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A M A N U A L
OF
M () D E R N S U R (; E R Y :
AN EXPOSITION OF THE ACCEPTED D0CTRINES AND APPROWED
OPERATIVE PROCEDURES OF THE PRESENT TIME,
FOR THE USE OF
STUDENTS AND PRACTITIONERS.
BY
JOHN B. ROBERTS, A.M., M.D.,
PROFESSOR OF SURGERY IN THE woMAN's MEDICAL COLLEGE OF PENNSYLVANIA ; PROFESSOR OF
ANATOMY AND SURGERY IN THP, PHILADELPHIA POLYCLINIC ; LECTURER IN ANATOMY
IN THE UNIVERSITY OF PEN NSYLVANIA.
WITH FIVE HUNDRED AND ONE ILLUSTRATIONS.
PHILADELPHIA:
L E A B R O T H E R S & C O.
1 8 9 0.

Entered according to the Act of Congress, in the year 1890, by
LEA BROTHERS & Co.,
in the office of the Librarian of Congress. All rights reserved.
D OR N A N , P R T N T E R .
THIS V O L U M E
IS INSCRIBED TO MY FATHER,
C A L E B C. R O B E R T S,
TO WHOSE LIBERALITY AND CARE I OWE EDUCATION AND SUCCESS;
FROM W HOSE PRECEPT AND EXAMPLE I HOPE I HAVE
GAINED ACCU. R. A.CY AND GOOD JUDG MENT.
PRE FA C E.
THIS treatise is the result of an effort to give the profession, in a con-
densed form, the accepted doctrines and approved procedures of Modern
Surgery.
I have endeavored to write a practical work, giving the surgical
principles and operative methods generally accepted and practised by
the leading surgeons of the world at the present time. The opinions of
the best authorities, the methods of the most practical surgeons, and the
well-established facts of surgical science are discussed; but the consider-
ation of theories, historical questions, traditional views and operations,
and innovations of undecided value has been rigidly avoided.
The value of an author's discretionary power in such rejection or
acceptance of material depends upon the carefulness of his analysis and
the impartiality and soundness of his judgment. It has been my aim
to bring these essentials to the work; hence, the statements of the
volume represent my appreciation of the questions that have presented
themselves.
In order to depict the present state of modern surgery I have con-
sulted standard text-books and current surgical literature. The best and
newest thought is usually found in the latest editions of monographs;
therefore much use has been made of such works.
I am indebted to my friend Dr. Thomas S. K. Morton for writing the
sections on Diseases and Injuries of the Joints, Diseases and Injuries of
the Genito-urinary Organs, Dislocations, Excisions, Amputations, and the
index. Without his efficient aid the publication of the volume would
have been greatly delayed. Dr. Morton and Dr. C. L. Bower have given
me much aid in reading the proof-sheets and in seeing the book through
the press.
J O H. N. B. R O B E R T S.
1627 WALNUT STREET, PHILADELPHIA.
September, 1890.
269433
C O N T E N T S.
P A R T I.
CHAPTER I.
INFLAMMATION.
Definition, Causes, Varieties, Extension of Inflammation. Micro-
organisms which are associated with Disease. Pathology,
Symptoms, and Termination of Inflammation . g tº
CHAPTER II.
DESTRUCTIVE INFLAMMATORY PROCESSES.
Suppuration. Abscess. Sinus and Fistula. Ulceration. Ulcers.
Mortification, or Gangrene. Hospital Gangrene
CHAPTER III.
ERYSIPELAS, SAPRAEMIA, SEPTICAEMIA. PYAEMIA
CHAPTER IV.
SCROFULA AND TUBERCULOSIS
CHAPTER V.
SYPHILIS .
CHAPTER VI.
RICKETS OR RACHITIS
CHAPTER VII.
TUMORS. SPECIAL TUMoRS .
PAGE
33–49
50–63
74–83
86–112
X C O N T E N T S.
CHAPTER VIII.
WOUNDS AND SHOCK . t - t tº e * - . 113–116
CHAPTER IX.
MODE OF REPAIR AND TREATMENT OF WOUNDS t - , 117–125
CHAPTER X.
PRACTICAL SURGERY AND ANAESTHESIA © ſº * - . 126–132
CHAPTER XI.
