrected.

(3) Infection of tlie Genito-urinary Tract, — That acts by inducing
inflammatory changes in the uterus or the adnexa leading to loss of
tone of the normal supports, sagging of the heavy uterus, exudates,
and perhaps adhesions. Such cases generally show some lateral dis-
placement as well as retrodisplacement ; any fixation is always an in-
dication of an old process and usually is indicative of inflammatory
or germ reaction.

(4) Pressure. — This may be due to sagging of the abdominal
contents in general (enteroptosis) or be more or less localized, as
from tumors, ascites, and the like, or it may arise from straining, as
from constipation, weight-bearing, lifting, riding, posture, coughing, .
vomiting, and a variety of similar factors tending toward oft-repeated
contractions of the abdominal muscles. Tight lacing, belts, and
various fashions of dress fall in this group.

(5) Weakness. — Illness or other depleting causes may rob the
organ of normal supports and thus lead to displacement. This
group comprises also those cases occurring in the feeble, poorly
nourished, and the aged, and in these the flabby abdominal wall is
usually an index of a more or less general visceroptosis.

(6) Injuries. — These are likely to play a part only when the
violence is capable of inducing a decided change of intra-abdominal
pressure, notably when the impact has been in the nature of compres-

750

TRAUMATIC SURGERY

sion received on the front of the mid-abdomen. For this reason the
most causative factors are falls against, or blows from, rather broad
projecting surfaces; squeezing accidents, as between moving vehicles

Fig. 603. — Uterine displacement, black line indicating tbe normal position of ante-
version: I, Retroversion; 2, anteflexion (moderate); 3, anteflexion (marLed).

or objects; or violent twists or wrenchings with the pelvis hxed. All
of these are associated with rather severe grades of trauma and other
evidences of intra-abdominal injury often coexist. Such an acute

.. 606, — Degrees of prolll>5e of ul

id third.

displacement generally restores itself to normal unless the individual
is predisposed to the malposition by previously overstretched, bogg>',
or sagging parts.

Personally, I have never seen a case of displacement of a pre-

RELATIONS OF INJURY TO VISCERAL PROLAPSE 75 1

' viously normal pelvic organ from any form of violence, and certainly
*the condition must occur at once if at all.

Indirect violence, such as blows or falls on the lateral or posterior

. abdominal walls, or jars transmitted from more or less distant parts,

must necessarily be even more remotely regarded as causative agents.

Forward Displacement. — In this form the normal position of ante-
version (65 to 85 degrees) is accentuated; and if the junction of the
body and cervix is kinked or angulated, the condition is said to be one
of anteflexion. This is a much rarer form of displacement, and
obviously is much more likely to be a personal equation of congential
origin.

Causes. — Accentuation of the normal forward tilting is said to
occur congenitally in 30 per cent, of cases. I'he acquired group of
causes is similar to the preceding and depends practically on the
same basic factors; namely, slowly increasing pressure from above
that gradually crowds or forces the organ to assume an abnormal
location (Fig. 605).

Downward Displacement or Prolapse. — This is always associated
with backward displacement and is due to the same factors (Fig. 606).

Degrees. — First: When the tip of the cervix is below the vault of
the vagina.

Second: When the tip of the cer\dx is at the vaginal outlet.

Third: When the cervix escapes from the vaginal outlet.

Nearly all of these cases show some cystocele and rectocele as well,
and they are all characterized by slow development up to a certain
point, and then suddenly they may become much aggravated as the
last remaining supporting elements give way.

Practically all the cases occur in multiparae with torn or relaxed
outlets, or in the obese or the aged. A considerable number, however,
occur in maiden ladies at or after the menopause, when a tonicity is
quite marked.

Kidney Displacement

At one time a kidney that could be palpated was regarded as being
abnormal, but now we know that normally each kidney has a range of
motion varying between i and 2 inches. This knowledge has made
the operation of kidney fixation very much less frequent.

Werelius^ says that Mesne in 1568 first mentioned this lesion in
his work published in Venice; and in 1862 Riolan described it as a
symptom-producing condition.

^ Jour, Amcr, Med. Assoc, March i, 1913.

75a TRAUMATIC SURGERY

Anatomy. — Each organ weighs about 4)^^ ounces and is about 4 to
5 inches long, 2 to 3 inches broad, and i J'^ inch thick. They are held
in position in the hollow of the lumbar region mainly by the fat,
areolar tissue, and retrorenal fascia surrounding their capsule, and
to some extent by the vesseb passing to and from them. The lower
border of the right kidney is an inch or two below that of the left
kidney because of the superimposed liver, and also because the right
kidney niche is broader, shallower, and more open below than that on
the left side (Volkow and Delitzin) . Ordinarily the lower pole is on
the level of the third lumbar vertebra reaching upward to the last
dorsal vertebra (Fig. 607). These anatomic factors tend to develop
kidney motility more frequently on the right than on the left side in
the proportion of 13 to i (Piersol).

and abnormal positions of the kidney: left. Posterior relationship;
right, anti'rior relationship.

Types and Terms.— Movable kidney is one in which the organ can
be freely felt to move during respiration, especially in inspiration.

Floating kidney is one that sags enough to feel the entire organ.

Wiind^:ring kidney is one that can be pushed freely about in all
directions.

These foregoing limits of motion are variously spoken of as first,
second, and third degrees respectively.

Causes.- — Congenital motility is often present, especially in women,
and some authorities assert that from 60 to 90 per cent, of women have
more or less sagging.

Kister states that abnormal'motility occurs once in 207 men, and

RELATIONS OF INJURY TO VISCERAL PROLAPSE 753

in women once in 22. Other statistics state that it is palpable on
the right side in 60 per cent, of cases, and in about 8 per cent, on the
left side in men, and 30 per cent, in women.

The right kidney is involved, according to various authors, from
twelve to eighteen times of tener than the left kidney. Both kidneys
are coincidentally affected in from 5 to 10 per cent, of cases, but the
excursion on the right side is usually greater than that on the left.
Associated enteroptosis and diseased conditions of the gall-bladder
and appendix are often present. Most cases occur between the ages
of twenty-five and fifty.

Structural formatimi plays a great part, and the long bodied and
the lean are most prone because the hollow in which the kidney rests
is less concave and also because the needed fatty support is scanty.
These anatomic considerations have led to the formula of the so-
called "kidney index'' of Becher and Lennhoff to mathematically
determine that a person of a certain structure is prone to displacement.
This "index" is obtained by measuring the distance between the
symphysis pubis and the ensiform appendix, and this is divided by the
smallest circumference of the abdomen. The product thus obtained
is multiplied by 100, and this gives the abdominal index. If this fig-
ure is over 75, there is a movable kidney tendency; if not, then,
anatomically at least, there is no such predisposition.

The intact abdominal wall and pelvic floor are powerful dynamic
and static elements in preserving the normal position of the kidney;
hence child bearing is one of the main factors in its causation. Tight
lacing is also an element, as is any form of pressure or dragging that
tends in time to stretch or loosen normal supports of the organ.

Spinal curvature, congenital or acquired, may also induce relaxa-
tion.

Trauma is an infrequent cause, the type of accident producing it
being generally a sharp impact in the lumbar region, as from a fall or
blow. Jamming, jarring, and squeezing accidents sometimes act in
the same way, assuming that the violence has been great enough to
reach the lumbar region in an undissipated manner.

Symptoms. — The majority of cases give no symptoms until at-
tention is called to the condition, but thereafter in suggestible
patients a host of subjective symptoms may be complained of, many
of them of the neurasthenic variety. The combination of subjective
^nervous" symptoms and movable kidney is very typical. Apparent-
ly the extent or degree of motility is not the measure of the severity
of the symptoms, although "wandering" forms are most likely to

754 TRAUMATIC SURGERY

give the maximum of discomfort. Symptoms referable to the mobil-
ity itself are backache, dragging or tugging sensations in the loin
or upper abdomen; indigestion, with or without vomiting, consti-
pation, and jaundice; radiating pain transmitted along the ilio-inguinal
and iliohypogastric nerves to the groin or external genitals; and
occasionally urinary irregularities.

In diagnosing obscure cases, it is advisable to palpate each organ
while the patient is prone, standing erect, standing leaning forward,
and in the hands-and-knees position.

''Dietl's crisis'' is a paroxysmal attack of severe abdominal pain
associated with vomiting and tympanites, followed by the passage of
large quantities of urine occasionally containing blood. Such a
seizure generally occurs in ancient cases and is sometimes induced by
severe exertion, twists, or wrenches that produce a kinking of the
ureter, leading to temporary hydronephrosis and increase in
size of the tender organ. It is usually right sided and always
unilateral.

An acute displacement, such as an injury may induce, is associated
with tenderness in the costovertebral angle, some abdominal dis-
tention, tenderness, and rectus rigidity, and the urine for a short time
generally contains blood. Ecchymosis and local evidences of injury
in the lumbar area may not appear for several days; but such late
signs are often corroborative of an acute origin or an exacerbation of a
chronic condition.

Treatment. — Relief is usually obtained by wearing a suitable "kid-
ney belt'' or ''kidney corset," either of which is applied while the
patient lies flat on the back with the lower part of the body much
elevated so that the abdominal contents may gravitate upward.
Measures directed to the general condition of the patient must not be
forgotten, especially forced feeding and exercises to strengthen weak
muscles and alter mechanical conditions that tend to cause persistent
sagging. Nervous symptoms also need attention, and no case will be
permanently benefited without controlUng ptosis of the other organs
so often coincidentally involved.

Operation , as stated, is not now regarded as so necessary because
most cases are controlled by non-operative measures, and the majority
of surgeons counsel palliative treatment unless careful attempts meet
with failure.

Nephrorrhaphy and nephropexy are the terms used for the opera-
tion of "kidney fixation," and a variety of procedures have been
devised to replace the organ and retain it in position by sutures intro-

RELATIONS OF INJURY TO VISCERAL PROLAPSE

155

duced into the capsule alone, or into the capsule and kidney
substance, thence fastening it to contiguous muscle, or muscle and
fascia.

In selected cases, operative treatment is exceedingly effective and
is relatively free from danger. Preliminary cystoscopic examination
is advisable. A'-ray views, with an implanted ureteral catheter
or an injected kidney pelvis, will often best show the exact amount of
displacement.

Gastro-intbstinal Displacement

The stomach, colon, cecum, liver, and other portions of the diges-
tive tract are sometimes found in abnormal positions (Fig. 608). We

Fig. 608. — Relation of viscera to parietcs.

now know that such conditions almost um'formly depend upon con-
genital malformations or are acquired as the outcome of long-standing
processes arising from posture, pressure, or infection. Abnormal
relaxation of the abdominal muscles, as in "Glenard's disease," is a
frequent finding in these cases. Trauma plays little or no part in
their production.

7S6 TRAUMATIC SURGERY

Speaking generally, any displacement of a viscus is essentially a
hernia, and is dependent more upon inherent structural causes than
upon external or incidental factors. Even in the presence of ver}-
severe injuries I have never seen a case associated with visceral dis-
placement, nor have I ever operated on a patient with a displace-
ment due to external violence. This observation appUes to my war
experience also.

CHAPTER XX

THE TRAUMATIC NEUROSES

These consist of neurasthenia and hysteria, and because they are
so often associated the name hysteroneurasthenia has often been
applied to them. My experience has been that neurasthenia may
exist alone quite frequently, but hysteria is quite regularly associated
with neurasthenia.

The diagnosis of neurasthenia is certainly less common now than
formerly, and the traumatic forms are very rarely encountered except
in litigated cases where the subjective manifestations are many and
varied, but the objective verifications few and limited.

In the Neurological Institute of this city in a period of 3 years a
diagnosis of neurasthenia "group'' has been made 149 times in 5967
hospital patients treated for all forms of nervous disease. Many cases
formerly diagnosed as neurasthenia are now known to be manifesta-
tions of arteriosclerosis, unsuspected lues, goiter, gastro-intestinal,
pelvic, rectal, internal gland, prostatic, and other diseases.

It is certainly true that the neuroses are excessively rare in ordinary
hospital and civil practice, and this has led to the belief that many
of the cases are due to autosuggestion or heterosuggestion from phys-
icians, lawyers, relatives, and others. Some of this is probably not
purposeful, but is the outgrowth of injudicious remarks made in the
presence of the patient or later repeated to the latter by others. A
certain class of physicians are fond of dilating on the subject of "pos-
sible internal injuries,'' "brain damage," and "spinal trouble" in the
presence of an injury respectively to the abdomen, head, or back.
The statement "you may be a cripple for life" sufficiently often
repeated is certainly not likely to increase optimism or act as a stimulus
toward recovery. If this is true where there is no special object to be
attained by prolonging disability, it is increasingly true when there is
gain in view.

In years gone by, railroad accidents were supposed to inflict special
forms of neural injury, and to these the name "spinal concussion,"
"raihroad spine," and '^railroad brain" were given. Erichsen, about
1874, thus christened this ailment, and since then it has been occasion-
ally heard of, but only in connection with claims for damages.

757

758 TRAUMATIC SURGERY

Strangely enough, of the 53 reported cases in Erichsen's two books,
less than one-third were hurt in railroad accidents, and, as stated by
Bailey, in the total number of cases reported there is not one in which
a diagnosis of "spinal concussion'* due to "molecular changes" would
stand present-day analysis. The only case of the group that was
subjected to autopsy was clearly a case of locomotor ataxia, and with
our present knowledge it certainly would not be denominated either
as "railroad spine" or "spinal concussion." Several of the cases cited
by Erichsen were very severe traumas of the spine that today would
be recognized as fractures of the laminae or other vertebral processes;
others less severe were intraspinal hemorrhages.

Since Erichsen's time a large number of books and articles have
been written abroad on the subject, some of the more important being
by Page,Westphal, Charcot, Striimpell, Oppenheim, Janet, Freud,
and others, and in this country by Dana, Hamilton, Walton, Outten,
Angell, Putnam, Dercum, Bailey, and many others. Oppenheim is
responsible for the name "traumatic neurosis.^'

The condition has been still further clarified by insurance statis-
tics, notably those from foreign countries, and it is from reliable
statistical official sources of this sort that the best knowledge is
obtainable.

A great many extreme views have been entertained and expressed
respecting these subjective nervous disturbances, one group of ob-
servers maintaining that the symptoms arc assumed and purposeful,
and, in reality, non-cxistant; another group maintaining their reality,
severity, and permanency.

The personal equation appears largely to govern these diverse
views, and many of the opinions expressed are based on a few cases
and a limited experience with injured patients, others are too strictly
racial or sexual. For this reason there is still a wide diversity of
opinion, but uniformity is now more marked than at any other pre-
vious time, not only as to diagnosis but also as to treatment and
prognosis.

The condition existed during the War and was termed at first
"shell shock," but later the term " psychoneurosis " was substi-
tuted so that patients would not get fixed ideas from self knowl-
edge as to causation or nomenclature. In the Chateau Thierr>'
sector especially, 1 saw a number of these cases.

The writer has had a rather varied experience in the examination
of persons claiming injuries in railroad and other accidents, and dur-
ing that same period has had an active traumatic service in hospital.

THE TRAUMATIC NEUROSES 759

dispensary, and private practice. The material thus provided, to-
gether with a fair knowledge of the existing literature on the sub-
ject and more recent War experience, causes the writer to state the
following as his interpretation of the present status of these
neuroses:

(i) They do occur, but are in no essential respects different from
the same diseases due to numerous other causes.

(2) They have a definite and demonstrable symptomatology and
many of the subjective symptoms can be made objective.

(3) In the vast majority of cases they are claimant-neuroses and
are rarely seen unless some claim or object is pending.

(4) They are rare in hospital practice or under similar environ-
ment.

(5) The element of suggestion, self or otherwise, is a powerful
stimulus.

(6)The less serious the injury, the greater the possibility of devel-
oping the neuroses.

(7) The manifestations, duration, and outcome bear a close rela-
tionship to the negotiations for settlement.

(8) Most cases recover after the mental source of worry or ex-
* pectancy is relieved.

(9) Neurasthenia with hysteria is commoner than hysteria with
neurasthenia.

(10) Recurrence in hysteria is more likely than in neurasthenia,
but both may return.

(11) Late development of neuroses does not often occur if settle-
ment has previously been made.

(12) In the vast majority of cases some motive is present, such as
money, vacation, revenge, pride, spite, pique, relief from duty.

As stated, in my experience it is rare to find hysteria alone or
neurasthenia alone, and for that reason I have come to use the term
iraujnasthenia to denote that combined grouping of nervous symp-
toms so frequently alleged after an accident. At the present time no
special form of neurosis is claimed to be typical of certain occupa-
tions, methods of construction, transportation, or development ; and,
practically speaking, a neurosis is just as likely to occur from falling
on the sidewalk as from a rear-end collision, from the fright of a fire,
or a wound received in battle.

In about three-fourths of the legal papers, allegations of "nervous
shock" are made and over one-half claim ** nervousness" of somesort;
thus in litigated cases the condition is wide-spread and examining

760 TRAUMATIC SURGERY

physicians in such instances expect these assertions almost as regu-
larly as complaints of pain. *

There is no good reason for accepting an injured patient's state-
ment that "nervousness*' is present, and then translating such an
assertion into a technical diagnosis of "traumatic neurosis" unless
there are definite objective symptoms for verification. In no other
condition is the assertion of the patient so unreservedly accepted and
acted upon by the attending physician, and thus by added suggestion
the mental side of the ailment is kept alive by the very person who
should do most to banish it by refraining from putting too much
value on mere complaints.

Neurasthenia

Literally, this means "weak nerves;" the terms "nervous prostra-
tion" and "nervous breakdown" are synonymous, and since Beard's
first description, it has been known as the "American disease.'*
My personal belief is that in less than a decade " traumatic neuras-
thenia " will pass out of medical literature after the manner of " spinal
concussion."

Definition. — A functional disease of the nervous system, due to a
large number of causes, characterized by mental and physical in-
capacity for sustained effort, and presenting numerous subjective and
some objective symptoms particularly connected with the cardio-
vascular and muscular systems.

Causes. — As stated, these are very numerous, and of them may be
mentioned any of the factors of modern stress and strain that go to
make up the strenuous life. Overwork, worry, grief, insomnia, alco-
holism, exhaustion, moral, mental, social, and physical excesses,
or, indeed, any set of causes that make for physical or nervous
depletion.

An unstable nervous equilibrium, hereditary or acquired, is usu-
ally a prerequisite, and it has been truly said that the neurasthenic is
born and not made, so strong is this element of predisposition.

A considerable number are due to disturbances of the physiology
of the abdominal, sexual, thoracic, and cranial organs, constituting
the so-called "reflex " sources. Visceral ptoses, notably nephroptosis
and cnteroptosis, produce or are associated with a certain proportion
of cases. Another factor is acute or long-continued disease, or
sudden changes incident to occupation, environment, or station in
life. Disturbance of the internal glandular mechanism, notably of
the thyroid and sex glands, is also an element.

THE TRAUMATIC NEUROSES 76 1

Men are more commonly aflfected than women ; it is rare before the
twentieth year and is distinctly an adult disease. Racially it is com-
mon among persons of Jewish ancestry, notably among the poorer
and richer classes. The middle class group of all races are less prone
than the rich or the poor. The more rational the work and play of
the person, the less liable the disease.

Traumatic sources have their basis in psychic and physical shocks,
and it is to be recalled that actual physical contact is not always nec-
essary to its production in those predisposed. It is claimed by some
that the psychic insult from the sights, sounds, and impressions of
an accident are as potent producing causes as the actual physical
hurts. This is not in accord with my experience, which is that the
occurrence from psychic impressions alone is far less frequent than in
hysteria, and the neurasthenia alleged to follow slight traumas must
be looked upon with great suspicion and sharply differentiated from
hypochondriasis and malmgering.

No physical injury to any part of the body is too great nor yet
none too slight to induce symptoms in those '' ripe'* for it.

The element of suggestion is very important, and this takes the
form of environment and treatment, as well as the sayings and doings
of friends and others. There is no special form of injury more
capable than another of inducing traumatic neurasthenia, and thus
head, spinal, and pelvic injuries are no more competent producing
causes than injuries elsewhere inflicted.

Symptoms. — These are most readily grouped according to their
regional distribution, and may be referred to as cerebrospinal, motor,
and visceral, all of which are subjective mainly, but also objective.
It is rare to have one group sharply defined, and the usual combina-
tion is the cerebrospinal.

The time of onset varies, but it is usually prompt and rarely de-
layed more than a few weeks.

Cerebrospinal Form. — Pains and aches in various regions are
largely complained of, and most of these cases start with the sugges-
tion implanted by an injury to the head or back.

"Cerebral neurasthenia" and "spinal neurasthenia" are some-
times used as denominative terms.

Headache is one of the common symptoms, and this is usually re-
ferred to the region of the forehead or base of the skull, and is de-
scribed as sharp and occasional or dull and constant. Usually ex-
citement or sustained effort increases it.

Backache, sometimes called "spinal tenderness," is the second

762 TRAUMATIC SURGERY

most frequent symptom, and because of it the patient often infers
** spinal trouble" and correspondingly worries respecting it.

This locational manifestation was the chief feature of the cases
formerly diagnosed as ** spinal irritation'' and '* railway spine."

The pain is ordinarily located at one or all of three locations, viz.:
Over the back of the neck about on a level with the vertebra promi-
nens; about the midscapular level; and near the dorsolumbar junc-
tion. The pain is said to be accentuated by motion and pressure and
the patient is able to sharply delimit its site by pressure of his own
finger. Usually the pain is said to be superficial and over the spinous
processes exactly in the midline, and less often just external thereto.
If the pain occupies a wide area, it is almost invariably said to be
located in the lumbar region. Pressure of the examiner's finger
causes the patient to wince or exclaim, and occasionally a muscular
contraction can be seen or felt. If these painful spots are marked
by pencil or pen, the patient can accurately relocate them in genuine
cases; this may be termed the ** relocation test" and is applicable to
any area of alleged tenderness. Increase or change of pulse-rate on
pressure over these or other painful areas — the so-called "Mann-
kopff-Rumpf test" — has not proved of much value to me.

The attitude of a patient with a tender back is often quite sug-
gestive, as a posture and gait are assumed to relieve pressure and
strain.

Occasionally the pain is said to be of a darting type, radiating to-
ward the intercostal spaces or up and down the back or into the
limbs.

Aching in the limbs is sometimes asserted, especially along the
calf, and this gets worse from walking and standing, and hence the
patient complains of weakness and incapacity for sustained effort
and pleads ready fatigability. The muscles thus get flabby and
soft from disuse, but actual atrophy practically never occurs. Joint
pain is occasional also, and rheumatism and other articular ailments
must be differentiated.

Mevwry deficiency may be complained of and the patient asserts
that recent events especially are not sharply impressed; less often
memory for distant happenings is blurred. This memory trouble is
also an evidence of tire or weakness and an added sign of the prevail-
ing instability or incapacity for effort, and it by no means denotes any
true mental failure or disease. All the details of the accident, how-
ever, and the minutest circumstance intervening can usually be nar-
rated with such effect that the patience of the listener will be taxed.

THE TRAUMATIC NEUROSES 763

Verbal display of this sort is common, but it is much more frequent in
non-traumatic forms.

Concentration loss is allied to the preceding and is often the actual
deficiency that leads to the suspicion that memory is hampered.
Lack of attention and inability to **put the mind on it'' are the main
elements.

Introspection and brooding are consequences of the patient's false
beliefs that some serious and incurable ill has befallen him He has
so often rehearsed his own symptoms to himself and others that he
comes to believe in their reality, and a fixed idea gets possession of him
to such an extent that he thinks of little else. Lacking judgment or
proper reasoning perspective, he gives inordinate prominence to
trivial events, remarks, and written statements, and thus builds
quite a structure that may have a slim foundation in fact.

Tears and various phobias are occasionally present, but less often
than in other forms of the disease.

The fear of riding in railway cars or vehicles is known as sidero-
dromophobia, and this sometimes develops in those hurt on trans-
portation lines.

Changes of temper and character are quite common, and the patient
is easily upset by trifling circumstances and is likely to be cross and
irritable. Emotional upsets are not as common as in hysteria, but
tearfulness is often prominent.

Hesitancy and lack of decision and precision may also occur as
indicative of the general lack of stability. Obsessions and imperative
impulses and similar conditions are exceedingly rare. Threats of self-
destructive are rather common in other forms, but very rare in this
type.

Insomnia is often claimed, and yet the general appearance is fre-
quently so good that this symptom is probably exaggerated in the
patient's mind. Dreams are not uncommon and these may rehearse
the circumstances of the accident.

Special senses also sometimes manifest similar evidences of
fatigue.

Vision may thus be said to be diminished, this being a combina-
tion of lack of concentration and weakness of the muscles of ac-
commodation. The patient may say that continued reading is im-
possible and in some cases the aid of glasses will be required. A host
of visual subjective symptoms may be alleged, such as bright lights,
floating specks, and other phenomena. Sometimes the pupil is quite
large, but it is never irresponsive.

764 TRAUMATIC SURGERY

Hearing may be said to be deficient and auditory sensations of
variable kinds may be mentioned, notably roaring and buzzing
sounds, perhaps associated with dizziness or vertigo. Usually
auditory symptoms are unilateral.

Smell and tasie may uncommonly also be subjectively upset, but
far less often than in hysteria.

Motor Form. — Here the injury is often to a muscled part, as an
arm or leg.

Weakness of muscle is a main feature, and the part is toneless,
flabby, and soft, but true atrophy does not occur, any shrinkage being
due to disuse. Sustained effort of the part involved is lessened, and
this may at times be measured by an instrument known as the
dynamometer, a form of gripping machine designed to test the grip.
This is so much under the control of the patient that it is practically a
subjective test and of no more positive value than the response ob-
tained by asking the patient to squeeze the examiner's hands. An
improvised test of a similar form has occasionally been of some use,
and all that is needed is an ordinary stationer's rubber band, the pa-
tient being requested to pull this against the resistance of his own
hands or those of the examiner.

Early fatigue may prevent walking, standing, and working, and
these people are given to sitting or lying around, thus increasing
their muscular flabbiness.

Tremor is quite common and generally is increased by exertion,
excitement, or emotion. It is most typically seen in the hands and
fingers, and when not fully visible can often be made palpable by
asking the patient to put the tips of four extended fingers against
the examiner's palm, when a vibration will be readily apparent.
The type of tremor is usually fine, ordinarily inconstant and irreg-
ular, and not of wide excursion. It may be seen in the tongue also,
and is very often seen in the eyelids, especially when the patient is
asked to stand erect with the eyes shut. The various muscles about
the face less often tremble or twitch, notably those about the fore-
head, corners of the mouth, and chin. The muscles of the trunk,
back, and limbs arc occasionally the seat of tremors, and these
become more prominent during manipulation of the parts, the move-
ment not infrequently then becoming very marked and almost con-
vulsive or spasmodic.

Reflexes are usually exaggerated, notably those of the knee, elbow,
and wrist. A rather characteristic feature is the variability of the
tendon-jerks, as on one occasion they may be quite lively, and at

THE TRAUMATIC NEUROSES 765

another relatively normal, and they may differ on opposite sides.
The extent of reflex response is often a personal equation, and may
have wide variations and still be within the normal for that particular
individual ; but sluggish or absent reflexes, especially if bilateral and
constant, should put the examiner on guard as to the possibility of
some organic ailment. The superficial reflexes are less constantly
affected than the deep, but when involved show the same degrees of
varying exaggeration. After repeated tests of the reflexes they may
act less promptly than at first, thus indicating fatigue.

Visceral Forms, — These are usually associated with that class of
accident in which the patient is impressed with the idea of "internal
injury. "

The heart and blood-vessels frequently manifest characteristic
evidences of unstable innervation, notably as to cardiac rhythm and
vasomotor control.

Heart action is generally rapid, and palpitation is not only com-
plained of but is ordinarily demonstrable. Various subjective com-
plaints are made, such as attacks of anginal pain, precordial distress,
and throbbing and pulsating sensations, notably in the neck. Short-
ness of breath and weakness on exertion may also be alleged.

Vasomotor tonal disturbance is indicated by alternate pallor and
blushing, or flushing of the skin, notably during exertion, emotion,
or excitement. It is most marked in the face and to a lesser degree
on the neck and upper chest.

Cold extremities are often present, and sweating and dampness
of the palms and soles are not uncommon. Ordinarily, sweating can
be induced by slight exertion, and it is common during excitement,
being most marked on the forehead and under the arms.

Digestive organs are generally little involved, although the appe-
tite is often said to be perverted or diminished; often this, like
marked insomnia, is a patent exaggeration, as the loss of weight
may be inconsiderable; subjectively, complaint may be made of
nausea, flatulency, constipation, and other signs of gastro-intestinal
atonicity.

Kidney action is generally normal, but the urinary output in a
person taking no exercise and living under strained conditions will
be necessarily altered. Arising at night to urinate is a frequent
complaint and is probably an index of restlessness or perturbation.
Occasionally an irritability of the bladder makes it necessary to
frequently empty this viscus. Actual urinary changes are rare; very
occasionally transient albuminuria and glycosuria may occur,

766 TRAUMATIC SURGERY

probably entirely dietetic in origin. Indican is generally increased,
but there is no basis for the belief once entertained that this ingre-
dient in excess is typical of neurasthenics.

Sexual organs are frequently less active, and at one time this
condition was dignified by the term "sexual neurasthenia." It is
much more common in the non-traumatic forms and not a little of it
is due to the suggestions of "lost manhood'' conveyed by certain
forms of literature. Apparently the prevailing neurasthenic element
of "sexual instability'' and incapacity is manifest here as elsewhere,
and men are more affected than women ; seemingly erectile is more
affected than the secretory or emission capability. Manifestly most
of these complaints are entirely subjective, and unless the external
parts are flabby and toneless, and the other neurasthenic symptoms
are demonstrable, it is inadvisable to regard these claims too strongly.
Actual impotency from non-organic sources is so excessively rare
that few authentic cases are recorded. Subjective complaints of
pain and altered sensations referable to the sexual organs are often
limited only by the patient's imagination and vocabulary. Women
occasionally refer to pelvic pain and feelings of aversion regarding
the sexual act, but objective manifestations are notably rare.

Emissions in either sex are very much rarer than in other forms
of the disease. Menstruation may become deficient or otherwise
altered in rare instances.