OPERATIVE SURGERY.
Preparation of the Patient and the Surgeon and mode of Con-
ducting Operations. Control of Hemorrhage. Sutures.
Dressings. Bandages. Counter-irritation. Abstraction of
Blood. Aspiration and Tapping . º © & º . 133–145
CHAPTER XII.
PLASTIC OR REPARATIVE SURGERY . tº - º - . 146–152
P A R T II.
CHAPTER XIII.
SURGERY OF SPECIAL STRUCTURES.
Diseases and Injuries of the Skin and its Appendages and of the
Cutaneous Tissues. Wart or Verruca. Corn or Clavus. Boil
or Furuncle. Carbuncle. Lupus. Arabian Elephantiasis.
Burns. Frostbite and Chilblain. Onychia or Onychitis.
Ingrowing Toe-nail . e e e º * ſº e . 153–168
CHAPTER XIV.
DISEASES AND INJURIES OF MUSCLES, TENDONS, AND BURSAE.
Wounds of Muscles and Tendons. Dislocation of Muscles and
Tendons. Inflammation of Tendons. Deformities from Mus-
cular Paralysis, Contraction, and Rigidity. Myotomy and
C O N T E N T S. xi
Tenotomy. Contraction of the Palmar Fascia and its Digital
Prolongations. Thecal Cyst or Ganglion. Inflammation of
Bursae or Bursitis, and Bursal Tumors. Bunion . te . 169–181
CHAPTER XV.
DISEASES AND INJURIES OF THE NERVE-CENTRES AND NERVES.
Diseases and Injuries of the Brain. Meningocele and Encephalo-
cele. Hydrocephalus. Inflammation of the Brain from Surgical
Causes. Injuries of the Brain. Concussion, Contusion, and
Laceration of the Brain. Compression of the Brain. Tumors
of the Brain. Diseases and Injuries of the Spinal Cord. Hy-
drorachis or Bifid Spine. Inflammation of the Spinal Cord from
Surgical Causes. Wounds of the Spinal Cord. Concussion or
Contusion, and Laceration of the Cord. Neuritis, or Inflam-
mation of Nerves. Injuries of Nerves. Neuralgia. Tetanus.
Hydrophobia. Traumatic Delirium Tremens . we tº . 182–218
CHAPTER XVI.
DISEASES AND INJURIES OF THE HEART AND BLOODVESSELS.
Wounds of the Pericardium and Heart. Tapping the Pericardium
or Pericardicentesis. Diseases and Injuries of the Arteries,
Veins, and Capillaries. Hemorrhage. Wounds of Weins.
Diseases of the Veins. Inflammation of Veins, or Phlebitis.
Hypertrophy and Varicosity of Veins. Diseases of Lymph-
atics. Wounds of Lymphatics. Inflammation of Lymphatic
Vessels or Lymphangitis. Lymphadenitis. Varicose Lymph-
atic Vessels. Injuries and Diseases of Arteries. Wounds of
Arteries. Traumatic Aneurism. Arterio-venous Wounds and
Fistules. Simple Arterio-venous Fistule or Aneurismoid Varix.
Sacculated Arterio-venous Fistule. Arteritis and Degenerative
Changes in Arteries. Atheromatous Degeneration and Calci-
fication of Arteries. Aneurism. Ligation of Arterial Trunks
in Continuity. Ligations of Special Arteries. Arterial Varix
or Varicose Arteries . * * tº * º & e . 219–301
CHAPTER XVII.
DISEASES AND INJURIES OF BONES.
Periostitis. Ostitis or Osteomyelitis. Necrosis, or Mortification of
Bone. Caries, or Tubercular Ulceration of Bone. Central
Caries or Tubercular Abscess of Bone. Epiphysitis. Hyper-
trophy and Atrophy of Bone. Osteomalacia. Softening of
Bone. Tumors in Bone. Injuries of Bones. Fractures.
Repair of Fractures. Treatment of Open Fractures. Ununited
Fractures or Pseudarthrosis. Deformed or Vicious Union of
Fractures. Special Fractures. Fractures of the Vertebrae.
Fractures of the Cranium. Fractures of the Bones of the
xii
C O N T E N T S.