The symptoms are so numerous and diverse that it would be
manifestly impossible to observe all of them in a given case, but a
typical instance of the traumatic form usually develops and presents
itself in some such way as this: A rather "highly strung'' but
perhaps otherwise perfectly well man or woman is in a collision be-
tween vehicles or is hurt in a falling elevator or on a "defective"
pavement or stairway. The actual physical injury would be diag-
nosed perhaps as "shock, general contusions and abrasions, and
lacerated scalp." At the time of the occurrence there was some
dizziness, nausea, and perhaps vomiting, but actual prolonged un-
consciousness did not occur and the circumstances of the accident
were perfectly apparent and readily remembered. After treatment
by the ambulance surgeon or a short stay at the hospital, the patient
returns home alone or by the aid of friends, frequently being able
to walk unaided. A physician is summoned and the patient is put
to bed, the hospital dressings usually being unremoved. Up to this
point there is nothing about the case to differentiate it from another
with identical injuries received in some manner that makes the

THE TRAUMATIC NEUROSES 767

collection of damages unlikely. In the case under discussion, how-
ever, visits -from lawyers, claim adjusters, advising friends, and others
soon leads the patient to proclaim various subjective symptoms of
'^nervousness'' which are dignified by the doctor or others into some"
high-sounding title like "traumatic neurasthenia."

Usually within a few days the patient is honestly, or otherwise,
impressed by the fact that the hurts are serious, and "nervous pros-
tration'' is in process of development. A doctor representing
the prospective defendant now appears, and his examination and
questions may suggest further symptoms and perhaps disclose
some objective signs which the patient and attending doctor had not
discovered, all of which will be ascribed to the accident.

The examining physician will be told of severe headaches and
pain along the spine, of insomnia and bad dreams, of irritability
weakness and dizziness, and of poor appetite. His examination
discloses a person of fair physique with some insignificant scars and
fading contusion discolorations. The pulse is at first rapid, and then
perhaps returns to normal; the temperature is not elevated. There
is some tremor of the fingers and tongue and closed eyelids. Some
places along the midspine are apparently tender to slight touch and
react thus to the "relocation test," yet the patient lies on these
supposedly tender spots and moves readily without comment. The
knee-jerks are lively and the muscular power somewhat diminished.
There are no central or superficial organic nervous changes.

Left alone, such a patient would be practically well in a few weeks
at the most.

Perhaps at this stage, however, the attending doctor, alarmed by
his patient's many complaints or the importunities of the family, calls
in a surgeon or neurologist, and again the patient gets a new set of sug-
gestions. In this manner a fortnight or a month passes, and mean-
. while no financial adjustment has been made, and legal papers are
served. The patient signs and swears to these after reading or hear-
ing the injuries described in awful terms, and then for the first time he
may learn that his hurts are '\ . . of such a nature as to render him sick,
sore, lame and disabled in mind and body, and he is and will be per-
manently incapacitated and forever unable to resume his regular
duties "

Naturally enough all these preliminaries are outrageously bad
for an honest claimant and ideally good for a fakir.

Admittedly a large number of cases are deliberately manufac-
tured by interested parties who find many of the injured readily

768 TRAUMATIC SURGERY

susceptible to suggestion and predisposed to neurotic manifesta-
tions. If the case goes on to trial, a year or two may elapse before the
actual "day in court" arrives, and in that interval the patient may
have done little or no work, and thus practically the whole time is
taken up by introspection and brooding. All sorts of doctors,
drugs, and "treatments'* may have been more or less diligently
employed, but meanwhile the patient has not been isolated and com-
plete change of environment cannot occur until litigation is ended.
Many rehearsals arc necessary before the jury appearance, and per-
haps also more examinations by experts for both sides, and then the
patient goes upon the witness stand and tells as much as is allowed
of the preceding and intervening circumstances. By tliis time the
average person is probably miich impressed with the gravity of the
ailments and may in court exhibit many indications corroborative of
the condition, especially if this form of excitement and exhibition
brings on violent trembling, agitation, emotion, and perhaps fits or
fainting. If the verdict meets anticipations a great source of worry
is removed and the patient promptly transfers his attentions from
himseK to something else and begins to get well. If, however,
litigation is prolonged by appeals, the neurosis often continues
until this source of suggestion is also removed.

Most of the symptoms begin within a few days, but in, some there
is an interval of a few weeks during which time the patient may
have been at work and apparently well. Some of these cases of late
onset bear a close relationship to the advent of not wholly disinter-
ested medical and legal advisers.

Ob\'iously a disease of this sort offers splendid opportunities for
the malingerer and fakir, and many cases are wholly of this spurious
type. There can be no question that many honestly disposed per-
sons are made neurasthenics by the circumstances surrounding our
present-day methods of dealing with compensation for injuries;
however, that compensation laws do not cure the evil is well shown
by pre-war statistics from England and France, which indicate that
mahngering is largely on the increase, inasmuch as there is a predeter-
mined legal payment during a disability that is asserted or apparent.
Soldiers who developed this condition (shell shock) in the war zone
were sent back to the line almost immediately and nearly all of
them recovered at once. I saw a number of these cases at the evac-
uation hospital of which I was commanding officer and there was
nothing in their condition dissimilar from the traumatic neuras-
thenia of civil life.

THE TRAUMATIC NEUROSES 769

Necessary to a Diagnosis. — It is not enough, as already stated,
to take the patient's say-so in regard to '* nervousness,'' but an
effort should be made to render some ot the subjective signs objective.
It is not to be forgotten that many persons may have nervous sympn
toms of a so-called neurasthenic type (notably the cardiovascular
group and tremors) and yet not have the symptom-complex of the
condition or enough symptoms grouped to complete the diagnosis.

There is no one pathognomonic sign, but a typical case of a few
weeks' duration should show several of the following more or less
prominent objective signs:

(i) General appearance is often suggestive, as might be expected
of one complaining so constantly and variedly.

(2) The expression is care-worn, anxious, and not alert, especially
if headache and insomnia are featured.

(3) Loss of weight may be apparent.

(4) Alternate pallor and blushing may appear.

(s) Tremors of the eyelids, mouth, chin, tongue, and fingers may
exist; jerking of the arms and hands may occur.

(6) Pulse is variable, and at first is likely to be rapid, as might be
expected on the arrival of a stranger. Later it slows down, but
again becomes rapid; this change of rate, especially on exertion, is
quite typical.

(7) Throbbing of the carotid, brachial, and femoral arteries may
be visible and palpable. When the pulse is first taken at the wrist
the jerking of the extremity may be quite marked and rhythmic,
but it can be stopped by diverting the attention.

(8) Cold extremities and sweating are quite common.

(9) Reflexes are lively, more so at first than later, especially at
the knee; a spurious ankle-clonus is sometimes present. The re-
flexes may be asymmetric.

(10) Tender areas along the spine are demonstrated as real by the
"relocation test" (page 762) and the general attitude and actions of
the patient.

(11) Muscular power is lessened as denoted by the atonicity of the
calf, thigh, arm, and forearm groups; some of this depends upon how
inactive the patient has been. Grip-power is determined by asking
the patient to squeeze and push to and from the examiner's hands;
also by pulling taut during the'* rubber band test" (page 764), or by
the dynamometer. The power of the legs can be tested by having
them moved against resistance. If the patient is honestly endeav-
oring, for example, to raise the right thigh off the bed against the

77° TRAUMATIC SURGERY

examiner's resistance, then the muscles on the front of the left thigfa
will be seen and felt to contract.

Of the foregoing, the chief importance in the traumatic form
would be the grouped manifestations under (i) General appearance,
(s) Tremors, (6) Pulse, (9) Reflexes, (ii) Muscular power. Of
these eleven objective signs, at least four should exist before a diag-
nosis is made or accepted.

Differential Diagnosis. — In an ailment of this sort with such
wealth of subjective and poverty of objective symptoms It is advis-
able to consider what is necessary to make a diagnosis of a true case
with a view to excluding—

Hysteria.
Malingering,
Epilepsy.
Pbrenasthenia.
Cerebral disease.
Spinal disease

Lumbago-rheumatism.

Goiter.

Visceroptosis.

Arteriosclerosis,

Paresis.

Multiple sclerosis.

Hysteria

The derivation of the word means "womh," and for a long time
the disease was supposed to be associated with and limited to female
disorders. This ailment has existed at least since the days of Hip-
pocrates (125 B. c.) and has been the subject of much controversy.
Charcot probably did most to clarify the situation respecting it.
and his views are even in this day substantially regarded as correct.
He taught that the traumatic form was, in effect, a manifestation of
self-hypnosis due to the psychic and physical shock, and that the
symptoms were in part determined by the suggestion made on the
patient's mind by the nature of the accident and the part of the body
injured.

Definition. — A functional disease of the central nervous sys ten* due
to a large number of causes, and characterized by mental, motor,
sensory, and visceral symptoms of such wide scope as to embrace at
least some of the manifestations of nearly every other derangement.

Causes. — These are legion, but the essential element is that the
person should manifest the hysteric "temperament" which is ordi-
narily hereditary. This implies that the so-called sdgmata or signs
of the disease pre-exist, and that the outbreak is due to a wide variety
of exciting causes capable of inducing manifestations known as acci-
dents of hysteria. In other words, the stigmata always have and will

THE TRAUMATIC NEUROSES 77 1

continue, to exist, but the accidents will disappear and can be induced
by certain mental and physical stimuli.

No true hysteria can occur unless the person was previously
hysteric in type, and to that extent susceptible and liable to its
development.

Psychic sources of origin are more potent than physical, and the
latter without the former are incapable of inducing it. Susceptibility
to suggestion is very prominent, and impressionability and emotion-
alism are quite characteristic.

Women are of tener affected than men, and it is commonest at the
age of puberty and most likely to appear at menstrual periods. All
grades of society are involved, but a larger share are provided by the
poor and overworked, or the indolent and rich. The Jewish race is
especially susceptible, and the Latins more prone than other
Europeans.

Any sort of mental or emotional shock may be the inducing essen-
tial cause, particularly sudden grief, joy, anger, sorrow, fear, fright,
anxiety , worry , distress, catastrophe. Likewise, abnormal stress and
strain, or sexual impressions, and fears and hopes are factors.
Religious excitement and the rigid advocacy of cults and sects are
sometimes causative, and the active devotees of some of these are by
many regarded as hysterics.

Traumatic sources of origin are, of course, very numerous, but the
essential and necessary element is fright or psychic shock, and for this
reason the sights and sounds of an accident may be provocative even
in the absence of actual physical damage. In this respect, as in many
others, it differs markedly from the allied neurosis, neurasthenia, in
which some physical injury is usually a sine qua non.

There is no special section of the body when injured more likely
than another to produce hysteria, nor is there any special sort of
violence especially provocative, assuming that the elements of fright
and psychic shock exist. However, the mental impression or sugges-
tion derived from the manner of the accident and the place of the
receipt of the violence often determine the hysteric symptoms; and,
indeed, certain manifestations can be predicted from a given set of
psychic causes and physical results, in a properly predisposed subject,
by a process of psycho-analysis, a topic so prominently brought
forward by Freud and his followers in an attempt to fathom symptoms
of a more or less hysteric type. For example, a blow on the arm may
create a strong mental impression and fear of paralysis, and by a pro-
cess of self-hypnosis the patient believes the arm powerless, and it

•jy2 TRAUMATIC SURGERY

thus becomes more ©r less disabled and useless and to all intents and
puqMses practically paralyzed. The same psychic control of "mind
over matter" may induce other forms of hysteria, and an analysis of
the manifestations of many of them will show that the condition
started from some mental suggestion, that is perhaps a repetition of a
memory or occurrence rendered fresh and active in the patient's mind
by the psychic shock or mental impression of the recent accident or
occurrence.

Hysteria has been aptly termed "the great mimic," and this is
true not only as to its production but also as to its capacity to feign ot
simulate ahnost every pathologic condition to which human flesh is
heir. The element of severe violence is not necessary, and, in fact,
many extreme cases arise without any external physical force
whatever.

A fit of anger, the occurrence of sudden good or bad fortune, an
escape from threatened disaster, or any sudden psychic trauma are
just as inducing in a hysteric as a similar grade of physical trauma.
That is one reason why hysteria so uncommonly occurs when
the patient is unconscious or asleep, or otherwise in a stage of
unpreparedness.

It is much less common than traumatic neurasthenia, and in
my experience, as stated, the combination of neuroses is much more
frequent than either separately.

Symptoms. — These are exceedingly numerous, and. as already
indicated, there is practically no human disorder that fails to present
some signs of hysteria, and in many instances the presence of
stigmata and the grouping of symptoms are the real differentiating
factors.

There are two main forms, major and minor hysteria, the former
being unusual in this country, but rather frequent abroad.

As stated, the sUgmata are permanent, innate and hereditary, and
may and ordinarily do exist unknown to the patient until some
occurrence or examination brings them to notice.

These stigmata are pre-existent and in the main consist of:

(i) Anestftesia Areas. — Certain segmental, irregularly distributed
surfaces of the body are insensitive to pain (analgesic) and touch
(anesthetic) and occasionally to heat and cold (thermal anesthesia).
and these are known as "hysteric zones" or "hysteric areas" or
"hysteric spots." None of them bear any anatomic relationship to
the underlying nerve-supply, and they are shifting, inconstant,
and very variable in degree and extent. Pressure on some of these

TKE TRAUMATIC NEUROSES

773

^reas may induce or suspend hysteric manifestations, and they are
I hence known as "hysterogenelic zones."

The commonest distribution is along the lower abdomen, near the

[ nipples, over certain portions of the back, and on irregularly and

' widely distributed spots on the extremities (Fig. 609). In women.

"ovarian zones" and "mammary zones" and "vaginal zones" are

frequent and denote areas of altered sensation in these respective

regions. Insensitiveness of the conjunctiva and pharynx are also

FiC. 609. — HyKteric zones and ane;
zone; b, ''stocking and glove" anesthe:
distributed areas of anesthesia, dorsal o

.rcas: a, Hcmi-anesthesia and ovarian
ian and umbilical zones; c, irregularly

(2) Hyperesthesia Areas. — These are the reverse of the preceding,
and consist of irregularly distributed areas unusually painful to
touch and pressure. They are commonest along the spine.

(3) Vasomotor ^reoi.— Certain portions of the skin, notably the
back and abdomen, become pinkish or more or less mottled when
irritated by pressure, and a red line with white edges can be produced
by the finger-tip or other blunt object drawn along the surface; this is
the so-called tacbe ccribrale and is supposed to indicate an anesthetic
condition of the superficial blood-supply.

(4) Visual Areas. — Perception for fight and color are altered,
resulting in "contraction of the visual field" and "reversal of the
color field" (Fig. 610).

(5) Emotional Stales. — The hysteric is generally of a highly
strung type and of imaginative and vivid mentality, readily given to

774 TRAUMATIC SURGERY

moods, whims and alterations in behavior and action toward self and
others.

The accidents or incidents are temporary, acquired, and variable,
and are the outgrowth of exciting causes reacting xipon a subject
possessed of the preceding stigmata; the main manifestations are:

(i) Paralyses, — Usually one limb is involved (monoplegia); occa-
sionally one lateral half of the body (hemiplegia) ; or two limbs (diple-
gia); or a lower extremity (paraplegia). The part paralyzed as to
motion is generally also anesthetic.

(2) Contractures. — Thesie are in the paralyzed areas, notably
manifest in the hands, feet, and limbs.

(3) Convulsions. — Fits of various degrees may occur and are usually
induced by emotional accessions.

(4) Visceral Changes. — Certain cerebral, abdominal, and genito-
urinary manifestations are relatively frequent*

An individual discussion of symptoms can best be made by divid-
ing the manifestations into motor-sensory, psychic, special sense, and
visceral groupings.

It is to be understood that a given case may demonstrate but one
set of the foregoing phenomena, or combine all of them.

The time of onset and extent of symptoms varies, but usually is
quite prompt and complete, and may immediately follow the accident.
Rarely is there an interval of more than a week, and the longer the
delay, the greater the probability of added suggestion, especially that
implanted by the medical treatment, or the remarks of visitors. I
have known cases to develop from newspaper accounts of court pro-
ceedings, and in the clientele of a certain class of ph>'^icians and
lawyers the occurrence is common enough to raise the suspicion that
the disease is directly due to their hypnosis by constant suggestion in
a susceptible and perhaps willing subject or "medium."

Motor-sensory Form. — This is perhaps the commonest, and is usu-
ally produced by some suggestion from an injured extremity, so that
the subject is impressed with the idea that the part can neither feel
nor move.

Paralysis is most commonly limited to one limb (monoplegia) or
a portion of it, notably a hand or leg. It may be a weakness or actual
complete loss of motor power, so that the part is lax (flaccidity), or it
may be somewhat rigid and tense (spasticity), notably when the
muscles opposing the palsied group are in a state of contraction. In-
volvement of the lateral half of the body may also occur (hemiplegia),
and this is commonly the left arm and leg, the face very rarely being

THE TRAUMATIC NEUROSES 775

affected. Two limbs (diplegia) or the lower extremity (paraplegia)
are less usual types of involvement. The paralyzed part dangles
limply and an affected arm or leg drops listlessly when raised. In
walking, the gait is characteristic, in that the foot of the involved leg
dangles along the toes as if the limb were hung on a springless hinge at
the knee.

Spasm and tremor may occur in the involved muscle group, or
independently; it is likely to be coarse and jerky and is usually
increased by effort (intention tremor).

IncO'Ordination of the affected limbs is common, and an ataxia of
some grade may exist. The gait is quite likely to be faulty and move-
ments generally may be awkward and attitudinal, this being rather
pathognomonic.

A stasis-abasia is inability to stand or walk, and is ordinarily an
associate of the paraplegic form; the patient, however, may be able to
slightly move the lower extremities when lying down. This usually is
a temporary occurrence in the course of the disease and may appear
suddenly in attacks; it is sometimes referred to as "cerebellar hys-
teria." I have seen but 4 traumatic cases of it.

Contractures may occur independently or in the paralyzed part, so
that a rigid postural attitude is maintained. This is often so charac-
teristic that a diagnosis is possible by inspection, and is most common
in the extremities, but may involve any part of the body and become
quite theatrical or acrobatic. These contractures were quite
common among the soldiers in the war zone, usually associated with
a relatively unimportant wound in the same extremity. See
"Camptocormia," page 147.

Sensory changes ordinarily are found in the paralyzed parts, but
may occur independently.

Anesthesia is the commonest form, and the loss of sensation to
pain (analgesia) is the usual manifestation, although the response to
touch and thermal stimuli may be coincidently involved. Sensation
may be wholly or partly lost (hypes thesia), and the rate of onset and
degree parallels the paralysis as a rule, so that when the part has
completely lost its motor power it is likewise wholly insensitive, so
that pin pricks or transfixion may cause neither pain nor bleeding,
and even red-hot irons may cause no flinching. Electric contrac-
tion, however, remains.

As previously stated, there are normally numerous "anesthesia
zones" in hysterics, and certain persons by fortitude, practice or
natural callosity can withstand pin pricking, thermal and other

774

TRAUMATK

moods, whims and alterations in I-
others.

The accidents or incidcftis ar.
and are the outgrowth of exc ii
possessed of the preceding sti;

(i) Paralyses, — Usually c>!.
sionally one lateral half of tli-
gia) ; or a lower extremity
motion is generally also an

(2) Co7itractures. — Tht
manifest in the hands, f«.r

(3) Cofivtdsions-- Vh
induced by emotional n

(4) Visceral Chany,-
urinary manifestation-

An individual clis< •
ing the manifestalicu
visceral groupings.

It is to beundi!
set of the forcgoiu;-

The time of oh

quite prompt an<i
Rarely is there ..

-as the response to
vaoUy authentic or

:e motor involvement,
-•■ )i the part, and hence
- ,-nental, especially when
...V apt to invade the area
. ^ i is then known as "glove
sjcctively; but any more or
:- .*ning parts of identical in-
_:: mucous membranes may
-..y that of the throat, nose,
:-:. These areas vary in their
. iin be made to shift by electric
.-willv the anesthesia is absent

delay, thegrtvti
implanted In
have known
ceedings, ;ii.
lawyers tin
the disea^
a suscei)ti:
Moioy
ally prcHl.
the sul)i'

•

nor mc»\
Par.
a port i
comj)I
mav ■
mu>'

V<)]\.

and * "*"

z^r preceding, and it may be an

..ii^c with others; h3rperalgesia is

215 set of superficial painful sensa-

.5-* confluent and predilect certain

,^ ne spine, near the groin, and about

_:. SI the latter region they are often

; m[-dri\dng type, known as clavus

-r-^-uently the seat of similar painful

\ ind knee; these are then known as

-. . ^ vints," and as such mav baffle

s-irch is made for associated hvsteric

- . the same joint is frequently asscnri-

.^-v : '. jn in sleep and always during narcosis.

-< or treatment. I recall the case of a

. ,_ t-: ^er hip at home by a sudden twist and

^ :.-. iisabled for a week later, and when she

.^;.-; '-'r suspected hip injury there wltc nr»

;^; *^ i'oout the joint except pain on active anil

.^t -r'Udined abed and was little atTectcd bv

^^ ^u :iierapeutic measures. She had several

..rf wr own physician assumed charge of her

i..:i^ earned that her complete disability was

^.iCi* ^'w. He thereupon threatened her with

^^v- » (le actual cautery and she promptly got well.

TV^crtc arthritis'* are less common than before

; TRAUMATIC NEUROSES 777

ffr^ys. and fewer of them are now long treated
Uilar rheumatism, specific, or even tubercular

tu constantly bear in mind that pain alone is never an

r manifestation, and that it cannot long genuinely exist

dated symptoms that soon stamp it as proceeding from

t from psychical sources.

hes ol hyperesthesia may also be found on various

branes. such as the throat, vagina, urethra, and rectum.

; give rise to contractions of the adjacent sphincters '

f appropriate symptoms.

r of these hjperesthetic areas are more painful to superficial

> pressure, and the patient may scream from the slightest

I yet thrash about in bed without complaint. On diver-

l great deal or all of the pain is absent, and for this reason and

i this symptom must have ample corroboration and reinforce-

i before it is accepted as diagnostic of hysteria. The location of

Injury frequently determines the site of the pain, and it is thus

f to simulate a neuritis or rheumatism in injuries to the extremi-

r the back, and in the latter region lumbago has to be differen-

i also.

'These patients cJaim much suffering and yet they do not look hag-
gard or worn, and they sleep and eat well and maintain a good general
appearance, and all of them exclaim most when the audience is of
their seeking or to their interest.

Psychic Form. — Emotional manifestations are very common, and
these may show extreme or all modifications between exaltation and
depression, joy and sorrow, laughter and tears. The well-known
"attack of the giggles," or "spells of weeping," or "fits of anger," or
"fainting spells," and other evidences of the play of emotions may
occur.

Introspection and impresstonabUity are quite characteristic.
Memory deficiency is quite often asserted, and this is so marked
and convenient at times that many of these people resemble plain
liars. In the typical traumatic forms, events just before and just
after the accident may be quite blurred, while all other events are
recalled with relative clearness; the accident itself may be forgotten.
This memory deficiency, or amnesia, is often more an element of
inattention than actual mental deterioration, and is characterized by
the same lack of consistency and continuity as other hysteric
symptoms.

778 TRAUMATIC SURGERY

Deficiency of will power, or abouHa, is quite common, and the
patient laclu initiative and volition.

Catalepsy, somnambulism, dual personality, and trance siattt
exceedingly rare in traumatic forms.

Conmhive or irritative seizures may occur in two forms:

(o) Hysteria minor, in which, after some strain, excitement,
emotion, the patient feels a choking sensation in the throat (globus
hystericus) or some other premonitory sensation, and this is soon fol-
lowed by an irresistible desire to laugh or cry, to become Jocose or
angry, or a violent outburst of anger occurs, or a torrent of abuse is
poured out without perhaps any warning or provocation. During
the outburst the patient tosses or wanders about, and spasmodic or
mild convulsive motions may occur. After the height of the rela-
tively short attack is over the patient may be bathed in perspiration
and fall asleep. Later, a large amount of pale urine is passed and the
patient may feel comparatively well, although headache and weak-
ness are usually complained of. Some manifestations are referred to
by the patient or friends as " fainting spells," and in these there is a
temporary unconsciousness ordinarily without any convulsive move-
ments. These not infrequently occur during the course of an exami-
nation or in court, and they are characterized by sudden onset and
slight, if any, preliminary excitement. The patient ordinarily is
apparently perfectly well and suddenly falls into a chair or on a
couch and remains quite motionless for a few moments, and then ap-
pears well again. Some of these attacks resemble the petit mal of
epilepsy, and they may be repeated many times daily under varying
forms of sdmuli, or there may be long intervals between them. The
duration may be momentary, or such an "attack of hysterics" may
last an hour or more. They rarely follow any set form and may be
induced by many kinds of mental impression.

At one time a joke may induce the attack; at another, the element
is sadness; or again, the mention of the accident may be the inducing
factor.

(b) Hysteria major may begin like the preceding or start without
any preliminaries and immediately the patient may become rigid,
staring, intent, and usually falls, selecting some place that is con-
spicuous and free from danger or personal discomfort. After tem-
porary rigidity, or without it, violent motions are made with the
arms and legs and other parts of the body, which move in a more or
less tonic convulsion. Efforts at restraint are resisted by almost
prodigious strength as the patient grasps, pushes, shoves, bites,

THE TRAUMATIC NEUROSES 779

claws, and contorts about. The eyes are usually staring, open and
rolling, and the antics may seem well directed and designed for an
imconscious person. All sorts of poses and poises may be assumed
and at times the body may rest on the head and heels {opisthotonos)^
or the reverse (emprosthotonos) . The pupils are usually equally
dilated. Respiration may temporarily cease long enough for
cyanosis and great lividity to occur and the pulse may be rapid from
the exertion. These rather slow motions of the limbs and other
parts of the body may later become very rapid {clonic convulsion)
and appear on one side or both and be epileptoid in appearance ; but
there is no such thing as hystero-epilepsy.

Such a procession may progress with an acrobatic display or a
series of remarkable contortions and attitudes more or less suggestive.
The duration may be a few minutes or an hour, and end only when
physical exhaustion appears, and they may again recur after a period
of sleep. There is never absolute unconsciousness in such a seizure,
and it can often be aborted by various forms of stimuli, of which may
be mentioned smelling-salts, ammonia, pressure on the supra-orbital
or intercostal nerves "the gridiron treatment,'' or the application
of vigorous slaps to the soles "the policeman's tattoo." Pressure
on a hysterogenetic zone or the use of an electric battery may also be
efifective. The nausea and vomiting induced by a hypodermic of
apomorphin is not only curative but also has a powerful deterrent
value. Mental suggestion in the form of verbal threats, promises,
or entreaties may stop some "fits." If the audience disappears, the
attack often spontaneously subsides. Bystanders may be kicked,
bitten, or scratched, but the patient is rarely self-harmed. Some-
times a period of delusion or hallucinations may follow, but generally
the attack ends as suddenly as it began. The extra-ordinary poses
and attitudes seen in some types of hysteria are rare in the traumatic
forms, and, indeed, they are unusual in all forms in this country.

Recurrence is likely, and the patient can often induce an attack at
pleasure, and many of them are able to ward off an attack by auto-
diversion or will power. After the seizure the patient is usually as
well as ever, but occasionally a period of so-called "hysteric coma"
may appear, and in this condition the patient may arrive at the hos-
pital; some professional "fit throwers" always become "comatose"
on the arrival of the ambulance, but they speedily revive if the sur-
geon in attendance recognizes them and threatens a police cell and
not the anticipated ward bed.

Occasionally the "spell" is followed by motor or sensory paralysis

ySo TRAUMATIC SURGERY

in one or more Umbs, or if these have preceded the attack, they may
disappear, and the "paralyzed" parts may move as actively as the
rest during the convulsion.

Special Sense Forms. — Vision. — Defects of this sort are usually
suggested by some slight injury about the face or forehead, or by the
display incidental to an electric short circuit, or a bright flash or
flame. "Shocks" from electricity and lightning are other sources.
Ahesthesia of the retina to light and color may occur, resulting in im-
pairment of vision (amblyopia) or blindness (amaurosis). Ordi-
narily this appears in one eye, rarely in both. Examination of the
eye may disclose normal conditions or ordinary derangements in
nowise attributable to the accident, and the majority of patients

Fic. 6:

know nothing of their visual defects until these are disclosed by the
examination. The affected eye and the areas of paralysis or anes-
thesia are usually on the same side. Perimeter examination shows
that there is "limitation of the peripheral field of vision," and this is
one of the pathognomonic signs of hysteria, as is also " reversal of the
color field." The field of visual limitation usually does not exceed
IS degrees, and it constantly shifts and is rarely twice alike. If the
limitation is marked It is ordinarily concentric in distribution.

This limitation of the scope of vision is usually associated with
alterations in»or reversal of the color scheme perception. Normally,
of the "primary colors," violet is perceived in a relatively small cen-
tral area; green, red, yellow, and blue in progressively wider areas
respectively; but in this condition the area for blue, instead of being

THE TRAUMATIC NEUROSES 781

the largest, may be contracted and fall within the red area, the others
being correspondingly altered or reversed. The sensitiveness to red
persists most, that to violet, green, and blue disappearing in the order
named. As stated, this is a manifestation of anesthesia and becomes
of functional importance in certain occupations. So characteristic
are these visual disturbances of this disease that they are termed by
Janet, "hysteria's barometers."

The palpebroconjunctival reflex is usually absent in these cases,
but true organic disturbances like hemianopsia and loss of the pupil-
lary reflex do not occur.

These patients may have bilateral blindness and not know it until
some definite examination discloses or suggests it to them.

Bailey states: "Hysteric patients in reality see, although visual
perception does not become known to the higher consciousness. This
hysteric amblyopia, hke other hysteric symptoms, is actually false,
although when the patient is conscious of it. it is real to him,"

There are all sorts of hysteric subjective symptoms referable to
vision, such as bright or dark lights, balls of fire, and other visual
impressions. There are also various spasmodic affections or "tics,"
like winking or blinking, or spasm of the eyelids (blepharospasm).
Involvement of some of the ocular muscles occasionally occurs,
leading to squint and ptosis {usually unilateral). Diplopia may also
infrequently appear. Pupillary changes amounting to sluggishness
may occur from muscular tire, but the Argyll-Robertson pupil is
never hysteric in origin.

Hearing. — This deficiency also is an anesthetic defect, and is usu-
ally found on the same side as the anesthesia or paralysis. It is rarely
total, and ordinarily is unilateral, presenting impairment alike to
bone and air conduction, and thus differing from pathologic deafness.
It is less common than, but infrequently corresponds and is associated
with, the visual contraction, and while these patients have no struc-
tural deficiency, yet they do not actually hear. It is generally
accompanied by anesthesia of the drum, external meatus, auricle,
or other parts of the ear.

Speech. — This may be associated with visual and hearing difficul-
ties and is wholly psychic, and ordinarily means that the muscles
connected with phpnation are paralyzed, spasmodic, or anesthetic.
Such patients can make sounds, but are ordinarily incapable of ar-
ticulation. This aphasia is usually sudden in onset, and may pre-
cede, follow, or be associated with other hysteric manifestations.
Paralysis of the vocal cords, and pharyngeal and laryngeal anesthesia

782 TIHUMATIC SURGERY

can usually be demonstrated, and hoarseness or peculiar vocal sounds
are often present. Dog-bites frequently suggest hydrophobic symp-
toms, like barking, whining, and salivation. A number of cases
occurred in soldiers as manifestation of "Shell Shock" with mutism
as a prominent feature.

Smell and Tasle.— There may be unilateral impariment of one nos-
tril or a symmetric portion of the tongue, and then the corresponding
portions of the mucous membrane of the nose, lips, and tongue are
respectively anesthetic. This combination may exist alone, but usu-
ally is found associated with visual-auditory defects corresponding to
anesthesia or paralysis of the same half of the body. This loss of
smell (anosmia) and taste (ageusia) are obviously wholly subjective
symptoms and hence difficult to demonstrate by tests; if, however,
unusual or often vile smells and tastes produce tears or saliva, the
degree of impairment is at least not very complete.

Visceral Forms.- — Any organ of the body may be involved enough
to suggest at first a true lesion, and the differentiation is made by the
complex of symptoms and the presence or absence of hysteric stig-
mata. Many of the manifestations are often quite neurasthenic in
type.

Beart involvement may be suggested by alterarions in pulse-rate
and attacks of precordial pain resembling angina pectoris.

Blood-vessel involvement may be suggested by cyanosis, edema,
peculiar rashes and blushes, and other surface manifestations, of
which dermographism {tache cerfebrale) or urticaria are typical.
Hysterics, as a rule, do aot readily bleed, probably due to spasm of
the coats of the vessels.

Gasiro-intestinal signs such as nausea and vomiting, eructations of
gas, perversions of appetite, epigastric or other "phanthom" tumors,
and severe abdominal crisis-like pains, are the usual manifestations.

Kidney and bladder signs take the form of painful and irritative
symptoms, but attacks of colic or changes in the urine are very rare,
but polyuria or retention are common.

Respiratory changes are occasionally indicated by dyspnea, cyano-
sis, and rapid breathing. Hysteric coughing and hemoptysis occur
infrequently.

Sphincters are never truly involved, but involuntary emission of
urine may occur as an index of lack of control ; such escape of urme
during emotion is not uncommon in many persons, notably young
women. Rectal involvement is less common, and neither in this nor
in vesical forms is there any great soiling or excoriation of outside

THE TRAUMATIC NEUROSES 783

parts. Anesthesia of the urethral and rectal mucous membranes is
generally coincident, and while the sphincters may be less taut than
normal, they are never wholly without contractility.

Spasmodic urethral stricture is common, but that of the rectum
relatively rare.

Equilibrium may be disturbed, leading to vertigo or instability
when standing erect with eyes shut (Romberg symptom), and even
gait defects of an inconstant and irregular form may occur. True
inco-ordination is absent.

Mental deficiency never goes on to a true psychosis or insanity, and
the patient's mind, indeed, may be preternaturally active; many a
"genius" or "prodigy" is markedly hysteric.

Phrenasthenia, or mental weakness, is very rarely traumatic, and
if it is, neurasthenia more than hysteria is at the basis.

Prognosis of the Traumatic Neuroses

The determining elements are largely alike in each neurosis, and
they can, therefore, be considered together; they may be said to
depend upon :

(i) The individual.

(2) The environment.

(3) The nature and extent of injury.

(4) The treatment.

(i) The Individual, — Neurotics, as has been stated, are often born
and not made; the raw product already exists, and the exciting cause
fashions it into some recognizable shape.

Poor heredity, and equally poor psychical or physical poise and
strength are a combination unfavorable to speedy recovery. The
naturally "high strung" do not get well as quickly as the better
balanced.

The extremes of age offer poorer prospects than the adult type.
Women are apt to recover as quickly as men; in hysteria, males usu-
aUy get well more promptly than females.

(2) Tlie Environment. — If the subject can be isolated and freed
from the attention of would-be advisers, the outlook is excellent.
Tact on the part of the physician and others is extremely important
and the habit of optimism is nowhere more needed than in these
ailments.

If the physician finds that the patient no longer imposes entire
faith and confidence in him, his value is so lessened that he had better
retire.

784 TRAUMATIC SUHGERV

The prospect of litigation, as indicated, is a marked deterrent to
recovery, and even in genuine cases serves to keep the patient alert
and alive to everj' change in symptoms. It is a constant source of
worry and expectation and is probably as potent a factor as any
in determining the outcome. Cases very rarely recover while
adjustment is pending; but the vast majority of them respond very
promptly when it is accomplished, and nearly all of them get well
soon thereafter.

I have known of a case of a woman about fifty years old who had
very marked evidences of major hysteria, and her trial was hastened
in view of affidaWts made by her attending physicians to the effect
that she was soon likely to die. She was markedly emaciated and
had well-defined contractures, with hemiplegia and hemi-anesthesia
of the left side. Her voice was almost inaudible and she had numer-
ous hallucinations and trances of a religious type. Originally she had
fallen from a car, and the onset of her hysteric manifestations were
associated with injuries to the back and legs which induced the sug-
gestion of paralysis. She had been abed some four months when I
saw her, and by starvation had become exceedingly weak. Her
claim was adjusted and within a short time she was reported as hav-
ing resumed her regular duties. Theoretically the outlook was bad
in this instance, considering her age, environment, and a weakness
greater than I had hitherto witnessed in a similar case, I once ex-
amined a young negress who had been in a collision of cars and who
had received a few contusions of the scalp and other parts of the body.
She promptly went into a trance on reaching home, and one arm and
leg was anesthetic enough to permit her to be made "a human pin-
cushion." Her doctor sensed the situation and stopped the " trance"
with a syphon of aerated water, but she was anesthetic and abed when
I saw her a few days later. Immediately after adjustment her
doctor told me she got well enough to go to Coney Island on part 0/
the proceeds. The first of these cases had received unremitting care
from four doctors, two nurses, and many relatives, and day by day
her condition got worse from too much attention. The second case
was a splendid subject or "medium," and under different manage-
ment was capable of developing ahnost any set of hysteric s\-mptoms,

(3) Nature and Extent oj the Injury. — How the accident happened
and what it physically does are not necessarily determinative, he-
cause we have seen that grave injuries are generally free from func-
tional nervous signs, and minor injuries are often full of them. Verj'
little was heard of the "traumatic neuroses" among the survivors ol

THE TRAUMATIC NEUROSES 78$

the well remembered "Triangle fire" holocaust, although most of the
young women employees were foreign born or their immediate
descendants, and of added susceptibility because of working condi-
tions. Had these same employees, however, been subjected to the
*' fright and shock" incident to a falling-elevator accident in their
own building, then the nervous claims would have been legion despite
the marked difference in the grade of probable shock accompanying
each of these accidents.

There is often no more reason for the development of the neuroses
from a rear-end railway collision than from a fall on a banana peel.
The extent of the physical damage, or the more or less tragic conse-
quences leading to it, are no infallible estimate as to the development
of the neuroses; without proper suggestion and environment they will
not appear or disappear. I saw a marked case of hysteria, plus wilful
exaggeration, developed by the fall of a small piece of plaster weighing
a few ounces which struck a woman on her hat, and then on her face,
while she was in an elevator. She was being treated for "spinal dis-
ease" because she said she could not move her legs or feel pins stuck
into them. She was carried to court on a stretcher and got a verdict
larger than if one leg had been actually amputated, and yet admit-
tedly she had scarcely a mark on her face and was able to go home
alone after being hurt.

If the patient has some actual injury, especially a fracture or some
condition causing real pain or requiring dressings, the chances of hys-
teria developing are very remote ; I do not recall many cases of definite
objective or serious injury complicated by hysteria. After the origi-
nal injury has been cured, however, it is not uncommon to hear many
hysteric or neurasthenic symptoms related.

(4) The Treatment. — This is a major factor, and the more prompt
the recognition by the doctor of the patient's susceptibility, the
greater the probability of warding off later nervous developments.

Prophylaxis is exceedingly important, and the wise doctor after
careful examination will positively assure the patient that "spinal
injury," or "internal injury," or "brain damage" has not occurred,
and that there is no good reason why recovery should not be just as ■
prompt and certain as if the injuries had occurred in a way for which
the patient was wholly to blame.. It is suggestive that these neu-
roses do not occur at play, even though such sports as football, base-
ball, golf, tennis, bowling, wrestling, swimming, boating, and others
have attendant injuries the equal of those for which somebody else
is liable in damages.

786 TRAUMATIC SURGERY

A great many of these "nervous'' symptoms would be checked
promptly by less zealous attention and fewer visits from the doctor,
as very many of them would never be heard from a second time vmless
referred to by needless inquiry and aimless therapy.

Next to freedom from suggestion, the element of changed en-
vironment, as by isolation, is of prime importance. The sight of
people with real suffering from actual injury is often a deterrent to
the neurotic, and for that reason a hospital stay is very valuable and
few cases develop there. A tactful nurse, attendant, or friend is of
much help, and, of all places, the "calamity howler" has no place in
the presence of a nervous patient. It is a strange thing that aU phy-
sicians and most friends are optimistic in the sick-room, except when
the neuroses are being treated ; but in these, it is common in the hear-
ing of the patient to parade all sorts of symptoms and predict almost
fatal consequences.

My personal belief is that the vast majority of these neurotics are
created by suggestion and nurtured by attention, and that the onset
and cure are alike dependent upon improper treatment. That hys-
teria may occur in the absence of motive and be quite difficult to cure
is. wholly true; it is liable also to recurrences either in its original,
added, or lessened manifestations. Recurrences, however, generaUy
show some of the elements of the preceding attacks, although the
dominant features may be the outgrowth of more recent mental
assaults. Hysteria is more likely to end quickly than neurasthenia,
and often a person "paralyzed for months" may regain use of the
limbs in an instant from some sudden shock or fright, just as the on-
set of the trouble was due to similar causes. Recovery from neuras-
thenia is generally more gradual, the pains, aches, and incapacity
becoming less marked slowly, or appearing only at times of stress and
strain.

The neurasthenic may become entirely well, but the hysteric may
continue to present the inherent "stigmata" throughout life, even
though the "accidents" have disappeared.

The duration of symptoms cannot be foretold accurately. Marked
manifestations of hysteria may disappear in an instant ; or they may
persist for years, but are practically never permanent. The cause,
grade, or extent of these hysteric signs is no measure as to their dura-
tion, for a hysteric deafness may be more resistant to treatment than
a hysteric paraplegia.

As indicated, traumatic neurasthenics develop and are cured more
slowly, but the recurrence is less Ukely than in hysteria or non-trau-

THE TRAUMATIC NEUROSES 787

malic forms of neurasthenia. These patients are quite unlikely to
improve pending adjustment of their claims, but the very great ma-
jority of them get well thereafter. All the cases of hysteria that have
come to my immediate attention have recovered except one, and she
had multiple sclerosis as well.

The outcome of the neurasthenia cases is harder to gauge because
their complaints are based so largely on their own statements, and
manifestly most of them are unwilling to admit recovery having
asserted permanency and perhaps having received indemnity on that
basis. But the fact remains that they are no longer idle or under
treatment, and the inference is that working capacity at least has
been restored.

True cases never lead to organic lesions such as insanities, and if
these subsequently develop, the neuroses must be looked upon as
premonitory and not initiating evidences.

It is not impossible for these functional conditions to coexist with
organic disease, this being especially true of hysteria.

Treatment of the Neuroses

This presupposes that the diagnosis has been accurately made,
and, as previously stated, most cases due to injury are a combination
of neurasthenia and some hysteria, rather than the reverse.

Management may be (i) general and (2) local.

(i) General Management. — Early recognition of a ** tendency
toward nervousness" is very important, and this leads to caution in
suggesting symptoms or their interpretation to the patient. If the
atmosphere is such that the accident is the main topic of conversa-
tion, then a change of environment must be made so that the patient
may not become a prey to self-imagining or that of others.

Isolation is valuable in most cases, and is most efficient when
carried out by a tactful attendant in whom the patient has confidence.

Careful examination and investigation by the physician gives the
patient a large sense of confidence and faith, but the opposite is
attained if the examination is cursory. Neither too little nor too
much attention must be paid to subjective complaints, but an
explanation of them is always in order.

A frank talk with the patient will often allay suspicion and dis-
abuse the mind as to feared symptoms or possible developments.
In this respect the physician is guided by answering for himself and
patient the question, "What usually and ordinarily happens imder
similar conditions?"

788 TRAUMATIC SURGERY

If possible, adjustment should be obtained promptly, as on this
much of the subsequent course often depends.

In every family there is always some level-headed person on whom
the physician may rely, and to such care the patient should be left
when possible. The less attention and chance for display the hys-
teric has, the less the manifestations; and the neurasthenic also needs
more than one auditor into whose tired ears his woes may be repeated.

The neuroses comprise a group of players in which the neuras-
thenics do the talking and the hysterics the acting; hence the quality
and quantity of the audience is very important.

The "rest cure" devised by Weir Mitchell is a very valuable
method in many of these cases.

Soldiers who developed hysteric symptoms as a part of "shell
shock" or after relatively trivial injuries were very often instantly
cured by one visit to a tactful specialist who attained results by
combining argument, persuasion and suggestion. In the French
Army, "Centres" for the treatment of this class of case were estab-
lished, notably at Paris and Besanjon. The British also maintained
similar places, and in conversation with me (Oxford, November,
1918) the late Sir William Osier spoke of the striking results obtained
at these centres aptly termed by him " Military Lourdes." A similar
expression of their efficacy was also made to me (Liverpool, December,
1 9 18) by General Sir Robert Jones, the well-known orthopedic
surgeon. Lasting cures have been obtained in the supposedly
blind, the mute, the lame, the paralyzed. General Jones called my
attention to a group of cases in which definite organic lesions occurred
in combination with inorganic or purely hysteric lesions.

(2) Local Management. — Pain and insomnia will be the two
chief symptoms requiring aid. It is to be remembered that a hypo-
dermic of morphin is no more potent to the hysteric than sterile
water; in fact, the latter is far more efficacious if administered with
the dramatic detail so craved by such a patient. Therefore the
relief of these and other allied mental symptoms must be largely by
mental means.

Pain is treated by various external applications, hot or cold.
The local use of the cautery is very effective in humbug and allied
pains. Electricity, massage, baking, and hydrotherapy all have their
place. It is unwise to rely on drugs, as they may prove habit induc-
ing and at best soon lose their effect. It is especially harmful to use
the hypodermic with these imitative people.

Insomnia is best relieved by nightly warm baths or spongings, or

THE TRAUMATIC NEUROSES 789

by cold compresses to the forehead or nape of neck. A brisk body
massage is quite effective in some cases. The suggestion that sleep
will result after a planned treatment is part of the therapy.

Paralyses and contractures require no special treatment aside from
massage, vibration, and electricity, but these must not be resorted
to if they tend to aggravate existing symptoms or suggest others.
Hypnotized and anesthetized patients are sometimes permanently
relieved of these symptoms by thus demonstrating their non-physical
existence.

Special sense defects are given the benefit of the suggestion im-
planted by electric or other forms of local treatment.

Convulsions are sometimes cut short by pressure on hysterogene-
tic zones or other painful areas, such as the supra-orbital or inter-
costal regions. Many fits stop just as soon as the audience departs.
These attacks never harm the patient, and thus they can be disre-
garded. Vigorous use of cold or hot water or spirits of ammonia cut
short many of them. A jet from a siphon of aerated water or a hose-
pipe is quite effective. The hysteric will not have a "spell" unless
the surroundings are comfortable, and thus the environment again
plays a prophylactic as well as a curative part. A girl with '*high-
sterics" is less likely to encore her exhibition if the only applause is an
old-fashioned spanking or a session alone in her room without food.

If " the punishment fits the crime *' there is usually little necessity
to again prove its punitive value.

Many of these people run the gamut of all sorts of treatment,
and finally derive much benefit from adherence to some cult or
"istic" belief. Shrines, relics and meccas from earliest times have
thus worked wonders by faith and suggestion when all else has failed.
The discipline and fixed attention of Christian Science may act
admirably in such a "mind disease," and there is no question that
"cures" and various "pathies" are active agents in some cases.
Hysteria may be induced or cured by the emotional strain of a re-
ligious " camp meeting " or by similar mental appeals. Psycho-analy-
sis, and interpretation of symptoms thereby, may also act in the
same way and be the starting-point of mental re-education leading
to cure.

Great care is to be exercised so that no underlying pathologic
condition is overlooked, and, indeed, a diagnosis of non-traumatic
"hysteria" or "neurasthenia" is now being looked upon more and
more as a cloak lor ignorance, because the neuroses are often shown
by careful analysis to be merely symptoms and not entities.

790 TRAUMATIC SURGERY

Differential Diagnosis

Hypochondriasis is imaginary illness, and is sometimes called
"imaginitis'' by persons familiar with accident claims. It presents
verbal evidences only, and is associated usually with minor injuries,
or is an acquired end-result after objective evidences of real injury
disappear. Motive, as in neurasthenia, generally exists, and women
are more commonly affected than men. All sorts of symptoms are
charged to the accident, notably those referable to the cardioneph-
ritic, gastro-intestinal, and genito-urinary tracts. These people are
generally well nourished, and a complete physical examination indi-
cates that they are first-class life insurance risks. Any demonstrable
defects are old and due to ordinary causes and perhaps became known
to the patient only as a result of examination after the accident.
The hypochondriac has often as many subjective symptoms as the
neurasthenic, but has none or few of the objective signs of the latter,
and wholly fails to demonstrate any evidences of the hysteric.
Many of these people are chronic complainers and persistently
have a *' grouch,'' independent of any added exclaiming due to an
accident. Their speech and deportment makes the diagnosis easy in
the absence of cardinal traumasthenia signs, and by questioning
them they may be readily induced to add to an already long list of
symptoms.

Malingering, or feigning of symptoms, is very common, and my
experience is that it manifests itself under the following guises: (i)
Absolute malingering ; the fakir. (2) Traumasthenia plus malingering.

(i) Absolute Malingering; the Fakir. — Here the symptoms are
purposely and deliberately assumed with the idea of magnifying the
condition and '^getting more out of it''; in other words, the faking is
consciously planned with intent to deceive. Numbers of these cases
appeared at recruiting stations.

These people do not look like persistent sufferers, and they are
actively alert and watchful lest they are caught off guard; but if the
examination is sufficiently thorough and prolonged, they either over-
act or underact to such an extent that detection is certain. If,
however, the symptoms are limited (as an alleged paralyzed limb) it
may be impossible for the examiner to make it functionate, and
surveillance will be needed to verify the suspected faking.

Subjectively, complaint is oftenest made of pain, weakness, in-
somnia, anorexia, and impaired genito-urinary functions.

Pain, if real and prolonged, inevitably shows in the countenance
and general appearance of the bearer. By resort to the "relocation

THE TRAUMATIC NEUROSES 79I

test" the actual persistence of pain can be determined, and the fakir
cannot accurately relocate spots previously marked as painful to
pressure. A zone that is tender is moved with care and is suitably
protected during every action, but the fakir forgets this when taken
oS his guard; for example, a back "too painful to move" is readily
bent when a request is made to remove the clothing or shoes. Pain-
ful spots on the scalp and elsewhere will stand considerable pressure
if the attention is elsewhere focused by identical pressure; in other
words, a fakir's pain is not consistent or persistent and is out of all
proportion to the severity of the original physical damage.

Weakness, if real and continuous, means flabby muscles and general
lack of tonicity; the fakir is not infrequently of athletic type.

Insomnia shows in the face and cannot long honestly exist with-
out giving objective signs.

Anorexia, if real, means malnutrition and generally atonicity of
the stomach, with demonstrable tympanites and other signs.
' Impaired genito-urinary powers show in flabby external parts,
and when urinary action is abnormal the urine will be concentrated
and perhaps otherwise altered.

Sexual claims are limited only by the imagination and verbal
capacity of the patient and are manifestly hard to disprove; but last-
ing diminution of this sort is very rare even in profound traumasthe-
nia. Lively cremasteric reflexes are usually incompatible with
sluggish sexual functions.

Objectively, complaint is oftenest made of lameness and stiffness,
paralysis (muscular or sensory), tremor, convulsions, and special
sense defects.

Lameness and stiffness have usually a demonstrable source and
are very rarely the only symptoms of real injury. Ordinarily they
are claimed in association with or following an injury to a joint,
notably the ankle, shoulder, knee, and hip. At first the fakir asserts
that the part cannot be moved at all on account of the lameness or
stiffness, but later most of them will admit some motion at least.
This is especially true in the shoulder, where it is often asserted that
motion to a right angle is possible, but not beyond. Many of these
cases are immediately disproved when the joint is noted to function
freely while the clothing is being removed. Nearly all of these
patients voluntarily hold the joint rigid during attempts to move it
further than they desire, and this purposeful contraction is never
twice alike and is much too general to indicate involuntary spasm of
muscle. Flabbiness of muscle and alteration in the appearance of

792 TKAUMATIC SURGERY

the joint inevitably follow prolonged limitation of movement, and
thus the absence of these or actual atrophy are suggestive. Motion
is always more active when the patient is diverted, and on the pre-
text of examining the chest the examiner's head may be placed under
the armpit, and by elevating the arm the "stiff shoulder*' can be
unsuspectingly raised often beyond former limits, and when this is
accomplished it frequently will remain there an instant until the
patient realizes what has happened, and then it is very promptly
dropped.

A really lame and stiff ankle should offer difficulty when the shoe
and stocking are removed or replaced, and some severe grades of
lameness and stiffness should require a special shoe. If the patient
is asked to walk backward, the genuine lame part will be favored and
weight will not be placed upon it; but the fakir, thus taken off his
guard, will use the good and bad extremity alike. This is a valuable
test and was first called to my attention by Dr. C. S. Benedict, of
this city.

A patient lying down with legs straight, when told to exert power
to lift one hip against resistance will also involuntarily contract the
thigh muscles of the opposite side; this does not occur when a fakir
is attempting to demonstrate lameness or stiffness in the hip.

Paralysis, — Motor power may be claimed to be wholly or partly
absent, usually the latter. The arm and leg are most often claimed
thus to suffer. A real condition of this sort necessarily must show
objective signs, but in their absence the examiner can be certain of
the mental origin of the condition, and by careful examination or
directed observ^ation may be able to demonstrate it to others.
Disuse of muscle invariably means alteration in its contour and con-
sistency, and this then becomes objectively visible and palpable. A
sudden pinch or pin prick has made more than one ^^paralyzed limb^'
jerk or move, and likewise the cautery and electric battery have
proved equally stimulative. Claims of paralysis in a hand or finger
are very common, and when the lost power is complete or nearly so,
some form of contracture is usually associated. In women, such
claims are frequently made, even though ordinary gloves are worn, a
thing manifestly impossible in genuine cases. Sometimes, if the
paralyzed part is designedly placed in an uncomfortable position,
the voluntary contraction maintaining the posture will so relax it
that another and less cramped attitude must be substituted, and
thus the deception will be uncovered. Genuine paralysis is usually
so flaccid or spastic that persistent mimicry of it is difficult.

THE TRAUMATIC NEUROSES 793

Sensory loss is usually claimed as existing in an arm or leg, and
many fakirs are capable of withstanding rather deep jabs from
pointed instruments, and less often contact from objects of high tem-
perature. This capacity is greatest when on guard, but the fallacy
can sometimes be proved by suddenly jabbing an area originally
claimed as anesthetic and observing the response. True lost sensa-
tion is rarely the sole evidence of injury, and when asserted as the
only manifestation must be regarded with suspicion. Actual loss of
sensory power presents no contraction, twitch, or reflex action on
stimulation; the fakir braces for the expected attack, b]ut the ex-
aminer will eventually gain some response in assumed cases. Elec-
tric stimulation is another means of showing the real from the false.
Many persons are insensitive to ordinary superficial pain either
naturally or from training, and some of this may have developed
from the school-boy trick of transfixing a finger-tip with a pin or
needle.

Tremor in the fakir always gets worse when observation is ex-
pected; but if it is deliberately watched, the rate and extent of it
will vary within wide limits and soon cease from fatigue. The as-
sumed tremor of fingers will often promplty stop or markedly vary
if the fakir is asked to demonstrate it by holding the arm out straight.
Likewise, twitching, jerking, grimacing, and more or less choreiform
motions will vary so much and so often that even the perpetrator
of them may soon admit "they are worse at some times than others. "
The signature of a fakir may be perfectly legible even though con-
tinuous jerking of the hand is alleged. A great many tremors are
alcoholic.

Convulsions, fits, and other "spells," "attacks," and "seizures"
are largely matters of convenience, and they are never attended by
real unconsciousness nor does the facial appearance vary much.
The pupils normally react, and any change of pulse and respiration
is produced by exertion. Professional "fit throwers" and "dummy
chuckers" are less common than formerly, largely because they
find it does not pay; even the tyro ambulance surgeon recognizes
them, and they go to jail and not to the expected hospital.

Special sense defects usually refer to aphonia and deafness, but
these rarely last long and are easily disproved.

(2) Traumasthenia Plus Malingering. — These are the cases pre-
senting some objective neurasthenic or hysteric signs, with many
subjective claims that cannot be legitimately ascribed to them.

I am aware that exaggeration and perhaps even deception are

794 TRAUMATIC SURGERY

part and parcel of hysteria; yet the cases I have in mind are not of a
grave enough sort to develop these as part of their hysteria. Such
a case may show some tremor, instability of muscle and the circula-
tory apparatus, and jierhaps even have a few areas of anesthesia,
and give the history of emotional upsets, and perhaps even an
occasional "hysteric convulsion." At the time of the examination
a host of dissociated subjective claims will be made, but the examina-
tion reveals practically nothing. Most of these patients are natural
hysterics trading on their newly discovered deficiencies and are
virtual malingerers so far as disability is concerned.

CHAPTER XXI

EYE AND EAR TESTS AND STANDARDS

Railway employees and others are often subjected to examina-
tion as to visual and aural capacity, the requisite standards having
been determined and fixed by such representative bodies as the
American Medical Association, the American Ophthalmological
Society, the American Association of Railways Surgeons, and adopted
and put into practice by the American Railway Association and other
large groups of employers.^

The usual requirements are herewith indicated, this standard
being in general use on the largest railway systems.

At the end is attached a form of report that may be used by the
examining surgeon.

RULES

1. The qualifications essential in certain positions must be detemiined by the exam-
inations prescribed by these rules.

2. Application Blank, Form , must be used by candidates for employment

and by those selected for promotion.

3. Candidates for employment or selected for promotion must pass the prescribed
examinations and tests before being permitted to enter, except temporarily, upon the
duties of the position sought.

4. The general mental characteristics and the bearing of the candidate must be
noted on the application blank by the examiner.

5. Re-examination may be ordered at any time by proper authority.

6. Applications will be approved or rejected by proper authority.

PHYSICAL EXAMINATIONS
Visual Qualifications

7. Examinations must develop —

(a) Sufficient acuteness of vision to clearly see the prescribed visible signals.

(b) Ability to clearly distinguish the colors of the prescribed visible signals.

ya. Acuteness of Vision — Requisites

Class A. — Enginemen, Firemen, Conductors, Train Baggagemen, Brakcmcn, and Flagmen

in Road and Yard,

Service

Entrance to service.

Promotion.

Rc-examination of those in the
service.

^%o in one eye and not less
than ^%Q in the other;
tested without glasses.

2%o in one eye and not less
than 2^^Q in the other;
tested without glasses.

2%o in one eye and not less
than '^%Q in the other;
tested without glasses.

* Internal. Jour. Surg., Nov., 1907.

795

790

TRAUMATIC SURGERY

Class B. — Signalmen, Signal Repairmen^ and Telegraphers,

Entrance to service.

Promotion.

Re-examination of those in the
service.

*>io in one eye and not less
in the other;

than

?io

tested without glasses.

Not less than ^%q in one
eye and not less than ^%o
in the other; tested with-
out glasses.

29^0 in one eye and not less
than ^%o in the other;
tested without glasses.

Class C. — Other Employees in the Engine, Train, or Yard Service, Car and Engine In-
spectors, and Bridge and Track Foremen.

Entrance to service.

Promotion.

Re-examination of those in the
service.

Not less than 2 930 in one eye
and not less than ^%o in
the other; tested without
glasses.

Not less than ^%o in one
eye and not less than ^%o
in the other; tested with-
out glasses.

2%o in one eye and not less
less than ^%o in the other;
tested without glasses.

Class D. — Crossing Watchmen.

Entrance to service.

Re-examination of those in the service.

**40 ^vith both eyes open, without glasses.

^%o with both eyes open, without glasses.

In cases of failure of a candidate for re-examination under Class A, or for entrance
to service, promotion, or re-e.xamination under Classes B, C, and D to pass the tests
when examined without glasses and when further expert examination shows that with
jrtASScs the tests can be met satisfactorily, the acceptance of the candidate is optional.

EgnPMENT

I. .V sot of at least two standard cards of Snellen's test letters showing letters of
NnrixHis si/cs, from 20 to 70 inclusive. The letters lo be arranged in different order in
the vX'^rri'Si^oiuling lines of each card.

:. V standard reading test card with matter printed in various type.

;. A test spectacle frame with opaque disk.

Adjunct

rho fv^llowing may be used if desired:

\ >v I v^t test cards showing semaphores in various positions.

Mkthod of Testing — Lettkr Card Test

riavt" the candidate to be examined so that he will not face a strong light; cover one
v^t his V \vs with the opaque disk in the test frame; place one of the cards at a distance
ot \^ tvvt tuMu him in clear light, but not in direct sunlight, and direct him to read the
KiujN vM\ vvjt.ui\ lines as selected by the examiner, including the line marked 20. -V
|H>rtion oi llic ti>t-card may be covered and the candidate required to read the remain-

EYE AND EAR TESTS AND STANDARDS 797

der of the line of letters, or certain letters at each end of the line may be covered and
the candidate required to read the intervening letters. If he can read the letters on
the line marked 20 correctly, substitute another card with a different arrangement of
letters and test in a similar manner. If he reads the letters on the line marked 20 on
both cards correctly, it indicates normal vision. If he cannot read the letters on the
line marked 20, direct him to read the lines above 20 successively until a line is found
which he can read.

Record in fractions the acuteness of vision as determined, the numerator being 20
(the distance at which the card is placed) and the denominator the number on the card
showing the smallest size letters that he had read correctly.

Repeat this test with the other eye and record the results.

Mistakes of not more than three letters on the 20 line, two letters on the 30 line, and
one letter on the 40 line will be considered as a satisfactory reading. Other lines must
be read without error.

Reading Card Test

Direct the candidate to read certain letters or sentences from the standard reading
test card and record the smallest size of print read correctly at the ordinary distance of
from 14 to 18 inches. A portion of the test card may be covered and the candidate
required to read the remainder of the paragraph. The candidates should be able to
read the print in paragraph No. 2 of the standard card to pass the test satisfactorily.
This test should be made without glasses, except at the age or under other conditions
where the use of glasses is permitted.