Face. Fracture of the Nasal Bones and Cartilages. Fracture
of the Malar Bone and Zygoma. Fractures of the Superior
Maxillary Bone. Fracture of the Inferior Maxillary Bone.
Fracture of the Hyoid Bone. Fracture of the Cartilages of
the Larynx. Fractures of the Sternum. Fractures of the
Ribs and Costal Cartilages. Fractures of the Costal Cartilages.
Fractures of the Pelvic Bones. Fracture of the Clavicle. Frac-
tures of the Scapula. Fractures of the Humerus. Fractures
of the Bones of the Forearm. Fractures near the Wrist-joint.
Fractures of the Carpus, Metacarpus, and Phalanges. Frac-
tures of the Femur. Fractures of the Shaft of the Femur.
Fractures of the Patella. Fractures of the Tibia, and Fibula.
Fracture of the Bones of the Foot
CHAPTER XVIII.
PAGE
302—445
DISEASES AND INJURIES OF THE JOINTs, CARTILAGES, AND LIGAMENTs.
Congenital Deformities of Joints (Congenital Dislocations). Syno-
vitis. Hemarthrosis. Arthritis. Gonorrhoeal Arthritis. Tuber-
cular Arthritis. Tuberculous Arthritis of Special Joints.
Tuberculosis of Vertebral Articulations (Spondylitis, Pott's
Disease). Tuberculosis of the Sacro-iliac Articulation. Tuber-
culosis of Hip-joint. Syphilitic Arthritis. Osteo-arthritis
(Arthritis Deformans). Atrophic Arthritis (Charcot's Disease).
Hysterical and Neuralgic Joint Affections. Ankylosis. Loose
Bodies in Joints. Injuries of Joints, Wounds of Joints. Dis-
locations. Treatment of Old Dislocations. Special Dislocations.
Dislocations of the Vertebrae. Atlo-axoid and Occipito-atloid
Dislocations. Dislocations of the Dorsal Vertebrae. Disloca-
tions of the Ribs from the Vertebral Column. Dislocations
of the Coccyx. Dislocations of the Jaw. Dislocations of the
Sternum. Dislocations of the Clavicle. Dislocations of the
Scapula. Dislocations of the Humerus. Downward or Sub-
glenoid Dislocations. Subcoracoid Dislocations. Subclavicular
Dislocations. Subspinous Dislocations. Conjoint Dislocations
of Radius and Ulna. Divergent Dislocations of the Radius
and Ulna. Dislocations of the Radius. Dislocations of the
Upper End of the Ulna. Dislocations of the Lower End of the
Ulna. Dislocations of the Carpus. Dislocations of the Meta-
carpal Bones. Dislocations of the Phalanges of the Hand.
Dislocations of the Femur. Posterior or Backward Disloca-
tions. Treatment of Posterior Dislocations. Anterior or
Forward Dislocations. Old Dislocations of the Femur. Dis-
locations of the Tibia. Dislocations of the Patella. Disloca-
tions of the Fibula. Dislocations at the Ankle-joint. Disloca-
tions of the Various Bones of the Tarsus. Dislocation of
Cartilages. Dislocation of the Costal Cartilages. Dislocation
of the Ensiform Cartilage. Dislocation of the Semi-lunar
Cartilages. Operations upon Joints. Excision of Joints.
C O N T E N T S. xiii
PAGE
Excision of Temporo-maxillary Joint. Excision of Shoulder-
joint. Excision of Elbow-joint. Excision of Wrist-joint.
Excision of Metacarpo-phalangeal, and Inter-phalangeal Joints.
Excision of Hip joint. Excision of Knee-joint. Excision of
Ankle-joint. Excision of Metatarso-tarsal, Metatarso-pha-
langeal, and Inter-phalangeal Joints & ſº g tº . 446–525
CHAPTER XIX.
SURGICAL DISEASES OF THE RESPIRATORY ORGANs.
Surgical Diseases and Injuries of the Nose. Foreign Bodies in the
Nose. Epistaxis. Nasal Catarrh. Nasal Polyps. Adenoid
Vegetations in the Pharynx. Deformities of the Nose. Abscess
of the Antrum. CEdema of the Glottis. Fracture of the
Larynx and Trachea. Foreign Bodies in the Air-passages.
Tumors of the Larynx and Trachea. Tracheotomy. Intuba-
tion of the Larynx. Diseases of the Chest. Contusions and
Abscesses. Surgical Treatment of Pleural Effusions. Pul-
monary Abscess and Gangrene. Mediastinal Tumors and
Abscesses. Diseases of the Neck. Diseases of the Thyroid
Body. Bronchocele or Goitre . * ſº ſº º * . 526—551
CHAPTER XX.
SURGICAL DISEASES OF THE MOUTH.
Cleft Palate. Epithelioma of the Lip. Tumors of the Mouth.
Alveolar Abscess. Tumors of the Jaw. Necrosis of the Jaw.
Diseases of the Tongue. Inflammation of the Tongue. Epi-
thelioma of the Tongue, Diseases of the Tonsils. Salivary
Fistule. Retro-pharyngeal Abscess. Diseases of the CEsoph-
agus. Foreign Bodies in the CEsophagus. Tumors of the
CEsophagus. Stricture of the CEsophagus. Introduction of
the CEsophageal Bougie or Stomach-pump Tube . tº . 552–570
CHAPTER XXI.
SURGICAL DISEASES OF THE ABDOMEN AND PELVIS.
Method of Operating within the Abdomen and Pelvis. Traumatic
Peritonitis. Tapping the Abdomen. Abdominal and Pelvic
Abscesses. Diseases and Injuries of the Stomach. Foreign
Bodies in the Stomach. Wounds of the Stomach. Operations
upon the Stomach. Gastrostomy. Gastrotomy. Tumors of
the Stomach. Stricture of Gastric Orifices. Diseases and Inju-
ries of the Intestines. Foreign Bodies. Rupture, Wounds,
and Perforating Ulcers of the Intestines. Intestinal Obstruc-
tion. Tumors of the Intestines and Omentum. Operations
on the Intestines. Artificial Anus. Appendicitis and Typhlitis.
Colotomy. Laparo-colotomy. Resection of the Intestine.
xiv.
CO N T E N T S.
Intestinal Anastomosis. Diseases and Injuries of the Liver.
Malignant Diseases of the Liver, Diseases and Injuries of
the Gall-bladder. Cholecystotomy. Diseases and Injuries of
the Spleen. Diseases and Injuries of the Pancreas. Diseases
and Injuries of the Uterus and its Appendages. Tumors of
the Ovary. Diseases of the Fallopian Tubes. Hernia.
Strangulated Hernia. Herniotomy or Kelotomy. Special
Hernias. Inguinal Hernia. Femoral Hernia. Umbilical
Ełernia
CHAPTER XXII.
SURGICAL DISEASES OF THE RECTUM.
Pruritus of the Anus. Inflammation of the Rectum. Foreign
Bodies in the Rectum. Impacted Feces. Prolapse of the
Rectum. Hemorrhoids. External Hemorrhoids. Rectal
Abscess. Anal Fistule. Recto-vesical, Recto-urethral, and
Recto-vaginal Fistules. Anal Fissure. Ulceration of the
Anus and Rectum. Stricture of the Rectum. Malignant Dis-
ease of the Anus and Rectum. Non-malignant Rectal Tumors
CHAPTER XXIII.
PAGE
571–631
632–654
SURGICAL DISEASES AND INJURIES OF THE URINARY ORGANs.
Diseases and Injuries of the Kidney. Congenital Malformations.
Misplacements. Simple Misplacement. Movable and Floating
Kidney. Hydro-nephrosis. Pyo-nephrosis. Suppurative Neph-
ritis. Peri-nephritis. Tuberculosis of Kidney. Renal Calculi.
Renal Colic. Renal Fistulae. Tumors of the Kidney. Injuries
of the Kidney. Open Wounds of the Kidney. Operations
upon the Kidney. Aspiration. Nephrorrhaphy. Nephrotomy.
Nephro-lithotomy. Nephrectomy. The Ureter. The Bladder.
Congenital Malformations. Exstrophy. Pervious Urachus.
Displacements. Vaginal Cystocele. Cystitis. Acute Cystitis.