Fig. 6x1. — Grow "unleamable*' vision test card. Used in U. S. Navy.

To prevent deception, especially where any large group are to be examined the test
card shown in Fig. 611 may be used instead of the well-known Snellen test card.

76. Color Perception — Equipment

One set of Holmgren's colored worsteds, as simplified by Dr. Wm. Thomson, tagged
for reference by lettering A, B, and C and numbering i to 40.

Group A, containing the light green skein A, the similar shades numbered i, 3, 5, 7,
9, II, 13, IS, 17, and 19, and the confusion shades numbered 2, 4, 6, 8, 10, 12, 14, 16, 18,
and 20.

Group B, containing the rose skein B, the similar shades numbered 21, 23, 25, 27,
and 29, and the confusion shades numbered 22, 24, 26, 28, and 30.

Group C, containing the red skein C, the similar shades numbered 31, ss, 35, 37,
and 39, and the confusion shades numbered 32, 34, 36, 38, and 40.

798 TRAUMATIC SURGERY

Adjunct

The following may be used if desired : A lantern showing a number of colored lights
which can be varied in size and intensity.

Method of Testinx — Holmgren Test

Place the whole number of colored worsteds on a table in good, clear daylight. Put
the test skein A at a distance of about 2 feet from the other colors, and ask the candidate
being examined to select from the heap of colors all that look to him like the test skein,
and place them beside it. Have him understand that he is not expected to find an
exact match for the test skein, but that he is to choose all the colors that appear to him
of the same general color as the test skein, both those that are lighter and those that
are darker in shade. If he does not easily understand what is wanted, let the examiner
himself select the colors; then, having returned them to the general heap and mixed
them thoroughly with the rest of the colors, let him call on the candidate being examined
to repeat the selection. This demonstration will not enable a candidate who is defec-
tive in his color perception to select the colors correctly, and he may pick out as looking
to him like the test skein A some greens and also some of the gray or brown confusion
colors, which will app>ear to him of the same general color as the test skein, only vary-
ing from it in shade. Record on the form the numbers on the tags of the colors incor-
rectly selected as being similar to the test skein A, and also note whether the selection
is prompt or hesitating, by writing the letter '*?'* or "H" on the line opposite each of
the names of the colors as printed. Return all the colors to the heap and mix them
together, then place the test skeins B and C successively apart from the rest and have
the candidate being examined select, as before, all the colors that look to him like each
skein, and record the results as for skein A.

No names should be mentioned in connection with any color in the above worsted
tests, which should be based only on a comparison of colors.

If the candidate being examined selects as looking like the green test skein A any of
the reds, or as looking like the rose test skein B any of the greens, he shall be rejected.

If the candidate for employment selects some of the grays or browns as looking like
the green test skein A, or some of the grays, blues, or violets as looking like the rose test
skein B, the candidate shall be rejected. If a candidate for promotion or re-examination
makes such a selection, full report shall be made and left to the oculist for decision.

The selection by the candidate of one of the ** colors of confusion" (even numbers
2 to 20) as matching test skein A indicates color-blindness. The failure to do this, but
a manifest disposition to do so, indicates feeble color perception; making correct selec-
tion to match test skein B, having failed to match test skein A, incomplete color-blind-
ness is indicated. But should he in this test select the purple, the green, and gray
shades also, or one of them, complete green blindness is indicated. The test vdxh skein
C (which is applied only to those who are color-blind as to green or red) should be con-
tinued until the candidate under examination has selected the specimens of or a greater
part of the skeins belonging to this color, or else one of several "colors of confusion"
(even skeins 32 to 40). In this test red blindness is proved by the selections, besides
the red shades, of olive green and dark brown shades of a darker quality than the red
test skein. Green blindness is proved by the selection of similar confusion colors, but
of a quality lighter than the red test skein.

Aural Qualifications
8. Examinations must develop ability to hear distinctly.

EQL^PMENT — Adjunct
The following may be used if desired : A ratchet acoumeter.

EYE AND EAR TESTS AND STANDARDS

799

Method op Testing

Place the candidate at a distance of 20 feet, with one ear toward the examiner; have
him close the ear furthest from the examiner by placing the finger over it, then let him
repeat aloud the words or numbers spoken in a conversational tone by the examiner
and record the distance in feet at which they can be repeated correctly. Have him turn
the other ear toward the examiner and repeat the test.

Candidates for employment will not be accepted unless able to hear ordinary con-
versation the full distance of 20 feet.

No candidate for promotion or re-examination can be considered to have sufficient
acuteness of hearing who is unable to repeat, with his eyes closed, words or numbers
spoken in an ordinary conversational tone of voice at a distance of 10 feet.

9. Re-examinalion for acuteness of vision, color perception, and hearing shall be
made at periods of not less than three years; and after severe illness, injury, or in em-
ployees addicted to alcohol.

10. If upon re-examination for acuteness of vision, color perception, or hearing an
employee who has been at least three years in the ser\ice shall fail to pass the prescribed
tests, if he so desire, he may be accorded a field test under service conditions. If he is
able to pass the field test successfully, and upon the approval, after examination, by
the company's oculist, he may be retained in the service.

We also suggest the adoption of the following application blank, to be known as

Form , for recording all \isual and aural tests, and that all visual and aural tests

be made by regularly appointed oculists.

Form

Railway

Division

Record of Examination of Vision, Color-sense, and Hearing

Name Age

Employed as

Applicant for

Original Examination. Re-examination for

Acuteness

•

OF Vision

Without glasses.

With glasses.

Right
eye.

Left
eye.

Both
eyes.

Right
eye.

Left
eye.

Both
eyes.

Distance at which standard test-type are
read

Smallest line of standard test-type read
correctly

Range op Vision

1
Without glasses. | With glasses.

Right
eye.

Left
eye.

Both
eyes.

Right
'eye.

Left
eye.

Both
[eyes.

Least number of inches at which type 0.5
on test-card are read

8oo

TRAUMATIC SURGERY

Field op Vision
Right eye good bad. | Left eye good.

.bad.

Color Sense
test-skein submitted. number selected to match.

A. — Green.

B. — Rose.

C— Red.

Flag Test.

Lantern Test.

PROMPT.

Remarks.

HESITATING.

Hearing

Right ear.

Left ear.

Watch..
Ordinar

V conversation

inches.

feet.

inches.

feet.

Approved.
Rejected.

Examiner.

When an examination is made of an injured person the following
elements in reference to eyes and ears should be kept in mind.

EYES

Lids. — Open or shut; normal in color or ecchymotic; normal in
size, swollen, or retracted.

Eyeball. — Normal, scarred, squinted, receding or protruding.

Conjunctiva. — Normal, ecchymotic (diffuse, localized, crescentic,
or semilunar) .

Cornea. — Normal, sckrred, irregular, opacities.

Pupil. — Normal, contracted, dilated, action to light and accom-
modation.

Vision. — Fingers counted at i8 inches; fine type read with either,
eye; restriction of visual field.

The main things to detemine are the general appearance of the eye-
ball, the presence or absence of scars or squint, and the response of the
pupils to light and accommodation. Opthalmoscopic examination

EYE AND EAR TESTS AND STANDARDS 8oi

will give valuable evidences of intracranial tension and may be one
of the earliest indications of pressure, as from hemorrhage or edema.

EARS

Externally, — General conformation and signs of injury.

External Canal. — Normal or lacerated; bleeding; serous effusion;
wax; furuncles; neoplasms.

Drum, — Normal, thickened, or retracted; open, scarred, or
inflamed.

Mastoid, — Nomal; ecchymotic; tender; swollen.

Hearing, — To ordinary and whispered voice at varying distances ;
with one ear plugged ; tuning-fork and whistle tests.

Do not fail to examine the nose and throat for possible naso-
pharyngeal sources of aural trouble, as the vast majority of ear defects
originate therein.

A good test for hearing is known as the ^^stethoscope test," and in
making this the end pieces of the stethoscope are placed in the
patient's ears, the other end passing behind his head. The examiner
holds a watch against the "bell" part of the instrument and asks the
patient to tell in which ear the ticking is heard, and then the rubber
tubing is pinched on alternate sides and the answers verified while the
sound is transmitted along one tube only.

Another method is to apparently examine the scalp for tenderness
and block the good ear with the hand or finger, meanwhile keeping up
conversation, and if the patient answers when thus off guard the
injured ear cannot be really much damaged. Catarrhal deafness
from old nasopharyngeal or other causes is quite likely to show
diurnal variations depending on weather and other conditions. In
middle-ear disease from **catarrh," air conduction is better than bone
conduction; but when the deafness is due to auditory nerve damage,
bone is poorer than air conduction. In the former type of deafness,
hearing is best in noisy places and is improved by inflating the drum;
in the latter type, the reverse pertains.

CHAPTER XXII

, X-RAYS; X-RAY BURNS

X-Rays

RoNTGEN, of Wurzberg, in 1895 gave the first practical application
of Crookes' tubes to rnedicine, and since then vast progress has been
made with this valuable diagnostic agent.

It is to be recalled that the rays portray outlines of the denser
tissues and that they are in the truest sense shadow-pictures or
silhouettes, and to that degree capable of distortion and misinterpre-
tation unless every care is taken.

In traumatic surgery the ir-rays are of greatest value in fractures
and dislocations and in the localization of foreign bodies, and to a
lesser extent in various other lesions of bones, joints, and soft parts.

Fluoroscopic examination is not regarded as wholly reliable, and
for that reason is not much used except as an emergency measure or
in connection with an actual x-ray plate.

Radiographic examination or the actual photograph is the method
of choice, and the product is known respectively as a radiograph ^
radiogram^ skiagraph, skiagram, rontgenograph, rofttgenogratn, or,
more commonly than all, as **an a:-ray plate."

Use in Fractures and Dislocations

For the purpose of diagnosis it is extremely valuable, especially
in obscure cases; but it is of even greater value in determining the
outcome of attempts at reduction or setting. When only one series
of plates can be obtained, I am in the habit of advising that the
ir-ray examination be made for the purpose of ascertaining the
accuracy of treatment more than for the accuracy of diagnosis.

Precautions must be taken so that no false shadows are cast, and
for that reason it is always advisable to radiograph the injured and
the uninjured parts on the same plate if possible, making an antero-
posterior and a lateral exposure when feasible. This means that
four images will be obtained, two of the normal and two of the abnor-
mal, each taken from the same angle at the same time by the same
operator and the same machine. If this is not done, and if the tube

802

rC-RAYS ; X-RAY BURNS 803

is not directly at right angles to the object and the latter as close
as possible to the plate, all sorts of distortions are possible.

Some of these errors were long ago brought out by Lewis G. Cole
in his article "Skiagraphic Errors; their Causes, Dangers and Preven-
tion."^ Among other experiments, he so radiographed his own
wrist that the plate could be said to indicate a healed CoUes' fracture,
although he never had such an injury.

The plates are better indications of the actual situation than
prints made from them, and neither plates nor prints should be
chemically or otherwise altered in attempts to '^touch up" or "tone"
them, unless some predetermined reason so demands.

Aside from the mere taking of the radiographs, the question of
interpreting what they show is an art in itself, and should not be
imdertaken lightly by a novice except in perfectly apparent cases.
This is especially true in determining the relation of certain irregu-
larities on long bones or suture lines and pacchionian bodies in the
skull. The interpretation of the radiograms of the deeper joints,
like the shoulder and hip, may be very difficult, and the condition of
the spinal column and the sacro-iliac joint may baffle the most expert.

Radiology has become a definite specialty, and is of greatest
value when the radiologist is a trained physician who has opportunity
to see and study his cases clinically as well as in there-ray laboratory.

The X'Tciy findings should bear some definite relationship to the
clinical findings, and one should corroborate the other.

Epiphyseal separations are often confusing, and I have seen
plates introduced in court to indicate fractures when, in reality, the
disjunction was an unjoined epiphysis and diaphysis, not recognized
by an inexperienced physician. In cases like this and many others a
comparative view of the uninjured part would clear up the difficulty.

Medicolegally it is to be remembered that one plate of a part may
show little or much, and that deductions from it may be quite untrue
imless a plate of the uninjured portion is taken in the same axis.
As already stated, two plates respectively of the injured and un-
injured side afford the best evidence, just as a full-face photograph
may show one type of features and a side or profile view an altogether
different aspect.

The ir-ray appearance following a fracture may be such that good
fimction would seem most unlikely; but this is by no means true, as
there is often a wide variation between it-ray findings and actual
fimctional or clinical results. For this reason the exhibition of

* New York and Philadelphia Med. Jour., March 26 and April 2 and 9, 1904.

8o4 TRAUMATIC SURGERY

ic-ray plates may be quite misleading, if not actually prejudidal,
unless accompanied by the statement that they nearly always make
the part look worse than it acts. In many instances a doctor is sued
for malpractice because the x-ray appearance indicates much irregu-
larity and perhaps even malalignment, even in the presence of an
excellent cosmetic and a perfect functional recovery. For this and
other reasons a patient should be forewarned that the radiogram may
often show much distortion that will not in the least affect the actual
outcome. The same facts should be made known to the court and
jury in malpractice and negligence suits.

Duration of callus is variable, and the less the original displace-
ment and the more exact the setting, the less the callus. Large bones,
like the shaft of the femur, may give x-ray evidences of callus for
years, and this may also be true of smaller bones in which union has
been malaligned; the clavicle is an example of this last group. Frac-
tures of the ribs may fail to show callus even after three months if
there has been merely a "crack" without actual separation or over-
lapping of the fragments.

Prints are not so good exhibits as plates, and the latter should

always be free of "fogging'^ or other imperfections. The use of

films instead of plates v/ill prove valuable if they can be further

perfected, and the Coolidge tubes are much in advance over those

formerly in use.

Localization of Foreign Bodies

Foreign bodies, like needles and other materials, in the hand and
elsewhere are best located by stereoscopic plates. In the same man-
ner bullets are located. Various methods are used to locate bodies by
criss-crossing the skin over the affected part with fine wires or layers
of bismuth or solutions of silver nitrate. Other more or less practical
means are also employed for the same purpose, of which the principle
of triangulation may be mentioned. In the location of shell and
other fragments, the Radiologists at our Evacuation Hospital were
so uniformly accurate in fluoroscopic localization that failure to find
the missile was looked upon as the fault of the surgeon.

X-Ray Burns

These are now practically restricted to x-ray laboratory w^orkers,
and are rare even among members of this group who have observed the
precautions adopted in the past seven years particularly. Patients
are now rarely burned except when repeated exposure becomes neces-
sary for therapeutic purposes. The exposure for the average x-ray

:r-RAY; x-ray burns 805

work incident to traumatic surgery is so short that bums practically
never occur unless the patient has some peculiar idiosyncrasy.

Varieties — Three grades are described, as in ordinary heat bums,
and all are characterized by late onset, and the symptoms may not
appear for as long as three weeks, and it is quite the rule for no
**reaction" to occur for several days after exposure.

First degree forms cause redness, burning, itching, and some
swelling of the part and later the "skin peels oflf." It is closely allied
to sunburn and is, in e£Fect, a radio-dermatitis.

Secofid degree forms are aggravations of the preceding, with the
formation of blebs in addition. When these are broken the involved
part is red and raw and may become eczematous.

Third degree forms involve the deeper layers and cause eschars
and ulcers, and often areas of sloughing and gangrene. This is an
exceedingly serious situation, and large areas of subcutaneous slough-
ing may occur with much pain and systemic prostration. The process
may lead to burrowing and sinus formation from a mixed infection.

Chronic burns were common among x-xdcy workers some years
ago, but they are fortunately rare now. In this city I know several
pioneers in the field who bear the marks of their early work in the
form of atrophied, scarred and crooked fingers, scaly hands, and
brittle or ragged nails. Some of the victims develop warty growths on
the fingers somewhat allied to epithelioma, and at times the condition
is reawakened so actively that they must cease work for a period.
This form of irritation is very insidious in onset and many months or
even years may elapse before ulceration follows the initial dermatitis.
Carcinoma has occasionally appeared in such a chronically inflamed
area. Sterilization may be produced in either sex by these continued
or repeated exposures.

Treatment — The first and second degree forms are treated like
other burns. The ulcerative third degree form is exceedingly hard
to manage, and the part may have to be exsected and skin-grafted
before healing occurs. In some instances amputation may be
required.

Of late, radium has been used with much success in some of
these cases, and recently I saw one radiologist who was apparently
completely relieved of numerous warty growths by this agency.
Carbon-dioxide snow is also said to yield good results.^

Needless to say, the essential of treatment is to avoid contact
with the rays, and this has a prophylactic as well as curative value.

* Jour, de Radiologie et d^EUctrologiCf Paris, May, 1919, 3, No. 5, p. 217.

CHAPTER XXIII

MEDICOLEGAL PHASES

Accident cases are very frequent sources of litigation, and the
attending or examining physician may be called upon to give evidence
before, during, or even after such a case has been submitted to a
court or jury.

Some injured patients may come under the Workmen's Compensa-
tion Law now operative in nearly all states, and others are covered
by the policies of accident, casualty, or insurance companies.

Because of the possibility of legal procedure it is prudent for the
attending physician to make careful notes of every accident case
coming to his notice, so that a complete history may be available
when needed. Such a history should contain a full account of the
manner of the accident and the inamediate and intervening objective
and subjective symptoms and treatment. The presence or absence
of initial unconsciousness should be noted with great care, and an
attempt must be made to determine whether such an unconscious
period was due to syncope, fright, shock, bleeding, concussion, or
other forms of head injury. In this latter connection it may not be
amiss to repeat that an essential feature of concussion is immediate
unconsciousness ordinarily associated with vomiting.

In obtaining a history of suspected bone or joint injury it is quite
important to inquire whether or not any manipulation of the injured
part had been made by the preceding physicians in attendance.
This is particularly valuable, for example, in determining such a
condition as dislocation of the shoulder, because the majority of such
injuries and many others may fall into the care of the family or attend-
ing doctor after initial treatment by an ambulance surgeon or another
physician summoned in the emergency. If the patient is able to
describe the maneuvers made by this first doctor in setting a dis-
location or fracture much valuable information may thus be supplied,
and the diagnosis will be finally corroborated by the existing findings.

In making the diagnosis too much attention must not be given to
subjective complaints unless they have an objective basis, for it is to be
remembered that a real hurt or injury always has some objective mani-
festation, and that many genuine subjective complaints can be made
objective by suitable examination tests. Of these subjective com-

806

MEDICOLEGAL PHASES 807

plaintS; pain is the commonest ; but long-continued pain shows in the
countenance, and the affected parts are automatically spared and
favored by every move or action of the patient. Areas of pain on
pressure should be relocated with accuracy, and thus tender spots on
the spine previously indicated by ink markings should remain tender
each time they are touched in genuine cases.

Objective findings should be noted in detail, and when possible
dimensions should be recorded. A diagram is a great help, and, how-
ever crude, it serves best to revisualize the conditions after a lapse of
time.

Disused parts waste, and for that reason atrophy is a most im-
portant finding in connection with injuries of limbs, flabbiness and
changes of skin texture are correlated findings.

The history should also contain a record of the treatment and
notes as to the progress of the patient from visit to visit. In cases
of fracture and allied injuries, tracings or prints from rc-ray plates
are very valuable. Laboratory findings are also added, notably
blood, urine, and sputum analyses.

The history should contain a note as to the period of total and
partial disability and a statement as to the period abed and indoors.

The period of total disability means the time during which the
patient was wholly incapacitated and entirely unable to perform any
regular or substituted duties.

The period of partial disability means the time during which the
patient could perform some or all of the regular duties. Obviously
this disability period depends primarily upon the extent of the injury,
but also to a large degree upon the occupation, age, station in life,
and general mental and physical make-up of the individual.

For example, a laborer with a fractured ankle might have a period
of total disability of ten or more weeks because his work required him
to use both legs, but a bookkeeper with the same injury might be able
to do some work within a few hours, and thus would have practically
no period of total disability. But if the injury was a fracture of the
wrist, the situation might be reversed iji these two preceding occupa-
tions, for then the laborer could be put to work as a flagman, but the
bookkeeper could do little or nothing until his fingers were free to
write. ,

The age, station in life, physique, and mentality of patients may
also be factors, and, as a general rule, the higher the station in life
and the mentality, the less complete and prolonged will be the dis-
ability.

8o8 TRAUMATIC SURGERY

DOCUMENTS Relating to the Condition of Patients

The attending doctor is often asked to furnish a written statement
as to the extent of a given injury and the probable period of disa-
bility. This may be for presentation to an employer, accident or
insurance company, benefit organization, compensation commission,
or judge or court. In many instances printed forms are furnished,
and the careful physician will preserve a duplicate of these or any
other documents furnished.

When no specified form is requested, the language of the cer-
tificate is usually about as follows:

This is to certify that has been under

(Name of patient)

my care from to date and his injuries consist of

(Date of first visit)

He will be totally disabled about

and partially disabled about

(Signed) M. D.

(Date) (Address)

This form of report may be amplified if desired, and if for any
reason a serious outcome is to be feared that fact should be stated.

Many of the printed forms furnished by accident and insurance
companies are needlessly prolix and call for separate answers to the
same general line of questioning. But despite this the physician
should aim to give the desired information as completely and prompt-
ly as possible, so that his patient may not subsequently suffer from
delay or financial loss.

Occasionally it may be difl&cult to answer printed questions
such as this, '^Is the condition of the assured, your patient, wholly
and solely due to this accident independent of any other previous or
subsequent accident or illness?"

If the patient has an old cardionephritis, or has developed delir-
ium tremens, or has syphilis or varicose veins, and any or many of
these complicate the original injury, it may be quite hard to answer
such a query categorically^. In such an event the physician should
make whatever explanatory note he desires, always having in mind
absolute truthfulness and fairness, with no intent to become a party
to any deception, but with every desire to protect his patient in any
legitimate manner.

MEDICOLEGAL PHASES 809

COMPENSATION LAW CASES

In New York State the law allows employees sixty days medical
care and attention if they are injured during the course of their
employment. The operation of the medical part of this law is simi-
lar in many of the numerous states now enforcing it, and a typical
form of report is shown on page 8io, this being the blank used in
New York. The reverse of the form has space for diagrams.

Many employers will provide light or special work for employees
during a period of convalescence, and the attending physician should
take advantage of any such opportunity because it will allow the
employee to get a higher money allowance and also keep his mind and
body occupied.

Malingering and exaggeration will prevail to some extent within
and without the terms of this law, but repeated, full, and complete
examinations will diminish cases of this sort. When the physician
is in doubt as to the genuineness of symptoms in such a case he should
ask himself, ''What usually and ordinarily occurs when an injury of
that sort happens and there is no legal liability?" It is almost a
maxim that subjective complaints are exceedingly rare unless the
injury is being made an item of gain, financial or otherwise. Hurts
received in sports, or those due to the carelessness or ill fortune of the
recipient, are usually recovered from when objective evidences dis-
appear, but identical hurts, which are being charged to the financial
account of another, are rarely wholly relieved until adjustment is
made.

As physicians, we all of us know the usual and accepted average
disability of the daily run of injuries; but if for any reason this aver-
age disability period is prolonged there must be some reason for it.
Such a valid reason, for example, may be (a) undiscovered associated
injuries; (b) the treatment; (c) constitutional frailties that impair
reparative powers; (d) complications. In the absence of these
demonstrable or objective reasons there can only be non-demonstra-
ble or subjective reasons that are in the largest number of cases
wholly mental, and thus either imaginary, exaggerated, or feigned.
But the physician must not regard all subjective symptoms as wholly
feigned or exaggerated, for many of them are the legitmate and accu-
rate expression of objective manifestations; however, if the subjective
complaints have had no reasonable objective basis, and if they are
varied, dissociated, and have no anatomic or surgical relationship to
the original condition, then they must be regarded with suspicion and
labeled accordingly.

8lO TRAUMATIC SURGERY

BURBAU OF
WORKMBN'S COlCPSNSlkTION

STATE INDUSTRIAL COMMISSION

MVntON OP CtAIHS

WOb n »^^— ^j^j.^— »— — Ji« I •

of . - .

ATTENDINQ PHYS)ClAl>rS
REPORT

h4 ■■■ pronpttr t» Mm

1. MMtof tojuradpmoo Addri

2. Navaof wployw.— , Addntt.

9. Date Of MddMt <Qi ** M. Wm fint tiMtant randertd by you? Whaa).

4. If not, by wtKM7 AUims-_ ^

5. Wbo «nt«tt« ywr ««~«'^? -

•, Was iajnied pcfson raaoved to bi»pltal> Naat if Hospital

AOamu .

T. Chra an accunto daacflptloo of tlw natan aad extant of tiie tajaiy .

t. WiU ttaa li^ury raautt lo («) a peraaacot ddact? It ao. what}.

It 4lMMDty . Mch M loM of *kal««r #■!« e< taon. Mc MMt to accwiMty
(*)*fadal or hMd dlrfgnwaiit

9. It aakyloa!! praaeot? If so. vhara and to what dacna}.

10. Previotts to UiU acddcot was tbero loss of uaa of hand, am, foot, kc or ayt>.

Oat yMtf aMMT to a»KtacJ

tl. Oa what data do yoa tbiak tlw tnlurad can rasuaa """fc*

12. Stata, to patteot's own words, how acddaot occaned

AraAiafa nt Ysaf.

Dated at tblin day of , m.

IMPORTANT.-Exact point of amputatloa mad oCbtr p«rm«Miit partial dtoabilWM MUST BE KNOWN BY THE CO«M»
SION In order to detcrpiliic conpcoHtloii dua tojurad accordlag la panMtBtnt partial iflaabHir aekadale In tba law
DESCRIBE AND MARK DUQRAMS ACCURATELY.

Very baport«at cliaC all ^uaatloiia ba aaawand»

Fig. 6i2.

MEDICOLEGAL PHASES 8ll

Elsewhere I have ventured to classify some of these commoner
subjective ailments with suggestions as to the means of testing their
reality. (See pages 790 et seq.)

Accident Insurance and Casualty Company Cases

These are generally of two sorts, one in which the patient holds
an *' accident" or "health" policy (or a combination '* accident and
health" policy) ; the other in which a policy covers the holder in case
of accident to others. In each of these classes the basis of the pro-
cedure is the extent of the physical damage as certified to by the
physician.

Many of these "accident" and "health" policies cover only cer-
tain specified manifestations of injury or disease, and the physician is
often besought to make his diagnosis fit the policy rather than the
pathojogy of the case in hand.

Various printed forms are provided to be filled out, and they are
all of a type similar to the following:

certificate of attending physician.

Am htfit under frMrfRwnt bg mt for.

I Hfby Ciiify, thai 1/.

Gftar dlMMi. ■tala lU prwto* Mtoi*.)

/ was first called jo attmd him on tks dag of 191 , and continued

to attend kirn at various times untU the dag of 191

The sgmptoms and pkgsieal signs which ejcisted during his disabilitg were. -.v--!.. ..^c-^..-^--\

The treiUment consisted of- ^..^ »... .... . -, - ^ -, p

Surgical operation, if ang.

(If Skumi BKawtuted Higlcal opnailoa. gt«« 4ato aad ckaractir at t

TOTAL DISABILITY
/ Fufihar Cartify, that, soMg in eonsequenee of the illness above described, and independentlg of all other causes, he
was totallg disabled, that is, whoUg and eontinuouslg preoented from performing ang and all duties pertaining to his occupation

ahmm stated, during the space of ..weehs and dags, from 191 , at o'cloch

K to and including. 191 , at jo'cloch .. . M.

PARTIAL DISABILITY.

/ Fiir^0f Cwtffy, thai, soMg in aonsequene* of the illness above described, and independentlg of all other causes, he
mu partiaOg dimihled, thai is, eontinuouslg praoented from performing important duties pertaining to his occupation, so that he

sustained a loss of at least one-ha^ of his huiness time each dag, during the space of wcehs and dags,

fHm 191 , ai e'eUKk M. to and including 191 „ at o'cloch K.

Bis present condition at this date is , _• ,^-. , ^^^ _., ^^-v^*..

Dated ^ - .._ 191

/ a«« graduated bg „ . z.

Vmi seen seeme mm.'i

tt tha gear U

Pig. 613.

8l2 TRAUMATIC SURGERY

If for any reason the insurance carrier is dissatisfied with the
medical information first furnished, a further request is then made
to the physician for additional information, and this request may be
repeated several times, and the physician usually finds that the
terms of the policy require him to answer in the interests of the
patient. In case of death these insurance carriers require a medical
certificate as a part of their "proofs of claim," and this is generaUy
on another printed form.

The physician will save the patient and himself considerable
annoyance and delay if the first certificate is answered at great
length.

In cases of this sort no claim of professional secrecy is available
because the patient has already disclosed the nature of the injury or
disease; in addition, the certificate is made at the request of the
patient or a representative, and further, the terms of the policy allow
the insurer to obtain such information.

In the majority of cases of injury there is little room for contro-
versy in answering some such interrogatory as "Were the injuries
solely and wholly due to the accident in question?" However, if
the patient had, for example, a stroke of apoplexy, and in falling
struck his head and received a scalp wound or a fractured skull, it
may be rather difficult to answer a question of that sort, and equally
difficult at first to say whether the paralysis came from the apoplexy
or the fractured skull. The differentiation here should not be diffi-
cult after a few days, and in that interval the prudent physician will
indicate on the certificate any existing element of doubt.

In the event of death the terms of the policy often allow the
insurer to obtain an autopsy by a physician of their own selection,
and this is usually performed in the presence of the attending physi-
cian. The exact cause of death may or may not be agreed upon; if
not, the case may then be carried to court.

Aside from apoplexy, there are numerous other medical conditions
that are sometimes sought to be charged up to an accident; of these
may be mentioned cardionephritic and arterial disease, and liver,
lung, stomach, and intestinal conditions, all of which are classically
regarded and recognized as being due to intrinsic and not extrinsic
causes. Better class physicians do not, for instance, ascribe to any
isolated or single act of violence such an improbable condition as
endocarditis, yet I have known of several cases in which a blow on
the chest wall, with or without fractured ribs, has been the ascribed
cause of cardiac disease. Any such opinion as this, subscribed and

MEDICOLEGAL PHASES 813

sworn to by an attending physician, is but an invitation to refuse
the claim and submit the patient to examination by a physician of
recognized standing.

Furthermore, the attending physician must be on guard and not
subscribe to any unusual or irregular sequence of symptoms merely
because the patient wishes to come within the prescribed limits of
some policy; such stretches of medicine and surgery do no credit to
the profession, nor will such tactics often profit the insured, and they
are quite sure to strain the scruples of all concerned.

Relation of Injury to Disease

At times the physician will be in doubt as to what relationship,
if any, exists between an ancient disease and a recent injury.