Chronic Cystitis. Tuberculosis of the Bladder. Vesical Neu-
roses. Paralysis. Atony. Vesical Fistulae. Sounding the
Bladder. Foreign Bodies in the Bladder. Injuries of the
Bladder. Retention of Urine. Suppression of Urine. Incon-
tinence of Urine. Hematuria. Pneumo-uria. Chyluria.
Operations upon the Bladder. Aspiration. Lithotrity. Tumors
of the Bladder. Papillomata. Carcinomata. Myxomata.
Vesical Calculi (Stone in the Bladder). Perineal Cystotomy
(and Lithotomy). Lateral Perineal Cystotomy (and Lithotomy).
Median Perineal Cystotomy (and Lithotomy). Supra-pubic
Cystotomy (and Lithotomy). The Prostate. Prostatic Catarrh
(Prostatorrhoea). Prostatic Tuberculosis. Hypertrophy of the
Prostate. Tumors of the Prostate. Prostatic Calculi. The
|Urethra. Congenital Malformations. Prolapse of Urethra.
C O N T E N T S. XV
Urethritis. Specific or Gonorrhoeal Urethritis (Gonorrhoea).
Cowperitis. Stricture of the Urethra. Organic Stricture. Ex-
ploration of the Urethra. Dilatation of the Urethra. Urethral
Fever. Urethral Fistulae. Calculi and Foreign Bodies. Tumors.
Fibro-vascular Tumors. Injuries of the Urethra. Operations
upon the Urethra. Catheterization. Catheterization of the
Female. Internal Urethrotomy. External Urethrotomy. Di-
latation of the Female Urethra • º e º e . 655–709
CHAPTER XXIV.
SURGICAL DISEASES AND INJURIES OF THE REPRODUCTIVE ORGANS.
The Scrotum. Elephantiasis. Lymph Scrotum. Epithelioma.
Contusions of Scrotum. Wounds. The Tunica Vaginalis.
Hydrocele. Hydrocele of the Spermatic Cord. Hydrocele in
the Female. Hematocele of the Tunica Vaginalis. The
Spermatic Veins. Varicocele. Ligation of the Spermatic
Veins. The Testicle. Congenital Abnormalities. Malposition
of the Testicle. Epididymitis. Orchitis. Tuberculosis of the
Testicle. Tumors of the Testicle. Injuries of the Testicle.
Excision of the Testicle (Castration). Spermatorrhoea. The
Penis. Congenital Abnormalities. Phimosis. Paraphimosis.
Inflammation of the Penis. Balanitis. Herpes. Chancre and
Chancroid of the Penis. Tumors of the Penis. Papilloma.
Carcinoma. Injuries of the Penis. Excision of the Penis.
The Vulva. Adhesion. Varix. Hematoma. Vulvitis.
Follicular Vulvitis. Inflammation of the Vulvo-vaginal
Glands. Destructive Ulcers. Chancre and Chancroid. Ele-
phantiasis. Tumors. Injuries. Laceration of the Perineum.
The Vagina. Congenital Abnormalities. Retained Menses.
Vaginitis. Chancre and Chancroid. Fistulae. Tumors.
Foreign Bodies. Wounds e - º º o e . 710–718
CHAPTER XXV.
DEFORMITIES, OR ORTHOPAEDIC SURGERY.
Torticollis, or Wry-neck. Spinal Curvatures. Rotary Lateral
Curvature, or Scoliosis. Kyphosis. Lordosis. Webbed Fingers.
Club-foot. Pes Varus. Pes Valgus. Pes Equinus. Pes
Calcaneus. Pes Planus. Deformities of the Knee and Leg . 729—742
CHAPTER XXVI.
AMPUTATIONS.
Special Amputations. Amputation through Shoulder-joint. Am-
putation of the Arm. Amputation through the Elbow-
joint. Amputation of the Forearm. Amputation through
xvi
C O N T E N T S.
the Wrist-joint. Inter-carpal and Carpo-metacarpal Amputa-
tions. Amputation of the Hand. Amputation through the
Metacarpo-phalangeal Articulation. Amputation of the Thumb.
Amputation of Phalanges of Hand. Amputation through the
Hip-joint. Amputation of the Thigh. Amputation through the
Knee-joint. Amputation of the Leg. Amputation through the
Ankle-joint. Amputation through the Medio-tarsal Joint
(Chopart's), Amputation through the Tarso-metatarsal Joint
(Lisfranc's). Amputation through the Metatarsus .
CHAPTER XXVII.
SURGICAL DISEASES OF THE BREAST.
Diseases of the Mammary Glands. Mammary Neuralgia. Inflam-
PAGE
743–761
mation of the Breast. Chronic Inflammation of the Breast.
Abscess of the Breast. Paget's Disease of the Breast. Tumors
of the Breast. Excision of the Breast
762–770
P A R T I.
GENERAL SURGICAL PATHOLOGY, OR PRINCIPLES
OF SURGERY.
C H A P T E H. F.
INFLAMMATION.
DEFINITION, CAUSEs, VARIETIES, EXTENSION OF INFLAMMATION.
DEFINITION.—The process of inflammation, though of paramount
importance to the surgeon and the subject of profound study and
observation, is not easily definable. Its elementary features are unknown,
because it is a vital process which the microscope cannot study except by
its results. Hence, attempts to define inflammation are mere statements
of its symptoms and effects. The word refers to the changes observed in
animal structure following an injurious influence insufficient to cause
immediate loss of vitality. This initial factor may originate from with-
out, extrinsically, as a blow; or from within, intrinsically, as in inflam-
mations due to deleterious elements circulating in the blood-current.
Inflammation, according to the present condition of pathological
science, may be described as a peculiar molecular change in the walls
of the small bloodvessels, dependent upon an extrinsic or an intrinsic
irritation, which increases the adhesion of the blood to the vessel walls
and allows permeation of the blood elements through them. Until the
blood elements are allowed to escape by the abnormal permeability of
the vascular coats, inflammation may be said not to exist.
Inflammation is not strictly a disease. It is Nature's reparative effort
to overcome the perturbations caused by an injurious influence on the
animal organism.
There are three terms, to which authors have given somewhat different
applications, that, on account of their relationship to the process of in-
flammation, require explanation at this time. I give to them the definition
which seems most logical, in the attempt to bring order out of the exist-
ing confusion. Hyperamia is an unusual amount of blood in the vessels,
due to any cause whatever. A hyperaemia due to physiological causation,
as in glands during active secretion, in the skin in blushing, and in erectile
structures, is called a determination of blood. Hyperaemia resulting from
imperfect venous return, due to mechanical pressure on veins, gravity, or
diminished cardiac power, is called congestion, which term should be
employed only in this restricted sense. Hyperaemia produced by an
increased amount of blood thrown into a part is often denominated
“active congestion,” but this tends to produce confusion. For practical
3
34 I N F L A M M A TI O N .
purposes this form of hyperaemia is the first step toward inflammation,
and, though often no sensible effusion occurs, it might, with considerable
propriety, be styled inflammatory hyperania.
Hyperaemia and inflammation have a close relationship, since hyperaemia
whether physiological, mechanical, or active, if continued, leads to effusion
and exudation, and inflammation at once exists. When inflammation
subsides, hyperaemia is left as the last step toward restoration of the part
to health.
To indicate inflammation of a structure the termination “itis” is added
to the name indicating the structure affected, as synovitis, pleuritis.
CAUSES.—The causes of inflammation are: the exciting or determining,
which give rise to the actual outbreak of inflammation, and the predis-
posing, which have previously created a tendency that requires merely
an exciting cause to initiate the inflammatory process. Exciting causes
may be local, as in injuries, and constitutional, as in syphilis. Predis-
posing causes, in like manner, may be local, as in the weakness of an
organ resulting from previous inflammations, and constitutional, as in
inherited or acquired impairment of bodily vigor. A given cause may
be at one time an exciting, at another a predisposing, cause. For
example, hyperaemia due to increased functional activity of an organ may
be the exciting cause of inflammation; again, the same hyperaemia of the
same organ may be the predisposing cause to which an irritation, acting as
an exciting cause, must be added to induce the outbreak of inflammation.
Inflammation due to external injury is called traumatic, that without
definite assignable cause idiopathic. The latter term must not be under-
stood as implying that inflammation can arise without a cause. The
cause is always present, but may elude our search. Inflammation cannot
spread unless its cause has extended its area of influence, nor can it per-
sist without a similar persistence of its causation.