For example, a patient is known to have locomotor ataxia and, on
occasions, treatment has been given for this condition and the essen-
tial cause is known to be syphilis, the practically universal producing
factor in this widespread lesion. At times this patient, like most of
his kind, has periods of accession and remission, but nevertheless the
ailment is progressing* Perhaps the patient has not been examined
for some time, and may not be under more or less active treatment.
An accident occurs in which this patient falls or receives a blow, the
injury sustained being perhaps inherently trivial and often the out-
come of the patient's ataxia. But because of the previous poor
physical state of the patient due to the old ailment, there is precipi-
tated a period of accession of symptoms and the patient may even
be rendered wholly ataxic for a period. The question then arises as
to the responsibility of the accident for "lighting up" or "aggravat-
ing" a condition known to be of itself independently progressive.

The same situation may arise in certain cases of arteriosclerosis
and its results, and in nephritis, endocarditis, tuberculosis, diabetes,
prostatic disease, and a large number of chronic and naturally pro-
gressive diseases.

It is a known fact that serious injury is not well borne by a physi-
que already undermined by organic disease, and thus many accidents
can be justly accused of adding an unfavorable element that may
provoke an access of symptoms; hence, in a case of the type under
discussion the nature and extent of the injury would be very impor-
tant, as obviously the more serious the injury the greater the proba-
bility of affecting the disease.

The type, extent, and duration of the old lesion is also important,
and in a general way it may be asserted that the accident will or will

8 14 TRAUMATIC SURGERY

not be a contributory cause in direct proportion to the extent of the
injury and the duration of the disease. In other words, the injury
will rarely be the primary or initiating cause, but may be a secondary
or contributing cause of an accession of symptoms that may aggravate
a previously existing condition. Of itself and independently the acci-
dent and the attendant injuries would not of themselves produce the
existing symptoms, but combined with the old and perhaps more or
less latent disease the clinical picture is easily explained and accounted
for.

How much responsibility is to be attached to the disease and how
much to the accident is, therefore, one of degree, and this is to be
determined by the elements named above. We, however, must not
lose sight of the well-known fact of experience that organic disease
may be apparently latent and yet be actively progressing indepen-
dent of any extrinsic causes, accidents or others. It is an every-day
medical occurrence that cases of supposedly checked or quiescent
arteriosclerosis, endocarditis, nephritis, diabetes, gastric, intestinal,
and other troubles may suddenly and without any apparent or
ascribable cause result even in death.

Summated, the whole matter resolves itself into the clinical fact
that may patients with organic disease are potentially poor risks,
and may be at any time, from more or less definitely determinable
causes, precipitated into an acceR<;ion of symptoms.

The relation of injury to a recurrence of a former ailment is also
important, and this arises often in diseases of the nervous system,
pelvic disturbances, and other more or less non-organic lesions that
are normally characterized by a tendency to recur from various
provocative causes. The neuroses (hysteria and neurasthenia) are
in this group, as are also various tics, habit spasms, phobias, tremors,
and even some mental disturbances.

Here, again, main reliance is to be placed on the nature and ex-
tent of the injury and the present manifestations as compared with
the previous history of the recurring ailment. Special attention
should be given to the duration and manifestations of the original
condition, the interval in which there has been freedom from symp-
toms, and the medical verification, if any, of the claimed cessation
or cure.

As many of these cases are rich in subjective and poor in objective
symptoms, it will require more than the mere assertion of the patient
to determine the exact importance of any accident as the sole factor
in the alleged recurrence. The physician will, therefore, give careful

MEDICOLEGAL PHASES 815

scrutiny to this type of case and guard his opinion if the previous
history is based wholly on the present narration of the patient. This
caution is especially necessary in any case of alleged recurrence of
female pelvic disorders, such as uterine displacement or actual
adnexal inilammation *'due to a blow on the abdomen." Recur-
rent hernia also falls under suspicion, and likewise hernia appearing
in postoperative scars.

The physician must in a case of this sort be in a position to answer
for himself the self-propounded question, '* Independent of the
accident, would the present conditions appear sooner or later as part
of the ordinary progress of the lesion?''

Criminal Cases

The physician is brought into contact with this group usually
because of suicide, homicide, poisoning, infanticide, or abortion cases.
The doctor's appearance may be required by the judge, district
attorney, or coroner, and in this class of case it is very important
that careful notes are available respecting every phase of the issue.
Just after returning from the war I operated on a moribund woman
at U. S. Army General Hospital No. 39. She had multiple com-
pound comminuted fractures of the skull and ten scalp wounds.
One of the important issues at the subsequent trial was the question
of immediate unconsciousness bearing on her ability to recognize the
assailant. Notes dictated at the operating table became the basis
of my affidavit and testimony.

When a physician is called upon to attend a case of suspected
criminal abortion, it is a wise procedure to have a colleague in
consultation, so that no criminal responsibility or connivance by any
chance may be falsely placed. If another physician is unavailable, a
written statement should be obtained from the patient to the effect
that the symptoms began before the arrival of the present physician
and that the latter had hitherto not been in attendance. Such a
statement should be obtained in the presence of, and signed by, com-
petent witnesses. It is the height of folly for a physician to operate
upon any such case without some precautions of this nature, and it is
equally foolish to operate with any attempt at secrecy or without
the assistance of a colleague, nurse, or attendant who is familiar with
the proceedings undertaken. When feasible, patients of this class
should be cared for in a hospital, because the publicity incident to
such surroundings effectively precludes any charge of connivance or
complicity.

8l6 TRAUMATIC SURGERY

Abortionists exist in all places, and their work is, as a rule, grossly
unsurgical and almost brutally cruel, and patients treated by them
are presumptively infected, if not more seriously damaged. I once
operated upon a woman who was sent to the hospital with a section
of intestine hanging out of the vagina. This proved to be large in-
testine which had been pulled through a hole in the posterior vaginal
wall where some instrument had been poked, doubtless with the idea
that the uterus was being entered. Through this hole the loop of
intestine had been dragged and cut oflf , evidently on the assumption
that it was placental or other membrane, and, in addition, the mes-
entery of the sigmoid had been curetted so energetically that the
blood-supply was entirely abolished. When the abdomen was opened
the entire colon was gangrenous, and it was excised and a cecosig-
moidostomy performed. The patient lived only a short time.

Physical Examination of the Claimant

When a claim is made for damages due to an accident, a physical
examination is usually requested by the interests being held legally
responsible for the injuries. The attending physician is the proper
person to arrange this, and such an examination should be made when
feasible at the home of the patient or a doctor 's office.

Railways and insurance companies have a regular printed form
for such cases, and this is commonly known as the "surgeon's report."
A typical form is shown on pages 8i8, 819.

At the time of the examination the examining physician first
obtains the general history of the case from the patient, and then the
medical history from the attending physician, and later proceeds
with the examination, classifying the findings under regional head-
ings. Any examination of this sort should be full and complete to be
of value in rendering on opinion as to the nature of the injury and the
probable duration in terms of total and partial disability, and also
the extent of any deformity. An examination of the heart and
blood-vessels should be included, and the main reflexes at least should
be tested. It is important to look for hernia, flat-feet, varicose veins,
and other deformities or disabilities, so that their relation, if any, to
the injury may be determined. In the examination of women the
pelvic organs should not be overlooked, and visceroptosis and kidney
displacement must also receive attention. This latter condition,
however, as hitherto indicated, is found almost solely in thin persons,
and, indeed, a fat or protuberant abdominal wall precludes the
possibility of palpating with accuracy a movable kidney. In women

MEDICOLEGAL PHASES 817

at or about the climacteric period, or in those who have had the
menopause induced by operation or disease, it is quite important to
determine what relation this may bear to any symptoms of a nervous
or subjective type The condition of the thyroid gland should be
observed, especially if tachycardia is present.

It is unethical and unwise for an examining physician to discuss
his findings with the patient or to criticize the attending physician
either for improper diagnosis or treatment; and, in fact, the examiner
must disclose his findings, opinions, and criticisms only to the interest
engaging him, unless some arrangement to the contrary has been
previously agreed upon.

In some cases about to be presented to a court and jury, the
lawyer for the patient may be represented by a physician who has
examined the patient only for the purposes of testifying, and it is un-
fortunate for all concerned that the physician often selected for this
purpose is usually better qualified from a legal than medical stand-
point; and, indeed, the capacity of this sort of doctor is all too often
based on court rather than clinical experience. I know several
physicians of this stamp who glibly qualify as '^experts" in practi-
cally any branch of medicine and surgery, and yet their knowledge
is gained almost wholly as examiners and not as clinicians. Such
a doctor may have had little or no surgical or operative training, and
yet his opinion may be entirely different from that of the attending
or family physician, who speaks of what he actually knows and has
observed, and not of what he has superficially culled from some text-
book. I have heard doctors of this sort eloquently testify, for ex-
ample, as to brain and intra-abdominal injuries, and yet they have
scarcely seen the inside of a skull or abdomen since student days.
Men of this grade would not be selected as family advisers or con-
sultants by the patient, attending physician, or the attorney; but,
nevertheless, their opinion is regarded as good enough for court and
jury purposes. This practice is so flagrant that many physicians
and surgeons of the best type hesitate to appear in any capacity in
damage-suit cases, and if they treat the patient at all it is only on the
proviso that they will not be called upon to appear in court.

On occasions the judge will appoint a physician to conduct an
examination, the fee to be paid usually by the defendant, but some-
times by both parties. Such a "physician appointed by the court''
is served with a "court order,'' and the examination is then made by
the selected doctor, with or without a preliminary hearing before a
court-appointed referee. At this hearing the court physician is at

8i8

TRAUMATIC SURGERY

liberty to ask the patient any question that will elicit a complete past
and present history, and then the actual physical examination is
conducted in private. The questions asked and the replies given at
"the hearing before the referee" form a part of the court records, and
are usually read to the judge and jury at the trial, when the court
physician may or may not testify. The latter immediately makes a
report in writing to the court or judge, and these findings become a

SURGEON'S REPORT.

Case of.

.Employed by.

OcQupatloa,.
Residence,.-

Age,.

.Married or Slngter.

Date of Accident,.

»9

Name of Attending Physician,

. P.O. Address.

OIAONOSI9.

•

NISTQRV

PATIENTS

ACCQUNT

ACetOKNT.

-- —

. - — _- . . —

IMMCOIATK

crrccT8

ACCIOKNT.

Fig. 614.

OONDITION

AND

PNVSICAL

KXAMINA-

TION

Fig. 615.

RKSULTS
DATE.

rnoQNOsis.

RKMAIIKS.

Examined at.

~ tljls.

Signed,

ulay of

Examining Surfcon.

»I9

Fig. 616.

819

820 TRAUMATIC SURGERY

part of the records in the case and may often with propriety be am-
plified for either party in interest to whom the bill is rendered, and
from whom a fee can be collected for court attendance or expert
testimony. Such a formal report is usually worded about as shown
below.

In some instances this report should be sworn to before a notary
public or commissioner of deeds, especially when the examination is
made at a place distant from the scene of trial. Unless specifically
directed, the court physician is not called upon to express in his report
any statement as to the future outcome of a given case, as that is
regarded as expert testimony. Ordinarily one of the ps^rties to the
litigation will summon the court physician as a witness, and he will
then have a right to render a separate bill for the added services, in
effect becoming an expert witness.

To the Honorable Justice of the Court.

County of

Dear Sir:

Pursuant to your appointment I examined on at

(Dau.)

{Place.) {Name of person examined)

that he (or she) had sustained the following ,

. {Here name findings.)

The remaining evidences are as folio v\'s:

(Here name existing signs.)

and found

Respectfully submitted,
M. D.

The object of having the examination by such a "court ap-
pointee" is to allow the judge to make an impartial selection of the
physician, but the latter thereby does not have any judicial functions
conferred, nor is his opinion necessarily any more sacred or valuable
than that of any other physician, and the party in interest paying for
it has a perfect right to interview this court appointee before making
him a witness.

Less often, during the course of a trial, both sides may ask the
judge to appoint a physician to make an examination, and agree to
have the appointee appear on the witness stand without making any
report to the court or either party in interest; in such an event the

MEDICOLEGAL PHASES 82 1

physician is in duty bound not to disclose his findings or opinion
until he testifies. Under these circumstances this physician is usu-
ally questioned first by the judge, and thereafter the lawyer for
either side may ask further questions if desired.

In giving testimony, the physician js ordinarily first called upon
to state his medical qualifications, and is then asked when and where
he saw the patient and what he found upon examination. In naming
his findings he must state the objective manifestations first, and then
. may or may not be allowed to relate the subjective complaints as they
were stated by the patient. At all times the witness must bear in
mind that he is talking to laymen who have little or no knowledge
of technical terms, and if it becomes necessary to use a technicality,
some simple explanation of the term should be given. The doctor
should be fair, hpnest, and unbiased and do his utmost to present the
facts as justly as possible. He must not weary the auditors with
needless detail of no great importance, nor should he exploit his own
skill or cleverness. He should be as willing to answer questions for
one side as the other, and he must not indulge in sarcasm, repartee, or
temper, for any such exhibition is undignified and will lend no value
to his testimony. At times he may think his questioner does not
know what he is talking about, and may even be tempted to tell him
so; but the physician must not scold or lecture the lawyer, however
great the temptation or provocation. Incidentally, it would be
foolish, because the questioner would soon place the. witness in a very
uncomfortable and embarrassing frame of mind.

At all times the doctor must remember that he comes to court to
fairly state what he saw and what he did in connection with the
case at issue, and having done this he will be asked to give a state-
ment as to the probable outcome of the injuries. At times the phy-
sidan will be asked by the lawyer to answer "yes" or "no" to some
question that does not properly permit of a categoric reply. In such
a case the witness may respond, "I cannot answer that question by
'yes' or 'no.' " Under such circumstances the witness will then usu-
ally be allowed to answer the question in his own way; or, he may
answer it "yes" or "no," and then state "I wish to qualify that by
saying. ..."

In testifying the doctor "will be allowed to look at his records
to refresh his recollection," but he will not be permitted to read any
extended account of the case, and, in fact, the written record is to be
used only when the memory of the matter in hand requires to be
refreshed.

822 TRAUMATIC SURGERY

The doctor may have hesitancy about disclosing some features
of the patient's history or present injury ; in such an event, the judge
will usually direct the witness to answer fully as to any medical fact
that might have a bearing upon the issue.

The question of "professional secrecy" is generally settled by the
bringing of the suit, as the legal papers in the case usually indicate
in more or less detail the actual nature of the physical ailments.
The courts also hold that the plaintiff has no inherent right to call
only the doctor desired or the one looked upon as most likely to give
favorable testimony; but if one physician testifies as to the medical
condition at issue, then any other physician may also be called upon,
because the "plaintiff by calling one doctor has opened the door for
the testimony of others . . ."and" . . . the seal of prof essional
secrecy cannot be made at once a sword and shield. ..."

This means that a dishonest litigant cannot, under the guise of
"professional secrecy," seal the lips of a former physician who per-
haps was in attendance for the same ailment or injury that is now
being testified to as being of recent origin by another physician ig-
norant of the original medical history.

After the physician has testified as to his findings, he is often
asked a hypothetical question that seeks to embody all the essential
facts in the case. • Such a question usually begins with the words
"Assuming that on such and such a date, . . ." and then follows an
account of the manner of the accident, the symptoms, and the testi-
mony as to medical findings. The ending of the question is usually
" . . . now assuming the facts in the hypothetical question to
be true, can you state with reasonable certainty whether or not an
accident of the tj^e described would or would not be a competent
producing cause for the conditions you found?" To this question
the physician replies, "I can state." Then the lawyer says, "Would
it?" and the physician then states, "It would" or "It would not,"
depending upon his belief in the matter. The next question then is
usually, "Assuming the same state of facts related in the hypothet-
ical question, can you state with reasonable certainty whether or not
the injury is or is not of a permanent and lasting nature?" The
doctor replies to this, "I can state." The lawyer then asks, "Is it,
or is it not permanent, with reasonable certainty?*' To this the
physician replies, "It is" or "It is not."

The doctor must answer the hypothetical 'question based only on
the facts in that question, disregarding anything and everything
else he knows or has heard of the case. The question is often the

MEDICOLEGAL PHASES 823

summation of the evidence in the language of the attorney, and the
answer must be predicated only on the premises laid down in the
question regardless of the physician's views in the matter. If,
however, the premises assumed are medically incomplete, wrong,
contradictory, inconsistent, or perhaps absurd, the witness can
with propriety state that he is unable to answer the question and
may be given an opportunity to state why he cannot give an
answer.

All such questions usually contain the premises that the litigant
was (i) perfectly well before the accident; that (2) the accident
occurred in the way related; that (3) certain symptoms followed and
now exist, that (4) there has been no other intervening accident or
illness. Assuming these foregoing to be true, the answer, of course,
is inevitable that the accident caused the present conditions; but the
vice and inherent flaw of such a question is that the witness is asked
to assume as true what he knows to be false; hence, the careful and
prudent witness should reply that he cannot answer a question of
that sort because some of the premises are medically impossible,
improbable, contradictory, or inconsistent. The lawyers would
legally denominate many of these questions as "irrelevant and
incompetent," and certainly the same objections to them hold
good from a medical standpoint.

The witness will not be allowed to speculate, guess, or surmise
as to the probable outcome of a case; the opinion must be based not
upon absolute, but upon reasonable certainty. This in many instances
is practically the equivalent of stating what usually and ordinarily
happens under a given set of circumstances. Similarly, the physician
is not permitted to answer any hypothetical question calling for an
opinion as to what '^ could happen'' under a certain set of conditions,
but the answer must be based on what ^^ would happen."

The witness must exercise great care in expressing an opinion as
to future permanency, especially if only a short period has intervened
since the accident, and he also must have in mind the benefits that
sometimes occur from a change of treatment, the care of a specialist,
a new environment, and the cessation of litigation. This caution
is esi>ecially necessary when the ssonptoms are, in the main, subjec-
tive rather than objective.

Cases that have a medicolegal bearing are very prone to breed
more or less conscious exaggeration and malingering, and the experi-
enced physician will soon find that claimants can be sorted into four
groups, presenting:

824 TRAUMATIC SURGERY

(i) Actual injury with demonstrable symptoms — the realUy.

(2) Actual injury with exaggerated symptoms — the exaggerator.

(3) Little or no injury' with objective and subjective symptoms
ascribable to other causes — the malingerer.

(4) Little or no injury with feigned objective and subjective
symptom — the fakir.

In other words:

Group one consists of wholly genuine cases.

Group two consists of partly genuine cases.

Group three consists of partly fraudulent cases.

Group four consists of wholly fraudulent cases.
Of these, groups one, two, and three are the most common in liti-
gated cases, and it is noteworthy that subjective complaints are
always most marked in patients treated out of hospitals, and also in
those having relatively trivial injuries. A hospital stay does not usu-
ally afford much opportunity to develop suggested symptoms, and
the association with patients who are actually hurt often" has a
salutary effect.

Since the Workmen's Compensation Law went into effect in this
State (July i, 1914) I have been impressed by the freedom from
exaggerated claims, and ascribe this to the fixed payment rates for
definite injuries and to the non-interference of a certain type of physi-
cian and lawyer. During the first twenty-six months of the opera-
tion of this law many thousands of employees were more or less
injured in the various activities of the railways with which I formerly
was connected. Of this number, over 90 per cent, required one
treatment only, and thus the very great proportion might have pro-
longed disability by asserting subjective symptoms if the proper
motives existed. Of the more seriously hurt, comparatively few
exaggerated to any great extent, and I recall but few whom we re-
garded as out-and-out fakirs. I know of but few cases in which
marked traumasthenic symptoms developed.

By contrast with an identical group of injuries occurring under
similar circumstances in men of a like station in life, this freedom
from exaggeration and the neuroses is certainly very remarkable, and
seems to give added basis for the belief that the traumatic neuroses
are made for and not bom of the patient.

CORONER'S AND MEDICAL EXAMINER'S CASES

The law requires the physician to report to the coroner, or other
designated official, any death occurring under unusual or suspicious

MEDICOLEGAL PHASES 825

circumstances, or any case of sudden death and those for which no
adequate reason is apparent. All deaths from criminal sources or
causes are also reportable.

The attending physician in such cases should make careful notes
of his initial findings and all the circumstances surrounding the
case, so that this information may be a matter of record and not of
recollection. .

If the physician has reason to believe a crime has been committed,
he must exercise every precaution so that the cause of justice may not
suffer by any act of omission or commission on his part.

When : ailed upon to make affidavit or give testimony the physi-
cian must state only what he knows and has observed, and not what he
thinks or has been told. Human life and happiness may depend on
what he declares, and, therefore, he should " tell the truth, the whole
truth, and nothing but the truth,'' leaving out any theory, specula-
tion, prejudice, or preconception that he thinks fits the conditions
better than the actual known facts.

' Homicide and Assault Cases

In these the physician will always be an important witness, and,
indeed, the measure of sentence may be directly dependent upon his
testimony.

Careful records must be made of every detail of the occurrence,
and these written notes, made at the time, will be much less subject to
dispute at the trial than any recollection, however accurate it may
appear to be.

If a bullet has been recovered, the physician must carefully pre-
serve it, making written record of any marks on it due to instrumenta-
tion or search. The importance of this will be apparent when it is
recalled that in many shooting cases the caliber and general appear-
ance of a bullet may have an important bearing in fixing the guilt or
locating the weapon.

In cases of suspected poisoning the odor of the breath and vomitus
may be very important, and all excreta should be preserved in a
clean glass-stoppered receptacle suitably sealed and marked for
identification.

Death traceable to a fractured skull sometimes causes confusion
if a fall has followed or has been occasioned by the original violence.
Cases in which an apoplectic stroke produced a fall, which later
broke the skull, also come into this group. Most of these cases are
cleared up by autopsy, and if a central and not a cortical hemorrhage

. L fill or attendant injury.

i i

« .

i I

I I

.«

i • :•

i i-

I I
i

CHAPTER XXIV

STANDARDIZED FIRST AID METHODS IN ACCIDENTS

Emergency treatment is very important in determining the out-
come of many injuries, and where groups of employees are engaged in
more or less hazardous occupations, it is humane and prudent to
provide means by which the ordinary accidents can be treated by
laymen until medical aid is obtainable.

Fig. 617. — First-aid jar as recommended by the National Affiliated Safety Organi-
zations. The jar is made of heavy glass and can be further protected by a metal
case into which it fits snugly.

"First aid men" should be selected and drilled in emergency
methods in all places where large groups of employees are working.
They should be specially trained in the methods of manual artificial

S^S. TRAI7MATIC SDRGERY

respiration, because any apparatus devised for this purpose fa often
difficult to assemble and much valuable time is lost awaiting its
arrival.

The appended standardized methods for first aid and phydcal
examinations were devised by a group of physicians^ who are \-ir-
tually s]iLciali>tA in the treatment of industrial accidents, and it is

S. O. jar openiHl.

noteworthy that the procedures originuUy adopted six years ago hs
been little changed as a result of subsequent experience. The author
is a member of this group and subscribes heartily to the following
first aid rules, and approves also of the first-aid kit shown in Figs,
617-619. It is understood that these directions are given for the
purposes of first aid only, and that laymen alone are supposed
them; hence the language and procedures are simple but c
' Conference Board of Phy&iduis in Indnstiy.

l3^^^^

STANDARDIZED FIRST AID METHODS IN AfCTDENTS

829

. Trcatmcnl of Injuria xnhick do not Blr<^:

(Such as contusEoDS and sprams.)

(a) Use several layers of sterile gauze o

(t) Apply bandage; use nothing else.

. Treatmetl of Injuries in whkli ihc Skin is

(a) Drop into the wound a 3 per cei

freely, but do not use it on the dressing,
(fc) Apply a sterile Rauze compress andi bandage,
(c) In CB-ie of excessive bleeding proceed as under
HemorrhaRe."

placed directly on the injured

e the injured part.

Broken:

t. alcoholic iodine solution.

"Treatment of

Fic. 619.— Contents of the N. A. S. O.

See p. 831 for contents.

3. Treaiatnt of HemoTrhagc:

(a) Place the patient at rest and elevate the injured part.

(6) Place a pad of sterile gauze over the bleeding spot, large enough so that
pressure can be made above, over and beloiv the wound,

{c) If bleeding does not stop apply a tourniquet between the wound and the
heart, using for this purpose a belt, shoe string, cord 01 suspender if
regular toumiqucC is not available.

4. Treaimenl of Nose Blading:

(o) Maintain the patient in an upright position and elevate the arms.

(b) Gel the patient to breathe gently through the mouih.
Caption; Do not attempt to blow the nose.

J. Trealntenl of Foreign Substances LaaUed in Ike Body:

Do not attempt to dig out any foreign bodies, no matter how smaU, from any

part of the body. (See below for eye injuries and suffocation.)
f>. TrealtnenI of Burns, Scalds, tie.:

(a) Do not open blisters.

(£) Apply vaseline and 3 per cent, bicarbonate of soda (baking soda).

830 TRAUMATIC SURGERY

7. Treaiment 0} Acid Burns:

(a) Get the patient under a shower bath as soon as possible and thoroughly
^ush the parts to remove all further damage from the acid.

(6) After the acid has been thoroughly washed off, dry and apply 3 per cent,
bicarbonate of soda (baking soda) and vaseline.

8. Treatment of Alkaline Bums:

(Such as from Lime, Plaster, Potash and Ammonia.) ,

(a) Get the patient under the shower bath as soon as possible and thoroughly

flush the parts to remove all further damage from the alkali.
(6) After the alkali has been thoroughly washed off, flood the part with vine-
gar or milk and apply 3 per cent, bicarbonate of soda (baking soda) and
vaseline,
(c) Cover wound with plenty of sterile gauze and bandag^e lightly.

9. Treatment of Electrical Burns:

(a) Apply 3 per cent, bicarbonate of soda (baking soda) and vaseline.
(6) Cover wound with plenty of sterile gauze and bandage lightly.

10. Treatment of Unconscious Patients (any cause) :

(a) Lay patient on the belly with the face turned to one side.
{h) Loosen all tight clothing,
(c) Do not give anything to drink.
{d) Call a doctor as soon as possible.

{e) If breathing has stopped, proceed with artificial respiration as described
under prone pressure method of resuscitation.

11. Treatment of Eye Injuries:

(a) No attempt should be made to remove a foreign body stuck in the eye.

{b) In case of foreign body in or injury to the eye, apply clean gauze and
bandages.

{d) In alkaline bums (from lime, plaster, potash or ammonia) wash out with
boric acid solution or vinegar.

12. Treatment for Suffocation and Electric Shock:

Proceed with prone pressure method for artificial respiration, adopted by the
Commission on Resuscitation and described on attached chart.

13. Resuscitation from Electric Shock:

Proceed with prone pressure method for artificial respiration, adopted by the
Commission on Resuscitation and described on attached chart.

STANDARDIZED FIRST-AID ROOM

A first-aid room should be not less than 9 ft. by 12 ft. in size,
should be well lighted and ventilated, should have running water —
hot as well as cold if possible — and should be provided with toilet
facilities in or near the first-aid room. The light should be partic-
ularly good at the point where first-aid service is to be rendered,
where an adjustable electric lamp would be very serviceable and
convenient. Aside from ordinary good ventilation, it is desirable
to arrange for a large inflow of air by fans or otherwise, to stimulate

4TANDABDIZED FIKST AID METHODS IN ACCIDENTS 83 1

jiLs when feeling faint. The ceiling and walls should be light
jolor and frequently cleansed.

The room should contain the following niinimum equipment:
hctiil combination dressing table with drawers to hold instru-
, mints and dressings;
faelii-l ohair with head and arm rest;
petal stool built in combination with metal waste can;
null wooden or metal examination table with pads, with ends
i hinged to drop down;

retcher, of the army type (canvas stretched over two round wood
poles) or of metal type;
mall instrument sterilizer arranged for electric, gas, alcohol or
kerosene burner;

^ dozen utensils, such as arm and foot basins, 3 or 4 quart ordinary
basins, 2 quart dipper, bed pan, etc.;
I portable first-aid outfit;
Appropriate instruments, including a razor;
Dressings; splints; drugs,

■ CONTENTS FIRST AID KIT (Figs. 617-619)
(Adopted by the National Affiliated Safety Organizations.)
I Tourniquet
I Pair scissors
1 Pair tweezers
I Triangular sling
I Wire gauze splint
II Assorted saCety pins
1 Teaspoon
I Metal cup
I Medicine glass
3 Medicine droppers
3 Paper drinking cups
First aid record cards
r i-oz. bottle castor oil
a 3-0Z. tubes bum ointment
1 a-oz. bottle 3 per cent, alcoholic iodine
I a-oz. bottle white wine vinegar
I a-oz. bottle 4 per cent, aqueous boric acid
I l-oz. bottle aromatic spirits of ammonia
1 i-oz. bottle Jamaica ginger (or substitute)
I piece Sannel 14 by 36
I roll absorbent cotton (1.5 oz.)
I 3 in. by 10 yds. gauze bandage

1 1 in. by to yds. gauze bandage

2 T in. by ro yds. gauze bandage

I spool r in. by 5 yds. adbedve plaster
6 sealed pkgs. 6 in. by 36 in. sterile gauze

832 TRAUMATIC SURGERY

STANDARDIZED METHOD OF PHYSICAL EXAMINATION

Preliminary to employment it is often necessary to learn the physique of emi^yees
for 'their own protection, the protection of others or the protection of property. For
example, ^tive phthisis or syphilis would make an applicant a menace to himself or
others; poor eyesight might endanger the employee himself, his associates or property.
Many employees are re-examined at stated intervals. This is especially needed
among engineers or others to whom are entrusted the safety of numbers of people.

Classification i. For persons physically fit for any employment;

Classification 2. For persons who have no physical defect, but because of under
size, under weight or other conditions, constitute a class of persons of a physically
lower grade than Classification i ;

Classification 3. For persons only fit for certain employment on account of phys-
ical defects, who may be engaged for special work only upon specific approval of the
examining physician;

Classification 4. For persons physically unfit for any employment.

In terms of percentage the relative value of these classifications is as follows:

Classification i 90 to 100 per cent.

Classification 2 75 to 90 per cent.

Classification 3 So to 75 per cent.

Classification 4 Under 50 per cent.

It is understood that in many cases and for many purposes a
partial examination will only be necessary, and that, barring special
cases, the examination would need to consume only an average of
from 6 to 10 minutes per person. It is also understood that the pro-
cedure may be added to or subtracted from as the i>eculiar require-
ments of each industry may make advisable in the judgment of
the examining physician.

1. Special Senses

(a) Eye

(b) Ear

(d) Speech

2. Chest

(a) Heart

(b) Lungs

3. Abdomen

(a) Hernia
(6) Tumors

(d) Kidneys
(c) Stomach
(/) Intestines
(g) Spleen

4. Rectum

5. Genitals

6. Limbs

(j) Muscles

(6) Nerves

STANDARDIZED FIRST ALD METHODS IN ACCIDENTS 833

7. Feet and toes

(a) Deformities

(b) Flat feet

8. Hand and fingers, right and left

(a) Deformities

(b) Grip

9. Nervous system

(a) Muscle reflex

(b) Superficial reflex

(d) Sclerosis

(e) Tremors
(/) Fits

(g) Tics

(h) Prior diseases and accidents
10. Mouth

(a) Teeth

(b) Tongue and tonsils

SPECIAL SENSES

Examination should include:

Eyes :

Visual Acuity: Right Eye Left Eye

Visual acuity of 20/40 or less in both eyes should in-
dicate rejection for further investigation.

Visual acuity of less than 20/30 in any eye and less than
20/200 in other should indicate rejection.

A great disparity in vision of the two eyes should in-
dicate need for further investigation.

Reading Test: Right Eye Left Eye

Size of type

Distance

Field of Vision: Right Eye Left Eye

Normal or limited

Loss of more than one-third of field of vision of both
eyes, or loss of two-thirds of field of either eye should
indicate rejection.

Color Sense: Ability to match colors and call them cor-
rectly.

Pupils: Reaction.

Retina and Fields by ophthalmoscope.

834 TRAUMATIC SURGERY

Ears:

Drums: Right Ear Left Ear

Appearance

Hearing power

By watch

By conversation

(Whispered voice at 20 feet away.)
Hearing power of less than one-half normal should in-
dicate rejection or specified employment.

Nose and Throat :

Septum.

Turbinates.

Smell.

Mouth breathing.

Speech :

Knowledge of English:

Stutter. . . . Stammer. . . . Lisp. . . . Impediment

Mouth:

No. of teeth gone

Any loose teeth

Condition of remaining teeth

Condition of gums

Chest and Abdomen :

Examination should include the findings as determined by in-
spection, palpation, percussion and auscultation, having special
reference to condition of heart and lungs, liver, kidneys, spleen,
intestines and tumors.

Hernia :

Liguinal, complete, incomplete, oblique, direct.

Size of external ring.

Impulse, present or absent.

Femoral hernia.

Ventral hernia.

Umbilical hernia.

Postoperative.

Abdominal wall.
Recttim should be examined for hemorrhoids, fissure, fistula,

protrusions.
Genitals should be examined for conformation, varicocele and con-
dition of testicles, scars.

STANDARDIZED FIRST AID METHODS IN ACCIDENTS

835

Limbs should be examined for conformation, deformities, contrac-
tures, varicose veins.

Feet and toes should be examined for flat feet, varicose veins.

Hands and fingers, right and left, should be examined for de-
formities and grip.

ANATOUCAL STAMP

'••^ .••.*fV.<

Ua OASSmUTION :

L— F«f ptnmt phptnlr Ik Im m$ _^,_

4.— F«f pwMM pkfiinlf hAi iir a^f

IfMS

TmAi I

I L sHmt. Valtl.

l.„ L J DlMMt«il.

„ I TWmI

• 7CS4S2I

• 7 < S 4 S 2 1

Sri.

1....

i..

k..

ih..

S«id

vu. .

i 2 3 4 S < 7 a

I 2 2 4 S • 7 a

L. CAr t. I.,

I Mmm «i Etm: I L ..

T«

i Uf t

t fMlt.

I TMiR

••^■••«<h**>«Bai

(MiA TmA 0 »kH alMliit X vhw 4mi|«4s + «M OMt^i = '^m faW)

CUMffKATlCM

Fig. 620.

Nervous system should be examined for knee-jerk, foot-jerk
(Romberg and Babinski signs, fits, tremors, tics).

Blood pressure should be taken and blood analysis and urinalysis
made at the discretion of the examining physician.

836

TRAUMATIC SURGERY

Veins and arteries should be examined as to their condition.
Neck should be examined for glands, goiter, pulsating vessels.
Spine and Joints. — Appearance and action should be noted.
Height, weight and age should be recorded.

As for examination of female employees, it is thought best to
provide a physician of their own sex if this should be demanded by
such employees.

The findings can be quickly noted on a filing card of the type
indicated herewith (Fig. 620).

WAR DEMONSTRATION HOSPITAL MODIFICATION (ROCKEFELLER

INSTITUTE) FOR DAKIN'S SOLUTION

•

To make about 40 liters, place in a 20 liter container the amount
of bleaching powder indicated in the appended table in accordance
with the titration of the bleaching powder, and mix well with 5 liters
of tap water. Shake vigorously and allow to stand for several hours,
or over night.

Table for /\pproximately 40 Liters of Dakin's Solution

Active chlorine in Bleaching powder in
bleaching powder ! 5 liters of water

Sodium carbonate in 5 liters
of water

Anhydrous 1 Monohydrated I Crystallme

Per cent.

Grams

1
800 1
600 1
500

i
Grams

600
420

335

Grams

20-26

28-34
36-42

700
490
380

1600

1 140

1 900

Dissolve the designated amounts of sodium carbonate in another
5 liters of tap water. Pour the solution of sodium carbonate into
the bottle containing the bleaching powder which has stood several
hours, shake well, and allow the precipitated calcium carbonate to
settle. Test for complete precipitation of calcium by adding a few
drops of carbonate solution to a few c.c. of the clear supernatant
liquid. After half an hour, siphon off the supernatant liquid through
a double filter paper. This solution is a strongly alkaline hypochlo-
rite solution of about quadruple strength, which will keep for several
mouths. It must be neutralized and diluted for use as needed, in
the following manner:

STANDARDIZED FIRST AID METHODS IN ACCIDENTS 837

Titrate a measured sample (20 or 50 c.c.) with 10 per cent, hy-
drochloric acid (or N/2 boric acid) to absence of color with solid
phenolphthalein. Add more powdered phenolphthalein to make
sure the decolorization was due to neutralization rather than to
bleaching; then calculate the amount of acid required for the volume
** V" of filtrate it is desired to neutralize.

For example: If 20 c.c. of filtrate required 2 c.c. of 10 per cent,
hydrochloric acid, 100 c.c. would require 10 c.c, or 8 liters of filtrate
would require 800 c.c. of acid. This is to be added to the 8 liters
slowly and with constant agitation. If boric acid is used, calculate
as indicated in method '*A'' above.

To this solution add the same volume " V of 6.25 per cent, solu-
tion of sodium bicarbonate, or the equivalent amount of sodium
bicarbonate. (In the above example this would equal 8 liters of
solution or 500 grams of sodium bicarbonate.)

Test a sample for alkalinity, as directed above, with both pow-
dered and alcoholic phenolphthalein.

Titrate a 10 c.c. sample with N/io thiosulphate, as indicated
above. Use 10 c.c. of iodide solution and 5-6 c.c. of acetic acid in
titrating this concentrated hj'pochlorite solution.

Dilute the solution with tap water and verify the concentration
by titrating a 10 c.c. sample.

INDEX

Abdomen, anatomy, 737
examination of, standardized method,

834
injuries of, 638

stab wounds, 30

wounds of, internal, with external
wound, 642
without external wound, 641
Abdominal cavity, bullet wounds, treat-
ment, 28
contents, injuries, 641
hydrocele, 657
wall, brush bums, 640
bullet wounds, 642
contusions, 638

treatment, 639
injuries of, 638

non-penetrating, 638
treatment, 642
muscles, ruptured, 640, 641
sprains, 640
stab wounds, 30, 642
wounds of, 639
Abducens nerve, involvement, in head

injury, 566
Abduction, voluntary, 482
Abortion, 731

after-treatment, 734
causes, 732

differential diagnosis, 734
frequency, 731
relation to trauma, 732
symptoms, 733
treatment, 734
varieties, 731
Abrasions, 17, 21
Abscess, 38, 39
bone, 493
Brodie, 494, 495

cerebral, after injuries of head, 558
collar-button, 86, 92
of hand, 108
treatment, 93
deep-seated, method of opening, 43
epidural, after injuries of head, 557
of brain, after injuries of head, 558

complicating fracture of skull, 304
of breast, method of incising, 44

sites of pus, 45
of dorsal subaponeurotic space, treat-
ment, 108
of fascial space of hand, 94
of hypo thenar space, 86, 93
treatment, 109

Abscess of septum complicating fracture
of nose, 315
of subaponeurotic space, treatment,

108
of thenar space, 86, 93

treatment, 108
palmar, middle, treatment of, 108
retropharyngeal, method of incising,

shirt -stud, 86
treatment, 92, 93

subdural, after injuries of head, 557

subepithelial, 86

subperiosteal, 493

web-space, of hand, 108
Accessory nerve, spinal, injury, 673
Accident, first aid methods in, standard-
ized, 827

insurance cases, 81 1
Acetabulum, fractures of, 408
Achilles tendon, bursitis of, 163

rupture of, 152
Achillodynia, 506

Acid burns, firet-aid treatment, 8^0
Acousticus nerve, involvement, m head

injury, 566
Actinomycosis, 81

diagnosis, 82

prognosis, 82

symptoms, 81

treatment, 82
Adam's operation in Dupuytren's con-
tracture, 515
Adductor tendons of thigh, rupture,

154
Adhesive plaster strapping for coapting

wound, 19
for sternoclavicular dislocation of

shoulder, 203
of knee, 143

of sacro-iliac region, 149
of wrist, 145
Aeroplane fracture, ^47
Aid, lirst, in accidents, standardized

methods, 827
Air, compressed, injuries due to, 719
Alcoholic wet brain, 304
Alcoholism in fracture of skull, 294
Alkaline bums, fijrst-aid treatment, 830
AUis* method of reducing anterior dis-
location of hip, 240
dislocation of hip, 240
Aluminum splint for fractures of thumb,
402

839

840

INDEX

Amaurosis, 565
American disease, 760
Ampere, definition, 708
Amputation, indications for, in infected
wounds, 51

of lower extremity, preferable sites, 269

of upper extremity, preferable sites, 268
Anastomosis of nerves, 667
Andrews* operation in hydrocele of

tunica vaginalis, 658
Anesthesia areas in hysteria, 775

glove, in hysteria, 776

in fractures, 258

stocking, in hysteria, 776

zones in hysteria, 775
Aneurysm, 688

arteriovenous, 61, 62
treatment, 689, 691

cirsoid, 689

complicadng wounds, 61

congenital, 689

embolic, 689

false, 61

Matas' operation for, 691

pathologic, 689

traumatic, 689

true, 688

varicose, 689
Aneurysma spurum, 689

verum, 688
Aneur>'smal varix, 689
Ankle bursitis, 163

dislocation of, 243
treatment, 244

fracture of, 399

sprain, 137
diagnosis, 142

stiff, rubber-band exerciser for, 264

tailor's, 163
Ankle-joint, righc, blood-supply in and

around, 128
Ankylosis, bony, of elbow, Murphy's
method of arthroplasty for, 176-
180
of hip, Murphy's method of arthro-
plasty for, 180-184
of knee, ^lurphy's method of arthro-
plasty for, 185-188
Anosmia, 565

Antalgic spinal distortion, 148
Anteflexion of uterus, 751
Ante version of uterus, 747
Anthrax, 78

cutaneous, 79

diagnosis, 79

edematous, 79

intestinal, 79

pulmonary, 79

symptoms, 79

treatment, 79
Antitoxin, tetanus, 74
Apathetic shock, 114
Apoplexy, cerebral, 549, 555

Charcot's artery of, 555

in fractures of skull, 294

late, trauatimc, 556

Apoplexy, meningeal, 549
pulmonary, 630
spinal, 591
Appendicitis, traumatic, 735
Arm, glass, 134

lawn tennis, 134
Arterial catheterization, 687
Arteries, examination of, standardized
methods, 836
injury of, 686
Arteriovenous aneurysm, 61, 62, 689

treatment, 691
Arthritis, 172
acute, 173

treatment, 174
chronic, 173

treatment, 175
course, 174
hysteric, 776
prognosis, 174
purulent, 173

treatment, 175
septic, 173

treatment, 175
symptoms, 173
treatment, 174
Arthroplasty of elbow for bony ankylosis.
Murphy's method, 176-180
of hip for bony ankylosis. Murphy's

method, 180-184
of knee for bony ankylosis. Murphy's
method, 185-188
Articular fractures, 272

of lower end of tibia, 483
Artificial respiration in dro^^Tiing, 728
Schafer method, 729
Sylvester method, 729
Asch splints for nose fractures, 314
Asphyxia, traumatic, complicating

fracture of ribs, 333
Aspirating cup following incision for

breast abscess, 45
Aspiration and injection method in
septic arthritis, 176
of fluid in synovitis of knee, 169
Assault cases, medicolegal phases, 825
Association fields of brain, 546
Astasis-abasia, in hysteria, 775
Astragalus, fractures of, 483

treatment, 485
Auditory area of brain, 545
nerve, injury, 671

involvement, in head injury, 566
Autoplastic method of Miller and Konig

in nead injuries, 563
Avulsion, 25

disarticulation, 25, 27
of limb from socket, 27
of scalp, 25

B/VBEs' tubercles, 76
Bacelli's treatment of tetanus, 75
Bacillus aerogcnes capsulatus ana6ro-
bicus of Welch, 82
infection, 82
anthracis, 79

INDEX

841

Bacillus, mallei, 80
perfringens, 82
tetani, 71

Back, bent, 147
lame, 148
psLin in, 148
sprain of, 146
treatment, 147

Bacteremia, 39

Bacteria counting in Dakin-Carrel treat-
ment, 60

Bacterins, mixed, in wound infection, 46

Bandage, Bier's, in lymphangitis of hand,

non-slip, in ankle sprain, 140, 141

of extremities to conserve blood-supply
in severe hemorrhage, 23

plaster-of-Paris, in fractures, 259
Barks of shin, 21, 22
Barton's fracture, 395

reversed, 395
Basal ganglia, lesions, 547
Baseball fmger, 503 v
Bed -so res complicating fractures of femur,
422
of neck of femur,

in spinal cord lesions, 585, 619
Bell's palsy, 566, 669
Bends, 720

Bennett's fracture, 399
Bent back, 147
Biceps tendons, rupture, 154
Bier's bandage in lymphangitis of

hand, 95
Big toe bursitis, 163
Bigelow's method of reducing dislocation

of hip, 239
Bipp in infected wounds of joints, 134

m osteomyelitis, 497
Birth, premature, 731
Black eye, iii
Bladder, contusion of, treatment, 652

foreign bodies in, 526

involvement in fractures of pelvis, 404
Blake- Keller yi ring splint, 430

traction and suspension splint, 429
Blebs in fractures, 253

treatment, 257, 258
Bleeding, nose, first-aid treatment, 829
Blister, blood, no

Blocking nerves in crushing wounds, 23
Blood blister, no

pressure, examination of, standardized
method, 835
in fractures of skull, 293

transfusion of, in shock, 117
Blood-supply in and around joints,

119-129
Blood-vessels, injuries of, 660, 686
Bloody tap, 540
Boils of hand, 90
treatment, 92
Bone abscess, 493

felons, 87

furunculosis, 493

tuberculosis of, 492]

Bone-pressure in fractures of skull, 293
Bones, diseases of, 491
Bony ankylosis of elbow. Murphy's
method of arthroplasty for,
176-180
of hip. Murphy's method of arthro-
plasty for, 180-184
of knee. Murphy's method of arthro-
plasty for, 185-188
defects complicating fractures of skull,

397
Brachial plexus, injury, 674
Brain, abscess of, after injuries of head,

558
complicating fractures of skull, 304

areas, localization, 540
association fields of, 546
auditory area, 545
caudate nuclei, lesions of, 547
compression of, 534
causes, 534
Cushing's subtemporal decompres-
sion method in, 538
differential diagnosis, 537
first stage, 537
fourth stage, 537
lumbar puncture. in, 539
second stage, 537

stage of acme of manifest compres-
sion, 537
of compensation, 537
of manifest beginning compression,

537
of paralysis, 537

symptoms, 536

third stage, 537

treatment, 538

varieties, 535

venesection in, 540
concussion of, 531

determining elements, 535

diagnosis, 533

treatment, 532
contusion of, 533

by contrecoup, 534

treatment, 534
convolutions of, 542
cortex of, 540
cortical centers of, 543

portion, 540
functionating, 544
fissures of, 541, 542
frontal lobes of, 546
gustatory area of, 546
gyri of, 542
hemorrhage of, 549

hernia of, complicating fractures of
skull, 306

following head injury, 564
infection of, after injuries of head,

558
internal capsule, lesions of, 547
laceraition of, 533
lenticular nuclei, lesions of, 547
motor area, 544
motor cortex, 544

842

INDEX

Brain, olfactory area of, 546

optic thalamus, lesions of, 547

pars opercula of, 544

railroad, 757

second frontal convolution of, 544

sensory area of, 545

silent areas of, 546

speech area of. 546

subcortical area, involvement of, effect,
548

sulci of, 541, 542

visual area of, 545
word center of, 546

writing center of, 546
Breast, abscess of, method of incising,

sites of pus, 45

contusions of,

female, injury of, 626

male, injury of, 628
Broca's convolution, 546
Brodie's abscess, 494, 495

joints, 776
Bronchi, foreign bodies in, 520
treatment, 521

injury of, 633
Brown-S6quard paralysis in hematomyelia,

593
Bruises, no

Brush bum, 17, 21

of abdominal wall, 640

Bullet fractures, 270

debridement in, 271

treatment, 271

wounds, 27

of abdominal cavity, treatment, 28

of joints, treatment, 29

of skull, treatment, 28

of spine, 621

of thoracic cavity, treatment, 28

symptoms, 27

treatment, 28

Bump on head, no

Bunion, 163

Bums, 700

bmsh, 17, 2 1

of abdominal wall, 640

first degree, 700, 701

first-aid treatment, 829

acid, 830

alkaline, 830

electrical, 830

fourth degree, 700

from electricity, 713

from x-raj'S, 804

treatment, 805

varieties, 805

second degree, 700, 702

symptoms, 700

third degree, 700, 702

treatment, 702

varieties, 700

Bursa, contents of, operative steps in

removal, 160-162

infected, 163

inflammation of, 155

Bursa, of knee, 157
Bursitis, 155

ankle, 163

big toe, 163

calcaneal, 163

heel, 159

hip, 163

of Achilles tendon, 163

olecranon, 157

postcalcaneal, 506

prepatellar, 156

subacromial, 157
treatment of, 159

treatment, 156

Cabot splint, 464
Caisson disease, 719
cerebral t>'pe, 721
spinal t>'pe, 720
symptoms, 720
treatment, 721
Calcaneal bursitis, 163
Calcaneo-astragaloid dislocation, 245
Calcancum, fractures of, 485
Callus, bony, 251

cortical, 251

ensheathing, 251

false, 252

permanent, 251

provisional, 251

temporary, 251
Camptocormia, 147, 775
Camptorachis, 148

Carbolic acid injection in tetanus, 75
Carbon monoxid poisoning, 723
Carbuncle of hand, 86, 90, 91
treatment, 92

treatment, 92
Carpal bones, fractures, 397

dislocation, 220
Carrel-Dakin tcchnic in osteomyelitis,

497
treatment of empyema, 61
of infected wounds, 52-61
bacteria counting, 60
materials used, 56
Cartilage, costal, fracture of, 334
loose, 189

semilunar, of knee, displacements, 189
slipping, 189

recurrent, treatment of, 193
treatment, 192
Casts, plaster, in fractures, 260
split circular, in fractures, 260
window, in fractures, 261
Casualty company cases, 811
Cataphylaxis, 84
Catheterization, arterial, 687
Cauda equina, 577
Caudate nuclei, lesions, 547
Causalgia, 686
Caw-hand, 680
Cecum, displacement of, 755
Cellulitis, 38, 39

erysipelas and, differentiation, 39'.
mild, 47

INDEX

843

Cellulitis, moderate, 47
Central hemorrhage, 549
Cephalic tetanus, 72
Cerebellar hysteria, 775
Cerebellum, 540

lesions of, 547
Cerebral abscess after injuries of head, 558

apoplexy, 549, 555

embolism, 688

hemorrhage, 549
fractures of skull, 293
diagnosis, 294

hernia after head injuries, 504

localization, 540

topography, 540
Cerebrum, 540, 541
Charcot's artery of apoplexy, 555

joint, 166
Chau£feur's fracture, 393

symptoms and treatment, 395
Chest, anatomy of, 623

bullet wounds of, 625

contents, injury of, 628

contusions of, 624

examination of, standardized method,

834
injuries of, 62^

extrathoraac, 624
intrathoracic, 628
muscles of, rupture, 625
stab wounds, 30
wall, injuries of, 624
wounds of, 625
Chiene's method of finding fissure of

Rolando, 541
Chilblain, 706, 707

Choked disk in compression of brain, 537
Chokes, 720
Cigarette drain, 45
Circumflex nerve, injury of, 675
Cirsoid aneurysm, 689
Citrated blood method of transfusion

in shock, 117
Claim for damages, physical examination

of claimant, medicolegal phases, 816
Clamps for fractures, 277
Clavicle, anatomy and landmarks, 316
dislocations of, 202
prognosis, 204
symptoms, 203
treatment, 203
fracture of, 316
causes, 316

Couteaud*s position in, 322
Mayor's scarf sling in, 322
Moorhead's plaster-of- Paris abduc-
tion method in, 323
results, 324

Say re dressing in, 320]
symptoms, 317
treatment, 325
varieties, 317
Clavus hystericus, 776
Clicking patella, 165
Clonic convulsions in hysteria, 779
Coal-gas, 725

Coal-gas, poisoning from, 725
Coaptation of wounds, 20
Coat-sleeve sling, 256
Coccyx, dislocation of, 232

causes, 233

symptoms, 234

treatment, 235

varieties, 234
Codivilla-Steinmann nail extension
method in fractures of femur, 433, 435
Collapse, 113

Collar-bone, dislocation of, 202
fracture of, 316. See also Clavicle,

fraclure of.
Collar-button abscess, 86

treatments, 92, 93

of hand, 108
Colles' fracture, ^82

after-treatment, 392

causes, 383

modified, 383

Moore's dressing and sling for, 392

results, 393

reversed, 383

silver fork deformity in, 383

symptoms, 383

treatment, 385

varieties, 383
Colon, displacement of, 755
Color test, Holmgren, 798
Coma, hysteric, 779
Commotio cerebri, 531

thoraci, 628
Compensation law cases, 809
Compressed air, injuries due to, 719
Compression of brain, 534. See also

Brainy compression of.
Concealed hemorrhage, 115
Concussion of brain, 531

diagnosis, 533

treatment, 532

spinal, 595, 757
Congelations, 706
Congenital aneurj'sm, 689
Contraction, Dupuytren*s, 507
Contracture, 62

of Volkmann in fractures of radius, 381

treatment, 62
Contused wound, 17
Contusions, no

of abdominal wall, 638
treatment, 639

of bladder, 652
treatment, 652

of brain, 533

by contrecoup, 534
treatment, 534

of breast, 626

of chest, 624

of lung, 630

of nerves, 662

of jjenis, 652

of scalp, 528
treatment, 529

of scrotum, 654

of spinal cord, 596

844

INDEX

Contusions of spinal cord, treatment, 597
of spine, 586
of testicle, 658
of vagina, 659

of viscera in abdominal injury, 645
symptoms, no
treatment, in
Convolution, Broca's 546
of brain, 542

second frontal, of brain, 544
Convulsions, clonic, in hysteria, 779
Cooper's method of reducing dislocations

of elbow, 218
Coroner's cases, medicolegal phases, 824
Coronoid process, fracture of, 373
Corpora quadrigemina, lesions of, 547
Cortex, motor, of brain, 544

of brain, 540
Cortical callus, 251
centers of brain, 543
hemorrhage in fractures of skull, 293
diagnosis, 294
Costal cartilage, fracture of, 334
Coulomb, defmition, 708
Coup de ifouet, 695
Couteaud's position in fracture of clavicle,

322
Coxa valga, 507
vara, 507
after fractures of femur, 423
Cranial nerve, eighth, injury, 671

involvement, in head injury, 566
eleventh, injury, 673

involvement, in head injury, 567
fifth, injury, 668

involvement, in head injury, 566
first, involvement, in head in jury, 565
fourth, involvement, in head injury,

.565
ninth, injur>% 673

involvement, in head injury, 567

second, involvement, in head injury,

565
seventh, injury, 668

involvement, in head injury, 566
sixth, involvement, in head injury,

566 ^
tenth, injury, 673

involvement in head injury, 567
third, involvement in head injury, 565
twelfth, injur\', 674

involvement, in head injury, 567
Cranium. See SkiUl.
Crepitus in fractures, 254

muffled, 362
Criminal cases, medicolegal phases, 815
Crisis. Dictl's 754
Crossed hemiplegia, 547

paralysis, 670
Crura cerebri, lesion of, 547
Crushing wounds, 22
Crutch paralysis, 661
Gushing s subtemporal decompression
method in compression of brain,

operation for fractures of skull, 303

Cutaneous anthrax, 79
Cysts complicating fractures of skull, 307
spinal cord, 621

Dakin's solution, formula for, Rockefeller
Institute, 836
40 liters of, how to neutralize and

dilute, 836
method of using, 56
preparation, 55

war demonstration hospital modifi-
cation for, 836
Dakin-Carrel treatment of empyema, 61
of infected wounds, 52-61
bacteria coimting, 60
materials used, 56
. Death from electricity, 712
Debridement, 33, 35
in bullet fractures, 271
in wounds of abdominal wall, 640
Decompression operation for fractures
of skull, 303
suboccipital, for fracture of skull, 304
subtemporal, for fractures of skull, 303
Deformity, gun-stock, in fracture of
humerus, 367
of feet, 501
of hands, 501

silver fork, in Colles' fracture, 383
Delirium, traumatic, in fractures, 255
tremens in fractures, 255
of femur, 422
of skull, 304
Dichloramine in infected wounds, 61
Dietl's crisis, 754
Diplopia, 565

Disarticulation avulsion, 25^ 27
Dislocations, 194
ancient, 194

calcaneo-astragaloid, 245
causes, 194
closed, 194
complete, 194
complicated, 194
compound, 194
congenital, 195
defmition, 194
fracture-, of spine, 223

treatment, 198
frequency, 194
habitual, 194
incomplete, 194
metacarpophalangeal, 222
of ankle, 243

treatment, 244
of carpus, 220
of clavicle, 202
prognosis, 204
symptoms, 203
treatment, 203
of coccyx, 232
causes, 233
symptoms, 234
treatment, 235
varieties, 234
of collar-bone, 202

INDEX

84s

Dislocations, of elbow, 216. See also

EiboWy dislocations of,
of fingers, 222
of foot, 244
of hip, 235. See also Hipf dislocation

of.
of knee, 241
of lower jaw, 199
symptoms, 201
treatment, 201
of metacarpus, 220
of patella, 242

recurrent, 243

treatment, 243
of rib, 204
of scapula, 205
of shoulder, 205. See also Shoulder,

dislocations of,
of spine, 223, 588. See also Spine,

dislocation of.
of thumb, 222
of toes, 246
of ulnar nerve, 682
of wrist, 219
open, 194
pathologic, 195
patholog>', 195 .
prognosis, 199
recurrent, 194 ' .
sacro-iliac, 229

treatment of, 231
simple, 194
spontaneous, 195
subastragaloid, 245, 246
symptoms, 195
treatment, 197
unreduced, 194
varieties, 194
x-rays in, 802
Displacement, gastro-intestinal, 755
of cecum, 755
of colon, 755
of kidney, 751

treatment, 751, 754
of liver, 755
of stomach, 755
of uterus, 746

backward, 748

downward, 751

forward, 751
Dorrance's incision for felon, 88
Dorsal flexion, voluntary, 482
Douche, Scotch, for stiff joints, 262
Drain, cigarette, 45
rubber bands for, 46
rubber-tissue, 45
Drainage, gauze, 44
of wounds, 20, 40, 44
rubber, 45
Dressing, Gibney's for ankle injuries,

137
rail-fence for synovitis of knee, 167

Drop-finger, 503

Drop-foot, in peroneal paralysis, 684

Drowning, 727

Duchenne's main en griffe, 680

Dugas' test in dislocation of shoulder,

209
Dumb rabies, 77, 78
Dupuytren's contraction, 507

absence in plantar fascia, 511

Adam's operation in, 515

etiok)gy, 510

Keen's operation in, 515

Kocher's operation in, 515

location of lesions, 511

occurrence in non-laboring class,

511
p>athology, 510

period of onset, 511

symptoms, 512

treatment, 515

splint in Pott's fracture, 478

Dura mater, hematoma of, 549

Ear, examination of, standardized
methods, 834
foreign bodies in, 518
of injured person, examination of, 801
test for railway employees, 795
Ecchymosis, no
Ecchymotic mask, 333
Edema, malignant, 82
Edematous anthrax, 79
Eighth cranial nerve, injury, 671

involvement, in head injury, 566
Elbow, arthroplasty of, for bony anky-
losis, Murphy's method, 176-180
dislocations of, 216
causes, 217

Cooper's method of reducing, 218
diagnosis, 217
symptoms, 217
treatment, 217
after-treatment, 218
results, 218
varieties, 216
hyperflexion of, as improvised tourni-
quet, 23
miner's, 157

stiff, rubber-band exerciser for, 263
Elbow-joint, right, blood-supply in and

around, 121, 122
Electric neurosis, 715
shock, 715

first-aid treatment, 830
resuscitation from, 830
Electrical bums, first-aid treatment, 830
Electricity, bums from, 713
death from, 712
injuries due to, 708

nervous symptoms, 715
physical effects, 710, 712
treatment, 718
Elephantiasis phlebectatica, 695
Eleventh cranial nerve, injury, 673

involvement, in head injury, 567
Embolic aneurysm, 689
Embolism, 687
cerebral, 688
fat, in fractures, 255
kidney, 688

846

INDEX

Embolism, postoperative, 688

pulmonary, 688
Emergency treatment of accidents, 827
Emphysematous gangrene, 82
Employees, physical examination of,

standardized method, 832
Emprosthotonos, 73

in hysteria, 779
Empyema, Carrel-Dakin treatment, 61
En bouton de chemise, 86
Encephalitis, acute suppurative, after
injuries of head, 558

after injuries of head, 558
Ensheathing callus, 251
Enteroptotic female, 749
Epidural abscess, after injuries of head,

557
hemorrhage, 549
prognosis, 553
symptoms, 550
treatment, 552
Epilepsy after head injury, 567
differentiation, 570
onset, 569
results, 571
symptoms, 569
treatment, 571
complicating fractures of skull, 307
essential, s68
focal, 569
idiopathic, 568
Jackson ian, 307, 569
non-traumatic, 57b
reflex, 568
traumatic, 568
Epileptogenic zones, 568
Epiphyseal separation of humerus, 337,
362
treatment, 338
of lower end of femur, 444
treatment, 444
of fibula, 483
of tibia, 470
of upper end of femur, 425
of tibia and fibula, 456
Epiphyses of humerus, fractures of, 362

treatment, 337, 33^
Epistaxis from stab wounds, treatment,

in fracture of nose, 315
fipluchage, 33
Epsom salts in tetanus, 75
Erb's palsy, 674

point, 675
Erethistic shock, 114
Erysipelas, 38, 68

causes, 68

cellulitis and, differentiation, 39

complications, 69

duration, 69

facial, 69

following scalp wounds, 530

frequency, 68

gangrenous, 68

phlegmonous, 68

prognosis, 69

Erysipelas, relapses, 69
symptoms, 68
treatment, 70
ErysiF>eloid, 71
Escharation, stage of, 700
Esophagotomy, extenal, 524
Esophagus, foreign bodies in, 523
treatment, 524
injury of, 637
Essential epilepsy, 568
Extra-abdominal injuries, 638
Extradural hemorrhage, 549
in fractures of skull, 293

diagnosis, 294
prognosis, 553
symptoms, 550
treatment, 552
Extremities, bandage of, to conserve
blood-supply in severe hemorrhage, 2^
Eyes, black, iii
examination of, standardized method of

»33
foreign bodies in, 517

injuries, first-aid treatment, 830

of injured person, examination of, 800

tests for railway employees, 795

Facial er>'sipelas, 69
nerve, injury, 668
involvement, in head injury, 566

Fakir, traumatic neuroses and, differ-
entiation, 790

False aneurysm, 61, 689
callus, 252
joint, 252

Farcy, 80

Fascia-loss from wounds, treatment.