In considering the causes of inflammation it must be remembered that
there are two factors in its etiology—the cause which exerts an exciting
influence, and the tissue upon which such influence is exerted. In
some cases the exciting cause acts without any predisposition of the tissue
being present, while, at other times, the same exciting cause cannot pro-
duce inflammation unless the normal resisting power of the tissue is
lowered. This impaired resistance of the tissue may result from either
an acquired or an inherited predisposition. It is seen, therefore, that the
predisposing cause of inflammation may be anything which has a ten-
dency to lower the health of the body, or the health of any part of the
body. Among causes which may induce inflammation there are some
which are perfectly obvious and easily detected. These produce what
are often called simple traumatic inflammations. Under this head may
be included mechanical and chemical injuries; injuries due to the appli-
cation of heat or cold; those due to electricity, which causes electrolysis
of the fluids, or to prolonged anaemia, or bloodlessness, of the part. Ex-
cessive functional activity and nervous influences are said to produce
inflammation. Such inflammations do not tend to spread beyond the site
originally subjected to injurious influences, nor to increase in severity
after the application of the exciting cause has ceased. In fact, the
height of the inflammation is reached soon after the receipt of the injury,
and the inflammation rapidly subsides.
The irritation and consequent inflammation produced by a chemical
agent does not, however, always show itself at the point at which the
chemical agent gains admission to the body. Examples of this are seen
C A U S E S, 35
in instances of inflammation of the internal organs, such as the kidneys
and liver, produced by the absorption of drugs through the skin or
stomach. Alcohol, for instance, produces chemical inflammation of the
liver. Certain drugs, on the other hand, act injuriously on the kidneys,
by which organ they are eliminated from the blood. These are instances
of inflammation due to chemical causes, but widely different, of course,
from the inflammation of the skin produced by powerful caustics, where
the inflammation is produced at the point of application of the agent.
Rheumatic and gouty inflammations are perhaps due to a similar
action of chemical agents in the blood. The inflammations due to what
is ordinarily called exposure to cold or wet are probably associated with
an irritation of the vessels, due to driving the blood from the surface of
the body to the internal organs.
Many inflammations whose causation was formerly obscure, and which
were, therefore, called idiopathic, are now believed to be due to the
presence of vegetable organisms. These fungi, which are variously
called bacteria, microbes, and microörganisms, multiply in the fluids of
the human body, and therefore furnish continuously acting causes. In-
flammations resulting from these fungi, or microscopic plants, may be
due to the mechanical or chemical action exerted by them.
There is a very great variation in the severity or type of inflammation
due to these organisms; some of them are very virulent, causing at once
gangrene, others cause a suppurative inflammation, and still others a
chronic inflammation. The variety of inflammation may be fibrinous,
suppurative, or productive. One of the most important inflammations
produced by these fungi is that form which is called tuberculous. From
what has been said, it is easily perceived that these organisms have indi-
vidual characteristics. That form which produces a certain disease can-
not produce any other disease, but such other disease is caused only by
another form of organism having a different life history.
Again, there are many organisms which, by entering the fluids of the
body, do not, so far as known, produce any form of inflammation or dis-
ease. These are called non-pathogenic organisms in contra-distinction to
those above referred to, which are called pathogenic organisms.
In studying the microbic, or mycotic, origin of inflammation it must be
remembered that the inflammation is not due to the mere presence of the
microbes within the body, because, under ordinary circumstances, the
normal resistance of the tissues to pathogenic processes prevents the
occurrence of inflammation. In other words, bacteria moving freely in
the blood-current may not inflame the tissues. Certain contingencies are
requisite before their deleterious influence can be exerted. It is necessary
that the organisms shall be arrested so as to be able to multiply and pro-
duce irritation; because, it requires a large number of these organisms
in the tissue to produce a pathogenic change. Such arrest of bacteria
may be caused by the processes of embolism or thrombosis, or by injury
to a bloodvessel by which an extravasation of blood takes place into the
connective tissue surrounding the capillary vessels; or they may be
filtered out of the lymph-current by the lymph-glands. These processes
which allow the microörganisms to come to rest and settle may be the
needed factor which shall cause the advent of inflammation.