Fascial space of hand, abscess, 94

infections, 86, 107
Fascitis, 510

Fat embolism in fractures, 255
Feet, deformities of, 501
examination of, standardized method,

835
Felons, 86, 87

bone, 87
frog, 86

treatment, 93
treatment, 88
Female breast, injuries of, 626
Femoral hernia, 744

vessels, tourniquet for, 23, 24
Femur, anatomy and landmarks, 409
fracture of, diatrochanteric, 425
epiphyseal separation in, 425

treatment, 427
of head, 423
of lower end, 438
condyloid, 441

epiph>'seal separation in, 444
intercondyloid, 438
symptoms, 440
treatment, 440
results in, 446
supracondyloid, 438

INDEX

847

Femur, fracture of neck, 410
at base of neck, 410
bed-sores complicating, 422
causes, 410
complications, 425
coxa vara after, 423
delirium tremens complicating,

422
differential diagnosis, 420
dislocation of hip and differentia-
tion, 238
extracapsular, 410
intertrochanteric, 410
intracapsular, 410
pneumonia complicating, 420
results, 422

shock complicating, 422
Summary, 423
subcapital, 410
symptoms, 412

Thomas-Ridlon splint for, 417
through neck, 410
treatment, 414

for aged and infirm, 418
for rugged, 419
varieties and sites, 410
Whitman's treatment, 417
of shaft, 427
causes, 427

Cordivilla-Steinmann nail exten-
sion method in, 433, 435
in children, treatment, 436
results, 446

stirrup extension in, 434
symptoms, 428
treatment, 429
varieties and sites, 427
of trochanter, 423
subtrochanteric, 425
upper end, 410
neck of, incurvation of, 507
infraction of, 507
Fever, thermic, 705
Fibula, anatomy and landmarks, 451
fractures of, 451
of epiphysis, 470
of lower end, epiphysis, 483
of shaft, 457
causes, 457
disability |>eriod, 469
greenstick, 459
refracture in, 468
results, 468
symptoms, 459
treatment, 461
varieties and sites, 457
of upper end, 452
results, 456
treatment, 454
supramalleolar, 469
lower end, epiphyseal separation,

470
upper end, epiphyseal separation, 456
Fifth cranial nerve, injury, 668

involvement, in head injury, 566
Filium terminate, 575

Fingers and hands, examination of,
standardized method, 835
baseball, 503
dislocation of, 222
drop-, 503
felon of, 87
fractures of, 401
treatment, 402
index-, middle, and ring-, infection
of tendon sheaths, treatment, 104
jerk-, 502
little, infection of tendon sheath,

treatment, 105
lock-, 502
mallet-, 503
snap-, 502

stiff, rubber-band exerciser for, 63
trigger-, 502
Finochietto-Chutro stirrup, 465

in fractures of femur, 419
First cranial nerve, involvement in head

injury, 565
First-aid in accidents, standardized
methods, 827
in fractures, 257
kit, 827, 828, 829

contents, 831
men, 827

room, standardized, 830
equipment, 831
Fissures of Drain, 541
of Sylvius, 541
paric to-occipital, 542
Flares in osteomyelitis, 497
Flat-foot, 503
causes and varieties, 504
paralytic form, 504
static form, 504
symptoms, 504
traumatic, 504
treatment, 505
Flexion, dorsal, voluntary, 482
Floating kidney, 752

patella, 165
Fluoroscopic examination, 802
Focal epilepsy, 569
Foot, dislocation of, 244
flat-, 503
fractures of, 483
pronated, 503
right, blood-supply in and around,

129
splay-, 503
trench, 706
Football knee, 144

Forearm, anatomy and landmarks, 368
fractures of, 368

left, blood-supply in and around, 124
right, blood-supply in and around 123,
Foreign bodies, 517
in bladder, 52(3
in bronchi, 520

treatment, 521
in ears, 518
in esophagus, 523
treatment, 524

848

INDEX

Foreign bodies in eyes, 517

in heart, 637

in intestines, 525

in lungs, ^22
renx)va[, 631
treatment, 523

in nose, 519

in pericardium, 637

in rectum, 525

in stomach, 524

in throat, 519

in trachea, 520
treatment, 521

in urethra, 525

in uterus, 526

in vagina, 526

localization of, by x-rays, 804
substances in body, first-aid treatment,

829
Fourth cranial nerve, involvement, in

head injury, 565
Fourth-of-July tetanus, 72
Fracture-dislocation of spine, 223, 605.

See also Spine, fracture-dislocation 0}.
treatment, 198
Fractures, 247
anesthesia in, 258
articular, 272
Barton's, 395

reversed, 395
be.nding, 247
Bennett's, 399
blebs in, 253

treatment, 257, 258
bullet, 270

debridement in, 271

treatment of, 271
causes, 250

of impaired union, 252
chauffeur's, 393

symptoms and treatment, 395
clamps for, 277
classification, 279

general, 279
closed, 247

Colics', 382. See also CoUcs^ fracture,
complete, 247
complications, 254
compound, 247, 265

after-treatment, 267

primarv' suture, 266

primo-sccondar>' suture in, 266

sccondar>' suture in, 266

treatment, general, 270
primar>', 265
crepitus in, 254
delayed union, 252, 278
delirium tremens in, 255
displacement directions, 247
end-results in, rating, 274
fat embolism in, 255
faulty union, 252
fibrous union, 252
first aid in. 257
frequency, 248
grcenstick, 247

Fractures, healing by first intention, 251

by secondary intention, 251

impaired, 252

process, 250
impaired healing, 252
incomplete, 247
joint, 272
knuckle, 400
Lane's plates in, 276
Malar, 315

treatment, 316
navicular, 488
non-union, 252, 278
of acetabulum, 4oi8
of ankle, 470
of astragalus, 483

treatment, 485
of breast-bone, 326
of calcaneum, 485
of carpal bones, 307

of clavicle 316. See also Clavicle y frac-
ture of,
of collar-bone, 316. See also Clavicle y

fracture of,
of coronoid process, 373
of costal cartilage, 334
of epiphysis of humerus, 337
treatment, 338

of tibia, 456
and fibula, 470
of femur, 409. See also Femur ^ fractures

of.
of fingers, 401

treatment, 402
of foot, 483
of forearm, 368

sununary, 395
of head of radius, 373
of humerus, 334. See also Humerus,

fractures of^
of ilium, 402, 406

symptoms and treatment, 406
of ischium, 402, 408
of leg, 451

summary, 483
of lower jaw, 308
causes, 308
Matas' splint for, 310
results, 311

sites and varieties, 308
symptoms, 309
treatment, 309
of lung, 630
of malleolus, 480

treatment, 481
of metacarpal bones, 398

treatment, 400
of metatarsal bones, 489
results, 490
treatment, 490
of neck of femur, dislocation of hip and
differentiation, 238

of radius, 374
of nose, 311

causes and sites, 312

complications, 315

INDEX

849

Fractures of nose, metal splint in, 314
results, 315
symptoms, 313
treatment, 314

of olecranon, 370
treatment, 372

of OS calcis, 485
treatment, 486
pubis, 402, 408

of patella, 446. See also Patella, frac-
tures of,

of pelvis, 402. See also Pelvis, fractures
of,

of penis, 654

of radius, 373. See also Radius,
fractures of,

of ribs, 327. See also Ribs, fracture of.

of scaphoid, 397, 488
treatment, 398

of scapula, 324. See also Scapula,
fracture of.

of shaft of humerus, 347
treatment, 349
of radius, 375

of shoulder-blade, 324. See also Scap-
ula, fracture of.

of skuU, 280. See also SkuU, fractures

' of.

of spine, 589

treatment, 589
of sternum, 326

causes, 326

results, 327

sites and varieties, 326

symptoms, 327 •

treatment, 327
of surgical neck of humerus, 338
of tarsal bones, 483
of tibial spine, 457

tubercle, 456
of toes, 490

of tuberosities of "humerus, 337
of ulna, 368. See also Ulna, fractures

of.
of upjjer jaw, 311
open, 247, 265
operative treatment, 275
passive motion in, 262
periosteal, 135

bridge, 250
plaster casts in, 260
plaster-of- Paris bandage in, 259
plating, 276, 277
pneumonia in, 255

Pott*s 470. See also Pott's fracture,
radial styloid, 395
rating end-results, 274
reduction of, 258
restoring function, 262
results in general, 273
semilunar, 398
sepsis in, 255
setting of, 258
simple, 247
Smith's, 395
special, 280

Fractures, splints in, 259
split circular cast in, 260
spontaneous, 493
sprain-, 135, 142

of wrist, 146
symptoms, 252
traumatic delirium in, 255
treatment, 256
operative, 275
indications for, 275
material used, 276
metal pins and plates, 276
suture methods, 276
time for, 276
ulna styloid, 395
varieties, 247
vicious union, 252, 279
window casts in, 261
a:-rays in, 802
Fright neuroses, 717
Frog felon, 86

treatment, 93
Frontal lobes of brain, 546
Frost-bites, 706
Fxmgus cerebri, 564

ray-, 81
Furuncles of hand, 90

treatment, 92
Furunculosis, bone, 493

Gall-bladder involvement in abdominal

wounds, 649
Ganglion, 154, 501
compound, 154, 501

simple, 501
of wrist, 154
Gangrene, 687
emphysematous, 82
gas, 82

symptoms of, 83
treatment of, 83
Gangrenous erysipelas, 68
Gas, coal, 725
gangrene, 82
symptoms, 83
treatment, 83
illuminating, forms of, 725
injury from, 723
symptoms, 723
treatment, 725

oil-, 725

water-, 725
Gaseous phlegmon, 82
Gas-pwisoning, chronic, 726 •
Gastro-intestinal displacement, 755
Gastrotomy, 525
Gauze drainage, 44
Generative organs, wounds, treatment,

652
Genitals, examination of, standardized
method. 834

injuries of, 652
Germ carriers, 46

Gibney's dressing for ankle injuries, 137
Glanders, 80

chronic, 80

850

INDEX

Glanders, treatment, 80
Glass ann, 134
Globus hystericus, 778
Glossopharyngeal nerve, injury, 673

involvement, in head injury, 567
Glove anesthesia in hysteria, 776
Glue, Sinclair's, 50
Grafting, skin, in skin loss from wounds,

36, 37
Grand mal, 570
Greenstick fracture, 247
of radius, 375, 378
of ulna, 375, 378
Gun-stock deformity in fractures of

humerus, 367
Gustatory area of brain, 546
Gyri of brain, 542
Gyrus frontalis medius, 544 |

Hairpin splint for fracture dislocation of '
sprain of finger, 402 ,

Hallux valgus, 163
Hammer-toe, 490, 505
Hand and fingers, examination of, stan-
dardized method, 835
boils of, 90

treatment, 92
carbimcles of, 86, 90, 91

treatment, 92
collar-button abscess, 108 '
deformities of, 501
fascial space, abscess, 94

infections, 86, 107
furuncles of, 90
treatment, 92
infections of, 85
anatomy, 86
causes, 85
deep, 86, 93
location of pus in, table showing,

97
physiology, 86

superficial, 86, 87

left, blood-supply in and around, 124

lymphangitis of, 86, 93

deep, 94

treatment, 95

palmar infections, 86

suppurative tenosynovitis, 99

tendon sheaths, infection, 99

symptoms, loi

treatment, 102

tenosynovitis of, 86, 94

web-space abscess, 108

infections, 87

Hawley's extension table,

Head, injuries of, 528

complications, 557

extracranial forms, 528

intracranial forms, 531

sequela; of, 557

inflammatory, 557

non-inflammatory, 562

of neural origin, 564

Hearing in hysteria, 781

involvement of, in head injur>% 564

Heart, foreigti bodies in, 637

injury of, 633

non-penetrating, 633
penetrating, 633
stab wounds, 634

treatment, 635

wounds of, 633
Heat exhaustion, 705

stroke, 705
Heel, painful, 506

bursitis, 159

policeman's, 506
Hematocele of scrotum, 655

pathologic, 655
Hematoma, no

of dura mater, 549

of nail, 1X2

of scalp, 528

of scrotum, 655

of septum complicating fracture of nose,

315
pulsating, 689

subungual, 112

treatment, in

Hematomyelia, 590, 591

BrowTi-S^quard paral>'sis in, 593

diagnosis, 593

motor paralysis in, 592

paralysis in, 592, 593

primary focal, 591

sensory paral>^is in, 593

symptoms, 592

treatment, 594

Hematorachis, 590

Hemiplegia, crossed 547,

Hemorrhage and shock, coexistence, 115

central, 549

cerebral, 549

in fractures of skull, 293
diagnosis, 294
complicating fracture of ribs, 333
concealed, 115
cortical, in fractures of skull, 293

diagnosis, 294
epidural, 549

prognosis, 553

symptoms, 550

treatment, 552
extradural, 549

in fractures of skull, 293
diagnosis, 294

prognosis, 553

symptoms, 550

treatment, 552
first-aid treatment, 820
from wounds, treatment, i8
in fractures of skull, diagnosis, 294
in heart injuries, Rehn's method of

controlling, 635
intcrmeningeal, 549
intra-abdominal, treatment, 644
intracerebral, S49> 555
intracranial, in head injuries, 549
meningeal, 549
of brain, 549
spinal, 590

INDEX

Ssr

Hemorrhage, spinal, extradural, 590,

591
extramedullary, 590

intramedullary, 591

subarachnoid, 549, 554

subdural, 549, 553

in fractures of skull, 293

diagnosis, 294

Hemorrhagic s>Tiovitis, 163, 170

treatment, 171

Hernia cerebri after head injuries, 564

examination of, standardized method,

834
femoral, 744
inguinal, 737

causes, 738

history of case, 740
lumbar, 744
obturator, 744
of brain complicating fractures of skull,

308
of Petit's triangle, 745
of scrotum, 741
postoperative, 744
traumatic, 737
treatment, 746
umbilical, 743
Hey's internal derangement of knee-
joint, 189
High tracheotomy, for foreign bodies in

throat, 519
Hip, arthroplasty of, for bony ankylosis.

Murphy's method, 180-184
bursitis, 163
dislocation of, 235

AUis' method of reducing, 240

anterior, 240

AUis' method of reduction, 24.0
treatment, 240

Bigelovv's method of reduction, 239

causes, 236

differential points, 238

fracture of neck of femur and, dif-
ferentiation, 238

old, treatment, 241

Stimson's method of reducing, 240

symptoms, 237

treatment, 239

unreduced, treatment, 241

varieties, 236
Hip-joint, left, blood-supply in and around,

125

Hodgen's splint, 440

Holmgren color test, 798

Homicide cases, medicolegal phases, 825

Hoppe-Seyler test for demonstrating

carbon monoxid in blood, 724
Hour-glass hydrocele, 657
Housemaid's knee, 156
Humerus, anatomy and landmarks, 334
fractures of, 334

capitellum, 365

causes, 336

deformity following, 367

diacondylar, 355

diagnosis, 336

Humerus, fractures of, epicondyles, 362
epiphyses, 337, 362

treatment, 338, 362
external condyle, 360

treatment, 360
gun-stock deformity in, 367
internal condyle, 361

treatment, 362
Jones* arm splint in, 344
low supracondylar, 355
lower end, 354
causes, 355

hyperflexion position in, 356
Jones' position in, 356
symptoms, 355
treatment, 356
of shaft, 347

complications, 350
treatment, 349
sites and varieties, 336
summary, 365
supracondyloid, 355
T-shaped, 355, 358
Y-shaped, 355
surgical neck, 338

treatment, 344
Thomas splint in, 346, 349
treatment, 337
tuberosities, 337
Hydrocele, abdominal, 657
bilocularis, 657
hour-glass, 657
of spermatic cord, 657
of tunica vaginalis, 656

Andrews* operation in, 658
Jaboulay's operation in, 658
Hydrophobia, 76. See also Rabies.
Hydrops, intermittent, 171
Hymen, injury of, 659
Hyperemia, stage of, 700
Hyperesthesia areas in hysteria, 776
Hyperflexion of elbow as improvised

tourniquet, 23
Hypochondriasis, traumatic neuroses and

differentiation, 790
Hypoglossal nerve, injury, 674

involvement, in head injury, 567
Hypothenar space, abscess of, 86, 93

treatment, 109
Hysteria, 757, 77©
accidents of, 770
anesthesia areas in, 772, 775
barometers, 781
causes, 770
cerebellar, 775
clonic convulsion in, 779
complicating fractures of skull, 307
definition, 770
emotional states in, 773
emprosthotonos in, 779
glove anesthesia in, 776
hearing in, 781

hyperesthesia areas in, 773, 776
major, 778
minor, 778
motor-sensory form, 774

8S2

INDEX

Hysteria, opisthotonos in, 779

prognosis in, 783

raychic form, 777

Romberg symptom in, 783

smell in, 782

special sense fonns, 780

speech in, 781

stocking anesthesia in, 776

symptoms, 772

tache c^r^brale in, 773

taste in, 782

treatment, 787

vasomotor areas, 773

visceral forms, 782

vision in, 780

visual areas, 773
Hysteric arthritis, 776

coma, 779

joints, 776
H)rsterogenetic zones, 773
Hysteroneurasthenia, 757

after head injury, 573

Idiopathic epilepsy, 568

tetanus, 72
nium, fractures of, 402, 406

symptoms and treatment, 406
Illummating gas, forms of, 725
injury from, 723
treatment, 725
Immersion, injury due to, 727
Incised wounds, 17
Incurvation of neck of femur, 507
Index-fimger, infection of tendon sheath,

treatment, 104
Infected burs£, 163
Infection of brain, after injuries of head,

558
of hand, 85. See also Handf infection of.

of wounds, 37. See also Wounds y
infection of\
Inflammation of bursa, 155

of spinal cord, 604

of tendons, 154
Infraction of neck of femur, 507
Inguinal hernia, 737. See also Hernia,

inguinal.
Inhalation, smoke, injury due to, 727
Injuries in which the skin is broken, first-
aid treatment, 829

which do not bleed, first-aid treatment,
829
Insanity after head injury, 572
treatment, 574

complicating fractures of skull, 307
Insolation, 705

Intention tremor in hysteria, 775
Intercostal neuralgia complicating

fracture of ribs, 2)Z2>
Intermeningeal hemorrhage, 549
Intermittent hydrops, 171
Internal capsule lesions, 547
Intstinal anthrax, 79

involvement in fractures of pelvis, 405

wounds, treatment, 647
Intestines, foreign bodies in, 525

Intra-abdominal hemorrhage, treatment

644
injury, 641

treatment, 642
with external wounds, 642
without external wounds, 641
Intracerebral hemorrhage, 549* 555
Intracranial damage in fractures of
skull, 293
hemorrhage in head injuries, 549
Intramedullary splint, 251
Involucrimd, 494
Iodoform injection in tetanus, 76
Ischium, fractures of, 402, 408

Jaboulay's oi)eration in hydrocele of

tunica vaginalis, 658
Jack-knife posture, 146
Jacksonian epilepsy, 307, 569

non-traumatic, 570
Jaw, angle of, 308
body of, 308

lower, anatomy and landmarks, 308
dislocation of, 199
symptoms, 201
treatment, 201
fractures of, 308
causes, 308
Matas' splint for, 310
results, 311

sites and varieties, 308
symptoms, 309
treatment, 309
lumpy, 81
ramus of, 308
upper, fractures of, 311
Jerk-finger, 502
Joint, Charcot's, 166
false, 252
fractures, 272
thrower, 197
water on, 163
Joints, blood-supply in and around,
119-129
Brodie's, 776

bullet wounds, treatment, 29
examination of, standardized methods,

836
hysteric, 776

infection of, rheumatism and, dif-
ferentiation, 39
injuries of, 119
wounds of, 119
infected, active mobilization without
drainage in, 132
bipp in, 134
treatment, 130
Willems' treatment, 132
treatment, 130
Jones' arm splint with adhesive traction
straps, 344
cock-up splint for wrist-drop, 381
method of splitting patella, 176
position in fracture of lower end of

humerus, 356
test in Pott's fracture, 476

INDEX

853

Kanavel's incision for felon, 88
incision for paronychia, 89
line, 99
Keloids, 62

treatment, 62
Kidney, anatomy of, 752
corset, 754
displacement of, 751

treatment, 754
embolism, 688
fixation, 754
floating, 752
index, 753
movable, 752
wandering, 752
wounds, treatment, 649
Kit, first-aid, 827, 828, 829

contents, 831
Kitasato's treatment of tetanus, 76
Klumpke's palsy, 675
Knee, adhesive strapping, 143
arthroplasty of, for bony ankylosis.

Murphy's method, 185-188
bursae of, 157
dislocation of, 241
football, 144
housemaid's, 156

semilunar cartilages, displacements, 189
sprain, 142

diagnosis, 144
stiff, rubber-band exerciser for, 264
synovitis of, 165

chronic, treatment, 169
recurrent, treatment, 169
treatment, 166
Knee-joint, Hey's internal derangement,
189
oxygen injection, 190
right, blood-supply in and around,
126, 127
Knuckle fracture, 400
Kocher's method of reduction of disloca-
tion of shoulder, 210
operation in Dupuytren's contracture,

Konig and Miller, autoplastic method of,
in head injury, 563

Lacerated ligaments of spine, 587

wounds, 17
Laceration of brain, 533

of meninges in fractures of skull, 293

of nerves, 664

of pleura, 629

of spinal cord, 599
diagnosis, 600
treatment, 601

of viscera in abdominal wounds, 646
Lame back, 148, 587, 588
Laminectomy for contusions of spinal

cord, 598
Lane's plates in fractures, 276
Laryngotracheotomy, 522
Late traumatic apoplexy, 556
Laudable pus, 38
Lawn tennis arm, 134

Leg, rider's, 134

ulcer of, 64, 696
treatment, 66
Lenticular nuclei, lesions of, 547
Leptomeningitis interna after injuries of
head, 557

purulent, after injuries of head, 557
Leriche, {)eriarterial sympathectomy of,

in injury of arteries, 687
Ligaments, uterine, 747
Limbs, examination of, standardized

method, 835
Line, Kanavel's, 99
Little finger, infection of tendon sheath.

treatment, 105
Liver, displacement of, 755

wounds of, treatment, 647
Lobes, frontal, of brain, 546
Localization, cerebral, 540
Lock stitch, continuous, 19
Lock-finger, 302

Lockjaw, 71. See also Tetanus,
Loose cartilage, 189
Lumbago, traumatic, 147
Lumbar hernia, 744

puncture in compression of brain, 539
Lumpy jaw, 81
Lung, contusions of, 630

foreign bodies in, 522
removal, 631
treatment, 523

fracture of, 630

injury of, 630

traumatic tuberculosis complicating,

632
treatment, 630

rupture of, 630
Luxation, 194. See also Dislocations.
Lymphadenitis, 38, 39, 47, 697

treatment, 698
Lymphangitis, 38, 39, 47^ 697

of hand, 86, 93
deep, 94
treatment, 95

phlegmonous, 94

reticular, 698

treatment, 698

tubular, 698
Lymphorrhagia, subcutaneous, 697
Lymph- vessels, injuries of, 660, 697

Magnesium sulphate in tetanus, 75
Main en griff e, 680
Malar fracture, 315
treatment, 316
Malaria, wounds infection and, dif-
ferentiation, 39
Malgaigne's dressing in .fracture of ribs,

332
Malignant edema, 82

pustule, 78, 79
Malingering traumatic neuroses and,

differentiation, 790
Malleolus, fractures of, 480

treatment, 481
Mallet-finger, 503

854

INDEX

Mammary zones, 773

Mannkopff test, 588

Mamikopff-Rumpf test in neurasthenia,

762
Matas* operation for aneurysm, 691

splint for fracture of lower jaw, 310
Mayo's method of draining knee-joint,

132, 176
Mayor's scarf sling for fracture of clavicle,

322
Median nerve, injury of, 679
Medical examiner's cases, medicolegal

phases, 824
Medicolegal cases, physical examination
of claimant for damages, 816
phases, 806

accident insurance cases, 811

assault cases, 825

casualty company cases, 811

compensation law cases, 809

coroner's cases, 824

criminal cases, 815

documents relating to condition of

patients, 808
fractures of skull, 825
homicide cases, 825
hypothetical question, 822
medical examiner's cases, 824
period of partial disability, 807

of total disability, 807
poisoning, 825

relation of injury to disease, 813
surgeon's report, 816, 818
iT-ray plates in, 803
Medullary portion of brain, 540
Meningeal apoplexy, 549

hemorrhage, 549
Meninges, infection of, after injuries of
head, 557
laceration of, in fractures of skull, 293
Meningitis, 604
complicating fractures of skull, 304
septic, after injuries of head, 557
serous, 621

traumatic, after injuries of head, 557
Meningo-enccphalitis, after injuries of

head, 557
Meningomyelitis, 604
Metacarpal bones, fractures, 398
treatment, 400
dislocation, 220
Metacarpophalangeal dislocation, 222
Metal pins in fractures, 276

plates in fractures, 276
Metatarsal bones, fractures of, 489
results, 4QO
treatment, 490
Met a tarsalgia, 506
Middle tinger, infection of tendon sheath, ',
treatment, 104 |

Mikulicz packing in liver wounds, 648
Military Lourdes, 788
Miller and Konig, autoplastic method of,

in head injury, 563
Miner's elbow, 157
Miscarriage, 731

Miscarriage, after-treatment, 734

causes, 732

differential diagnosis, 734

frequency, 731

relation to trauma, 732

symptoms, 733

treatment, 734

varieties, 731
Momburg constrictor, 22

in abdominal injuries, 644
Moore's dressing and sling for Colles*

fracture, 392
Moorehead's plaster-of- Paris abduction
method in fracture of clavicle, 323

take-apart modification of Thomas
splint, 430
Morton's disease, 506

toe, 506, 685
Motor area of brain, 544

oculi nerve, involvement in head injury,

565
Mouth, examination of, standardized

method, 834

Movable kidney, 752

Mucous membrane, stab wounds, 30

Muffled crepitus, 362 •

Murphy's method of, arthroplasty of

elbow for bony ankylosis, 176-

180

of hip for Dony ankylosis, 180-

184

of knee for bony ankylosis, 185-188

of proctoclysis in shock, 117

operation for recurrent dislocation of

shoulder, 214, 215

Muscle-loss from wounds, treatment,

37
Muscles of abdominal wall, ruptured,

640, 641
ruptured, from chest injuries, 625
Muscular system, instabilityjin complicat-
ing fracture of skull, 306
Musculospiral nerve, injur>'' of, 677
Myelitis, O04, 605
Myositis ossificans, iii, 498

progressiva, 498

symptoms, 499

traumatica, 498

treatment. 499

Nail, hematoma of, 112
National Affiliated Safety Organization
first-aid jar. 827, 828, 829
treatment, 828-830
Navicular fractures, 488
Neck, examination of, standardized

method, 836
Negri bodies, 76
Nerves, anastomosis of, 667

blocking, in crushing wounds, 23

contusion of, 662

injuries of, 660

laceration of, 664

special, injury of, 668

stretching of, 663

suture of, 665-668

INDEX

855

Nervous prostration, 760. See also Neu-
rasthenia.
system, examination of, standardized
method, 835
Neural involvement complicating
fractures of skull, 304
in head injuries, 564 " ^

Neuralgia, intercostal, complicating

fracture of ribs, 333
Neurasthenia, 757 760
causes, 760

cerebrospinal form, 761
complicating fractures of skull, 307
definition, 760
diagnosis, 76Q

differential, 770, 790
Mannkopfl-Rumpf test in, 762
motor form, 764
relocation test in, 762
sexual, 766
symptoms, 761
traumatic, 573, 760
visceral forms, 765
Neuritis of individual nerves, 662
traumatic, 660
treatment, 662
Neurorrhaphy, 665-668
Neuroses, differential diagnosis, 790
electric, 715
fright, 717
post- trauma tic, 573
traumatic, 757

fakir and, differentiation, 790
hypochondriasis and, differentiation,

790
malingering and, differentiation, 790
prognosis, 783
treatment, 787
Ninth cranial nerve, injury, 673

involvement, in head injur>% 567
Non-penetrating injuries of abdominal

wall, 638
Nose, anatomy and landmarks, 311
bleeding, first-aid treatment, 829
examination of, standardized method,

834
foreign bodies in, 519
fracture of, 311

causes and sites, 312

complications, 315

metal splint in, 314

results, 315

symptoms, 313

treatment, 314
Nuclear involvement, non-traumatic, 669

Obturator hernia, 744

Occipital osteoplasty, 303

Occlusion of wounds, 20

Oculomotor nerve, involvement, in head

injury, 565
Ohm, definition, 708
Ohm's law, 709
Oil-gas, 725
Olecranon bursitis, 157

fracture of, 370

Olecranon, fracture of, treatment, 372
Olfactory area of brain, t)46

nerve, involvement, in head injury,

56s
Opisthotonos, 73

in hysteria, 779

Opium-habit in fractures of skull,

295
Optic nerve, involvement, in head injury,

565

thalamus, lesions of, 547
Os calcis, fractures of, 485
treatment, 486

pubis, fractures of, 402, 408

trigonum, 485
Osseous depressions of skull following

head injuries, 562
Osteitis, 696
Osteoblasts, 250
Osteomyelitis, 492

Carrel- Dakin technic in, 497

pathology, 493

symptoms, 495

traumatic, 493, 497

treatment, 495
Osteoperiostitis ossificans, toxic, 491
Osteoplasty, occipital, 303
Ovarian zones, 773
Oxygen injection of knee-joint, 190

Pachymentngitts externa, after injuries
of head, 557
purulent, after injuries of head, 557
Pain in back, 148
Painful heel, 506

Palmar abscess, middle, treatment,
108
fascia, anatomy of, 510
infections. 86
Palsy, Bell's, 669
Erb's, 674
Klumpke's, 675
peroneal, 684
Sunday morning, 677
Pancreas, wounds of, treatment, 651
Paralysis, after head injuries, 564

Brown-S<5quard, in hematomyelia, 593
crossed, 670
crutch, 661

in hematomyelia, 592, 593
Parieto-occipital fissure, 542
Paronychia, 86, 88

treatment, 89
Pars opercula of brain, 544
Pasteur's treatment of rabies, 78
Patella, clicking, 165
dislocation of, 242
recurrent, 243
treatment, 243
floating, 165
fractures of, 446
causes, 446
refracture in, 450
results, 450

sites and varieties, 447
Stimson's treatment in, 448

856

INDEX

Patella, fractures of, symptoms, 447

treatment, 447
Patellar tendon, rupture, 153
Patheticus nerve, involvement in head

injury, 565 ♦

Pelvis, anatomy and landmarks, 402

fractures of, 402

bladder involvement in, 404
intestinal involvement, 405
summary, 409

urethral involvement in, 404
with intrap)elvic injury, 403

treatment, 404
without intrapelvic injury, 406
Penetrating injunes of abdominal wall,
641

wounds, 17
of spine, 621
Penis, contusions of, 652

fractures of,* 654

injury of, 652

wounds of, 652
Perforation of viscera in abdominal

injuries, 646
Periarterial sympathectomy of Leriche,

in injury of arteries, 687
Pericarditis, traumatic, 633
Pericardium, foreign bodies in, 637

injury of, 633
Perineuritis, 660
Periosteal bridge, 250

fracture, 135
Periostitis, 491, 696

acute, 491

chronic, 491

traumatic, 491

treatment, 492
Peritonitis, traumatic, 643
Pernio, 706
Peroneal nerve, injur>' of, 684

palsy, 684
Pes planus, 503
Petit mal, 570

Petit's triangle, hernia of, 745
Phlebitis, 38, 692

from injur>', 693

treatment, 693
Phlegmasia alba dolens, 693
Phlegmon, gaseous, 82
Phlegmonous erysipelas, 68

lymphangitis, 94
Physical examination, standardized

method, 832
Pillow splint for knee-joint injuries,

143
Pins, metal, in fractures, 276

Plantar nerves, injury, 684

Plantaris tendon, rupture, 152

Plaster casts in fractures, 260

Plaster-of-Paris bandage in fractures,

259
Plates, Lane's in fractures, 276

metal, in fractures, 276
Plating fractures, 276, 277
Pleura, injur>' of, 628

lacerations of, 629

Pleurisy complicating fracture of ribs,

333
Pleuropneumonia, traumatic, 638
Pleurothotonos, 73
Pneumogastric nerve, injury, 673

involvement, in head injury, 567
Pneumonia after injury of lung, symptoms,
630
treatment, 631
complicating fractures of femur, 430
of ribs, 333
of skull, 304
in fractures, 255
traumatic, 623
Point, Erb's, 675

tying, 652
Poisoning, carbon monoxid, 723
from coal-^as, 725
from illummating gas, 723
gas-, chronic, 726
medicolegal phases,. 825
Policeman's heel, 506
Pons, lesions of, 547

varolii, 540
Popliteal nerve, external, injury of, 684

internal, injury of, 684
Post- traumatic neuroses, 573
Postcalcaneal bursitis, 506
Postoperative embolism, 688

hernia, 744
Posture, jack-knife, 146
Pott's fracture, 470
causes, 472
disability period, 480
Dupuytren's splint in, 478
Jones' test in, 476
modified, 470
results, 480
Stimson splint in, 477
symptoms, 474
treatment, 474
varieties and sites, 472
Premature birth, 731
Prepatellar bursitis, 156
Primary couple of Wylie, 546
Primo-secondar>' suture, 34
Probing of wounds, 40
Proctoclysis, Murphy's method in shock,

117
Prolapse of uterus, 751

visceral, relation of injury to, 737
Pronated foot, 503
Prone pressure method of artificial

respiration, 729
Prostate, injury of, 659
Pseudarthrosis, 252
Pseudohydrophobia, 77
Psychic shock, 113
Psychoneurosis, 758
Psychoses after head injury, 573

treatment, 574
Pulmonary anthrax, 79
apoplexy, 630
embolism, 688

tuberculosis, wound infection and,
differentiation, 39

INDEX

857

Pulsating hematoma, 689

Pulsations complicating fractures of skull,

308
Pimcture, lumbar, in fractures of skull,

291, 292
Punctured wound, 17
Purulent arthritis, 173
treatment, 175

leptomeningitis after Injuries of head,

557
pachymeningitis, after injuries of head,

557
synovitis, 163, 171
Pus, laudable, 38
location of, in infections of hand,
table showing, 97
Pustule, malignant, 78, 79
Pyemia, 38, 39, 48
Pyocyaneus infection of wounds, 38

Quadriceps tendon, rupture, 153

R.\BIES, 76

diagnosis, 77
dumb, 77, 78
furious form, 78
Pasteur's treatment, 78
pathology, 76
prognosis, 77
prophylaxis, 77 ^

symptoms, 76
treatment, 77
Radial styloid fractures, 395
Radio-dermatitis, 805
Radiographic examination, 802
Radius, fractures of, 368, 370
greenstick, 375
of head, 373
of neck, 374
of shaft, 375

complications, 381
treatment, 377

Volkmann's contracture in, 381
Rail-fence dressing for synovitis of knee,

167
Railroad brain, 757

spine, 595, 757
Ramey's tripod splint for femur fracture,

441
Ray-fungus, 81

Rectum, examination of, standardized
method, 834
foreign bodies in, 525
Reflex epilepsy, 568
Rehn's method of controlling hemorrhage

in heart injuries, 635
Reinfection of wounds, 37
Relocation test in lame back, 588

in neurasthenia, 762
Respiration, artificial, in drowning, 728
Schafer method, 729
Sylvester method, 729
Rest for wounds, 21
Resuscitation from electric shock, 830
Reticular lymphangitis, 698

Retrodisplacement of uterus, acquired,
748
congenital, 748
Retroflexion of uterus, 748
Retropharyngeal abscess, method of

incising, 43
Retroversion of uterus, 748
Reversed Barton's fracture, 395
Rheumatism, joint infections and, dif-
ferentiation, 39
Ribs, anatomy and landmarks, 327
dislocations of, 204
false, 327
floating, 327
fracture of, 327
causes, 327
complications, 333
emphysema in, 330
hemorrhage complicating, 333
hemothorax in, 330
intercostal neuralgia, complicating,

^333

Malgaigne's dressing in, 332

pleurisy complicating, 333

pneumonia complicating, 333

pneumothorax in, 330

sites and varieties, 329

strapping chest in, 331, 332

s>Tnptoms, 329

traumatic asphyxia complicating, 333

treatment, 331

true, 327

Rickety chest, 327

Rider's leg, 134

Ring-finger, infection of tendon sheath,

treatment, 104

Risus sardonicus in tetanus, 73

Rockefeller Institute modification for

Dakin*s solution, 836

Rolandic area, 541

Rolando's fissure, 541

Romberg symptom in hysteria, 783

Rontgen rays, 702. See also x-rays.

Room, first-aid, standardized, 830, 831

Rubber drainage, 45

Rubber-band exerciser for stiff ankle,

264

elbow, 263

fingers, 63

knee, 264

wrist, 263

for drains, 46

test in neurasthenia, 764, 769

Rubber- tissue drains, 45

Run-around, 86, 88

Rupture, 737

of Achilles tendon, 152

of adductor tendons of thigh, 154

of biceps tendons, 1 54

of lung, 630

of patellar tendon, 153

of plantaris tendon, 152

of quadriceps tendon, 153

of soleus group of tendons, 153

of tendons, 149

open, 150

8S8

INDEX

Rupture of triceps tendons, 154
Ruptured muscles from chest injuries,
625

Sacro-iliac dislocation, 229
treatment, 231
region, adhesive strapping, 149
sprains, 148
treatment, 149
Saline infusion in shock, 117
Sayre dressing for fracture of clavicle,

320
Scalds, 700

first-aid treatment, 829
Scalp, avulsion of, 25
contusions of, 528
treatment, 529
hematoma of, 528
wounds of, 529
treatment, 530
Scalping, 25
Scaphoid fractures, 397, 488

treatment, 398
Scapula, anatomy and landmarks,

324
dislocation of, 205
fracture of, 324
causes, 324
symptoms, 324
varieties and sites, 324
Scarlet red ointment for bums, 703
Schafer's method of artificial respiration,

729
Sciatic nerve, injury of, 682

stretched, 664
Sciatica, 682

Sclavo's serum in anthrax, 79
Scotch douche for stiff joints, 262
Scrotal hernia, 741
Scrotum, contusions of, 654
hematocele of, 655
hematoma of, 655
injuo' of, 654
wounds of, 654
Second cranial nerve, involvement, in
head injur\', 565
frontal convolution of brain, 544
Sedatives in wound infections, 46
Semilunar cartilages of knee, displace-
ments, 180
fractures, 398
Seminal vesicles, injury of, 659
Senses, special, examinations of, standard-
ized method, S^i,^
Sensorimotor cortical area of brain, 544
Sensory area of brain, 545
Sepsis, 39

complicating fractures of skull, 304
in fractures, 255
Septic arthritis, 173
treatment, 175
state, 39
temperature, 48
Septicemia, 38, 39, 48
Septum, abscess of, complicating fracture
of nose, 315

Septum, hematoma of, complicating frac-
ture of nose, 315
Sequestrum, 494
Serous meningitis, 621
Serums in wound infections, 46

Sclavo's in anthrax, 79
Seton wound, 271
Seventh cranial nerve, injury, 668

involvement, in head injury, 566
Sexual neurasthenia, 766
Shaft of humerus, fractures of, 347
Shell shock, 758
Sherrington's law, 616
Shin, barks of, 21, 22
Shirt-stud abscess, 86, 92

treatment, 93
Shock, 11^
apathetic, 114
causes, 113

complicating fractures of femur, 422
delayed, 114
electric, 715

first-aid treatment, 830
resuscitation from, 830
erethistic, 114

from wounds, treatment, 18
hemorrhage and, coexistence, 115
immediate, 114
late, 114, 1x5
local, 115
mild, 114 '
moderate, 114
primar>', 114
prognosis, 118
psychic, 113
secondary, 114, 115
severe, 114
shell, 758
surgical, 113
symptoms, 114
treatment, 116
Shoehorn, tin, splint for fracture of

thumb, 402
Shot-gun wounds, treatment, 29
Shoulder, dislocations of, 205
causes, 206
diaj^nostic signs, 209
Dugas' test, 209
habitual, 214

Kocher's method of reduction, 210
old, 214
patholog>', 206
recurrent, 214

Murphy's operation for, 214, 215
Stimson's method of reduction, 212
symptoms, 207

traction methods of reduction, 212
treatment, 210

results, 213
unreduced, 214
varieties, 206
synovitis of, 170
Shoulder-joint, left, blood-supply in and

around, 120
Siderodromophobia, 763
Sight, involvement of, in head injury, 564

INDEX

8S9

Silent areas of brain, 546

Silver fork deformity in Colics* fracture,

383
Sinclair's glue, 50

Sinew, weeping, 154, 501

Sinus thrombosis, after injuries of head,

561
treatment, 562
Sitting up cast for fractures of femur, 418
Sixth cranial nerve, involvement, in head

injury, 566
Skin grafting in skin loss from wounds,

36, 37
loss from wounds, skin grafting for,

3^ 37
treatment, 36

Skull, anatomy and landmarks, 280

base of, 280

bullet wounds,

treatment, 28

depression of, after head injurj', 562

fractures of, 280

abscess of brain complicating, 304

alcoholism in, 294

apoplexy in, 294

basal, 292

bending, 287

blood pressure in, 293

bone-pressure in, 203

bony defects complicating, 307

bursting, 287

cerebral hemorrhage in, 293

choked disk in, 292

complications, 304

contrecoup, 288

cortical hemorrhage in, 293

Cushing's decompression operation

in. 303

cysts complicating, 307

decomi)ression operation in, 303

defects of mcmorj' in, 306

delirium tremens complicating, 304

diagnosis. 294

epilepsy complicating, 307

etiology, 287

extracranial forms, symptoms, 288

extradural hemorrhage m, 293

frequency, 282

general cases, 288

hemorrhage in, 294
diagnosis, 294

hernia of brain complicating, 308

hysteria complicating, 307

insanity complicating, 307

instabilit> in muscular system compli-
cating, 306

internal table, 288

intracranial damage, 293

forms, symptoms, 289

laceration of meninges in, 293

lumbar puncture in, 291, 292

medicolegal phases, 825

meningitis complicating, 304

mental conditions complicating, 306

neural involvement, 304

neurasthenia complicating, 307

Skull, fractures of, operative indications
and methods, 298
opium-habit in, 295
pneumonia complicating, 304
pulsations complicating, 308
results, 306

sepsis complicating, 304
spmal puncture in, 291, 292
subdural hemorrhage in, 293
suboccipital decompression for, 304
subtemporal decompression for, 303
symptoms, 288

determining, 292
treatment, 295
operative indications and methods,
298
two inch zone in, 283
uremia in, 295
varieties, 283

with intracranial injury, 285
symptoms, 289
treatment, 296
without intracranial injur>', 285
symptoms, 288
treatment, 295
holes in, from head injur>', 563
vault of, 280
vertex of, 280
Sling, coat-sleeve, 256
Slipper splint, 261
Slipping cartilage, 189

chronic, treatment, 193
recurrent, treatment, 193
treatment, 192
Smell in hysteria, 782
Smith's fracture, 395
Smoke inhalation, injury due to, 727,

729
Snap-finger, 502
Snuff-box, 219
Soap solution for bums, 703
Soleus group of tendons, rupture, 153
Spatapoplexie, 556
Speech area of brain, 546

examination of, standardized method,

834
in hysteria, 781
Spermatic cord, contusions, 655
hydrocele of, 657
injur>% 655
Spinal accessor\' nerve, injur> , 673

involvement, in head injury, 567
apoplexy, 591
concussion, 595, 757
cord, anatomy, 575
contusions of, 596
treatment, 597
cysts, 621

inflammation of, 604
injuries of, 596
laceration of, 599
diagnosis, 600
treatment, 601
distortion, antalgic, 148
hemorrhage, 590
extradural, 590, 591

86o

INDEX

Sponal, hemorrhage, extramedullary, 590
intramedullary, 591
irritation, 762
meninges, 575
nerves, anatomy, 576
pimcture in compression of brain,

539
in fractures of skull, 291, 292

tenderness, 761
topography, 578
trouble, 762
Spine, anatomy of, 575
contusions of, 586
dislocation of, 223, 588
causes, 224
pathology, 224
region of coccyx, 232
of dorsal spines, 228
of four upper cervical spines, 224
of lower cervical spine, 227
of lumbar spines, 229
of sacral spmes, 229
symptoms, 224
varieties, 224
examination of, standardized methods,

836
fracture of, 589

treatment, 589
fracture-dislocation of, 223, 605
causes, 607
diagnostic factors, 615
frequency and varieties, 605
prognosis in general, 616
symptoms, 607
treatment, 617
injuries of, 575

extraspinal types, 575, 586
horizontal localization, 585
intraspinal types, 590
lacerated ligaments of, 587
penetrating wounds of, 621
railroad, 595, 757
sprains of, 587
tibial, fracture of, 457
Splay-foot, 503

Spleen wounds, treatment, 651
Splint in fracture, 259
intramedullary, 251
pillow, for knee-joint injuries, 143
slipp)cr, 261
trough, 261
Split circular cast in fractures, 260
Spondylose antalgique, 148
Spontaneous fracture, 493
Sporotrichium, 84
Sporotrichosis, 84

disseminated gummatous, 84

ulcerative, 85
extracutaneous, 85
localized, 84
symptoms, 84
treatment, 85
Sprain, 134
ankle, 137

diagnosis, 142
chronic, 136

Sprain, chronic, treatment, 137
knee, 142

diagnosis, 144
of abdominal wall, 640
of back, 146

treatment, 147
of spine, 587
sacro-iliac, 148

treatment, 149
tendency, 136
treatment, 135
wrist, 145
diagnosis, 146
Sprain-fracture, 135, 142, 395

of wrist, 146
Stab wounds, 30

epktaxis from, treatment, 30
01 abdomen, 30
of chest, 30
of heart, 634
of n>ucous membrane, 30
of spine, 621

of urethra, treatment, 31
Staggers, 721

Standardized first-aid methods m acci-
dents, 827
room, 830

equipment, 831
method of physical examination, 832
Staphylococcus infection of wounds,

37, 38
Sternum, anatomy and landmarks, 326

fracture of, 326
causes, 326
results, 327 ^
sites and varieties, 326
symptoms, 327
treatment, 327
Stiff ankle, rubber-band exerciser for,
264
elbow, rubber-band exerciser for, 263
fingers, rubber-band exerciser for, 63
knee, rubber-band exerciser for, 264
wrist, rubber-band exerciser for, 263
Stimson's method of reducing dislocation
of hip, 240
of shoulder, 212
splint in Pott's fracture, 477
vertical incision in fractures of patella.

Stocking anesthesia in hysteria, 776
Stomach, displacement of, 755
foreign bodies in, 524
wounds of, treatment, 646
Stone bruise, 491
Strabismus, 566
Strains, 134

treatment, 135
Strapping, adhesive, for sternoclavicular
dislocation of shoulder, 203
of knee, 143

of sacro-iliac region, 149
of wTist, 145
Stretching of ner\'es, 663
Stroke, heat, 705
Subacromial bursitis, 157

INDEX

86l

Subacromial bursitis, treatment, 159
Subaponeurotic space, abscess of, treat-
ment, 108
dorsal, abscess of, treatment, 108
Subarachnoid hemorrhage, 549, 554
Subastragaloid dislocation, 245, 246
Subcortical area of brain, lesions of,

effects, 548
Subdural abscess after injuries of head,

557

hemorrhage, 549, 553
in fractures of skull, 293
diagnosis, 294
Subepithelial abscess, 86
Subluxation, 194
Submersion, injury due to, 727
Suboccipital decompression for fracture

of skull, 304
Subperiosteal abscess, 49^
Subtemporal decompression for fractures

of skull, 303
Subungual hematoma, 112
Suffocation, first-aid treatment, 830

injury due to, 727, 729
Suggillation, no
Sulphur grain bodies, 81
Sunday morning palsy, 677
Sunstroke, 705
Supine pressure method of artificial

respiration, 729
Supramalleolar fracture of tibia and fibula,

469
Suprascapular nerve, injury, 677
Surgeon's report in medicolegal cases,

816, 818
Surgical shock, 113
Suture, continuous, 19
reinforced, 19

delayed primary, 34

intermediate, 34

late, 34

lock, continuous, 19

methods in fractures, 276

of nerves, 665-668

of wounds, 40

primary', in compound fractures, 266

primitif retardde, 34

primo-secondary, 34

in compound fractures, 266

secondaire, 34, 48

secondary', 34, 48

in compound fractures, 266
Sylvester's method of artificial respiration,

729
Sylvius, fissure of, 541
Sympathectomy, periarterial, of Leriche

in injury of arteries, 687
Synovitis, 163
chronic, 171

treatment of, 172
course, 164
hemorrhagic, 163, 170

treatment of, 171
of knee, 165

chronic, treatment, 169
recurrent, treatment, 169

Sjmovitis of knee, treatment, 166

of shoulder, 1 70

prognosis, 164

purulent, 163, 171

treatment, 164
Syringomyelia, traumatic, 591
Systemic evidences of infection in infected

wounds, treatment, 52

Tache c^r^brale in hysteria, 773
Tailor's ankle, 163
Tarsal bones, fractures of, 483
Taste in hysteria, 782
Tears of tendons, 149
Temperature, septic, 48
Tendon, Achilles, bursitis of, 163
ru[)ture of, 152

bridging, 151

lengthening, 151

patellar, rupture of, 153

plantaris, rupture of, 152

quadriceps, rupture of, 153

sheaths of hand, infection, 99
symptoms, loi
treatment, 102

splitting and transfer, 151
Tendons, adductor, of thigh, rupture, 154

biceps, ru{)ture of, 154

inflammation of, 154

injuries, 149

rupture of, 149
opKjn, 150

soleus group, rupture, 153

tears of, 149

triceps, rupture, 154

wounds of, 149
Tendoplasty methods, 151
Tenosynovitis, 154, 155

of hand, 86 j 94

suppurative, oif hand, 99
Tenth cranial nerve, injury, 673

involvement, in head injury, 567
Test, Dugas', in dislocation of shoulder,

209
Testicle, contusions of, 658

injury of, 658

wounds of, 658
Tetanolysin, 71
Tetanospasmin, 71
Tetanus, 71

acute, 72

antitoxin, 74

causes, 72

cephalic, 72

chronic, 72, 73

fourth-of-July, 72

idiopathic, 72

prognosis, 76

prophylaxis, 73

risus sardonicus in, 73

subacute, 72

symptoms, 72

traumatic, 72

treatment, 73

varieties, 72
Thecitis, 154, 501

862

INDEX

Thenar space, abscess of, 86, 93

treatment, 108
Thermic fever, 705

Thigh, adductor tendons, rupture, 154
Third cranial nerve, involvement in head

injury, 565
Thoracic cavity, bullet wounds, treat-
ment, 28
duct injury, 697
nerve, long, injury of, 676
Thomas splint with adhesive plaster
straps, 346, 349
with author's take-apart modification,

430
wrench, 390
Thomas-Ridlon hip splint for fractures of

femur, 417
"Throat, examination of, standardized
method, 834
foreign bodies in, 519
Thrombophlebitis, septic, 693
Thrombosis, 687

sinus, after head injury, 561
treatment, 562
Thumb, dislocations of, 222

infection of tendon sheath, treatment,
106
Tibia, anatomy and landmarks, 451
fractures of, 451

lower end, articular, 483
of epiphysis, 456, 470
of shaft, 457
causes, 457
disability period, 469
greenstick, 459
refracture in, 468
results, 468
symptoms, 459
treatment, 461
varieties and sites, 457
of spine, 457
of tubercle, 456
of upper end, 452
results, 456
treatment, 454
supramalleolar, 469
lower end, epiphyseal separation,

470
upper end, epiphyseal separation, 456
Tibial nerve, injury of, 684
Tic douloureux, 668
Tincl's sign in nerv-e injury, 665
Toe, big, bursitis of, 163
dislocation of, 246
hammer, 505
Morton's, 306, 685
Toes, dislocation of, 246

examination of, standardized method,

835
fractures of, 490

Topography, cerebral, 54c

spinal, 578

Tourniquet for femoral vessels, 23, 24

Toxic osteoperiostitis ossificans, 491

Trachea, foreign bodies in, 520

treatment, 521

Tracheotomy, high, for foreign bodks in

throat, 519
Transfusion of blood in shock, 117
Traumasthenia, 759

plus malingering, 793
Traumatic apoplexy, late, 556

asphyxia complicating fracture of ribs,

delirmm in fractures, 255

late apoplexy, 290

lumbago, 147

meningitis, after injuries of head, 557

periostitis, 491

tetanus, 72
Tremor, intention, in hysteria, 775
Trench foot, 706
Trendelenburg position, 747

test of valvular venous insuffidencyy
696
Triceps tendons, rupture, 154
Trigeminus nerve, injur>% 668

involvement, in head injury, 566
Trigger-finger, 502
Trochlear nerve, involvement, in head

injury, 565
Trough splint, 261
True aneurysm, 688
T-shaped supracondyloid fracture of

humerus, 355
Tubercles, Babes*, 76

tibial, fracture of, 456
Tuberculosis of bone, 492 ^

pulmonary, wound infection and, dif-
ferentiation, 39

traumatic complicating injury of lung,

633
Tuberosities of humerus, fractures, 337

Tubular lymphangitis, 6p8

Tunica vaginalis, contusions, 655

hydrocele of, 656

Andrews' operation. 658

Jaboulay's operation, 658

injuries, 655

Twelfth cranial nerve, injury, 674

involvement, in head injury, 567

Typhoid fever, wound infection and,

dilTcrentiation, 39

Ulcer, 63
causes, 63
cruris, 64, 696

treatment, 66
of leg, 64, 696

treatment, 66
symptoms, 64
treatment, 66
varicose, 695
Ulna, fractures of, 368, 370
greenstick, 375, 378
of shaft, complications, 381
treatment, 377

Volkmann's contracture in, 381
st3^1oid fractures, 395
Ulnar nerve, dislocation of, 682

injury of, 679
Umbilical hernia, 743

INDEX

863

Unconscious patients, first-aid treatment,

830'
Uremia in fractures of skull, 295
Urethra, foreign bodies in, 525
stab wounds, treatment, 31
wounds of, 654
Urethral involvement in fractures of

pelvis, 404
Uterine ligaments, 747
Uterus, anatomy, 747
anteflexion of, 751
anteversion of, 747
displacement of, 746
backward, 748
causes, 748
downward, 751
fonvard, 751
foreign bodies in, 526
position of, 747
prolapse of, 751
rctrodisplaccmcnt of, acquired, 748

congenital, 748
retroflexion of, 748
retroversion of, 748

Vaccines in wound infection, 46
Vagina, contusions of, 659

foreign bodies in, 526

injury of. 659

wounds of, 659
Vaginal zones, 773
Valleix's tender spots, 683
Valvular venous msufficiency, Trendelen-
burg test in, 696
Vanzctti's method in aneurysm, 691
Varicose aneurysm, 689

ulcers, 69s

veins, 694

treatment, 696
Varix, ancurj'smal, 689
Veins, examination of, standardized
method. 836

injur>' of, 692

varicose, 694
treatment, 696

wounds of, 692
Venesection in compression of brain,

540
Vertebra, dblocations of, 223. See also
Spine, dislocation of.
prominens, 223, 578
Vesication, stage of, 700
Viscera, contusion of, in abdominal
injury, 645
perforation of, in abdominal injury,
646
Visceral prolapse, relation of injury,

to, 7^7
Vision m hysteria, 780
Visual area of brain, 545

word center of brain, 546
Volkmann's contracture in fractures of

radius, 381
Volt, definition of, 708
Voluntary abduction, 482

dorsal flexion, 482

Wandering kidney, 752

War demonstration hospital modification

for Dakin's solution, 836
Watch-crystal protector, 40
Water on the joint, 163
Water-gas, 725

Web space of hand, infections, 87 *
Web-space abscess of hand, 108
Weeping sinew, 154, 501
Welch, Bacillus a^rogenes capsulatus

anaerobicus of, 82
White matter of brain, involvement of,

effect, 548
Whitman, joint thrower, 197

treatment of fractures of neck of femur,

.417
Willems' method of treating septic

arthritis, 1 76

treatment of infected wounds of joints,

132
Window casts in fractures, 261
Woolsorters* disease, 78
Wounds, 17

abscess complicating, 38, 39
aneurysms complicating, 61
bleeding from, treatment, 18
bullet, 27. See also Bullet wounds,
coaptation of, 20
complications, 17, 37
contractures complicating, 62
contused, 17
crushing, 22
drainage of, 20, 40, 44
erysipelas complicating, 68
er>'sipeloid complicating, 71
fascia-loss from, treatment, 37
first degree, 31, 47
treatment, 31
from fractured skull, treatment, 295
incised, 17
infection of, 37

Carrel- Dakin treatment, 52-61
bacteria counting, 60
materials used, 56
causes, 37
degrees, 47

diagnosis, differential, 39
dichloramine in, 61
first degree, 47

treatment, 48
indications for amputation, 51
malaria and, differentiation, 39
mild, 47

treatment, 48
moderate, 47
acute stage, treatment, 49
chronic stage, treatment, 49
subacute stage, treatment, 49
treatment, 49
prevention, 18, 38, 40
primary, 37

pulmonary tuberculosis and, dif-
ferentiation, 39
reinfection, 37
second degree, 47

acute stage, treatment, 49

864

INDEX

Wounds, infection of, second degree,
chronic stage, treatment, 49
subacute stage, treatment, 49
treatment, 49
secondary, 37
severe, 48

treatment, 51
symptoms, 38, 46
third degree, 48

treatment, 51
treatment, 40, 48
of systemic evidences of infection,

typhoid fever and, differentiation

vane ties, 37
intestinal, treatment, 647
keloids complicating, 62
lacerated, 17
lockjaw complicating, 71
mixed infection, 37
musde-loss from, treatment, 37
occlusion of, 20
of abdominal wall, 639
of chest, 625

of generative organs, treatment, 652
of heart, 633
of joints, 119
infected, active mobilization without
drainage in, 132

bipp in, 134

treatment, 130

Willems' treatment, 132
of kidney, treatment, 649
of liver, treatment, 649
of pancreas, treatment, 651
of penis, 652
of scalp, 529

treatment, 530
of scrotum, 654
of spine, penetrating, 621
of spleen, treatment, 651
of stomach, treatment, 646
of tendons, 149
of testicle, 658
of vagina, 659
of veins, 692
penetrating, 17
probing of, 40
punctured, 17
pyocyaneus infection, 38
reinfection, 37
rest for, 21

Wounds, second degree, 32, 47
treatment, 32
seton, 271

shock from, treatment, 18
shot-gun, treatment, 29
skin loss, from skin grafting for,

36,37
treatment, 36
special, 21

stab, 30. See also Stab wounds.
staphylococcus infection, 37, 38
streptococcus infection, 37, 38
suture of, 40
symptoms, 17
tetanus complicating, 71
third degree, 34, 48

treatment, 34
treatment, 18
ulcers complicating, 63
with loss ot tissue, 36
treatment, 36^
Wrist, adhesive strapping, 145
dislocations of, 219
ganglion of, 154
sprain, 14^

diagnosis, 146
sprain-fractures, 146
stiff, rubber-band exerciser for. 263
Wrist-drop in injury of musculospiral
nerve, 678
Jones' cock-up splint for, 381
Writing center of brain, 546
Wylie's primary couple, 546

X-RAYS, 802

bums from, 804

treatment, 805

varieties, 805
in dislocations, 802
in fractures, 802

in localization of foreign bodies, 804
medicolegal phase, 803

Y-SHAPED supracondyloid fracture of
humerus, 355

Zanfel's operation for thrombosis of

sigmoid sinus after head injur>', 562
Zones, anesthesia, in hysteria, 775

hysterogenetic, 773

mammar}', 773

ovarian, 773

vaginal, 773

■

L 1

^ ai?l Moorhead, J.J. dM96V 1
MI ... 1 Traumatic surgery. 1
MS .. 1 1

' DATB DUB

— tY\ ir>aiL k/

IPR 2 6 1951

"""■

1 /'

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—

WK^M

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