It may occur that, notwithstanding the arrest of bacteria, no inflam-
mation occurs because there is no predisposition in the tissue at the point
of arrest, or, in the general system of the patient, to suffer from microbic
1I] Wasl OI).
36 I N F L A M M ATION
This makes clear to us what is meant in the preceding paragraph by
“predisposing causes of inflammation.” Any circumstance which results
in a depression of the vital powers, such, for example, as the continued
abuse of alcohol, or prolonged anxiety and exhaustion, may induce a
general or constitutional predisposition to inflammation. Bruises which
cause extravasation of blood may act as a local predisposing cause; as,
indeed, may any variety of wound. Wounds which are open to the air,
by giving entrance to microörganisms upon the surface of the body and
in the air, are much more prone to inflammation than subcutaneous
wounds, since the latter exclude the bacteria which are external to the
patient's body.
Some bacteria will cause inflammation only when they gain access to a
certain kind of soil which is favorable for growth and development.
Portions of the body, for instance, may be too cold for their development,
in which event inflammation will not occur or will be arrested. If, how-
ever, these same organisms happen to become located in some part of the
body which is warmer, they multiply and may at once excite inflamma-
tion. This illustrates what has been said before, that each organism has
its peculiarity which must be accommodated in order to allow its devel-
opment and pathogenic action. These microscopic plants are just as
particular as to the kind of soil in which they grow, and as to the cir-
cumstances surrounding their growth, as are the trees with which we
come in contact in the larger world.
Certain conditions of the blood, such as diabetes and Bright's disease,
are particularly favorable for the development of certain forms of bacte-
rial life and consequent inflammations.
The occurrence of inflammation depends upon other conditions than
those already mentioned. The species of organism with which wounds
and tissues are affected is a factor of imporance. Some organisms are
much more virulent than others.
Again, the number of organisms which gain access to the tissues is a
matter of importance. It can easily be understood that if but a small
number infect the animal or human being, they can be destroyed or ren-
dered inert by the normal resistance of the tissue. It is known that the
leucocytes have a tendency to surround germs and to enclose them so as
to prevent their acting upon the tissues. At other times the leucocytes
or white blood-cells appear to eat up the bacteria, and hence are called
phagocytes. If, however, the dose of pathogenic organisms is very large,
or relatively large compared with the resistant power of the tissues and
the leucocytes, inflammation will be induced.
It is a curious fact that the growth of several organisms together may
induce inflammatory results, which no one of them alone is capable of
effecting. This is seen in the harmful effects resulting from the associa-
tion of putrefactive organisms and pus-causing organisms. In this in-
stance it is probable that the putrefactive bacteria destroying the granu-
lation tissue which may be present, allow the pyogenic fungi to gain
access to the general circulation.
It is believed, also, that some organisms act antagonistically to other
species of fungi. A patient inoculated with erysipelas becomes immune
to infection with the anthrax bacillus.
The poison from microörganisms may be attenuated by certain labora-
tory methods of handling the fungi. If they are cultivated outside of
the animal body, and not passed through some animal for a long period
of time, they soon diminish in virulence. There are other methods of
MIC RO6 RG ANISM S ASSOCIATED WITH DISE As E. 37
cultivating these organisms, which in a similar way weaken or attenuate
the poison. It is stated that the poisonous qualities may also be increased
by similar manipulation in the bacteriological laboratory.
MICROöRGANISMS WHICH ARE ASSOCIATED WITH DISEASE.
The pathogenic vegetable parasites or fungi are of three kinds—bac-
teria, yeasts, and moulds. The first are the organisms to whose action
most of the infective diseases are attributed. The disease which we call
thrush, and which is characterized by grayish patches forming upon the
mucous membrane of the mouth and adjacent parts, is due to a parasite
which is one of the yeasts. A number of skin diseases are caused by the
growth of pathogenic moulds. Favus, tinea tonsurans, tinea sycosis, and
pityriasis are instances of parasitic skin diseases due to moulds. Actino-
mycosis is thought to be due to a fungus belonging to this class. It will
be seen, therefore, that, for the surgeon, yeasts and moulds have little
interest, while the first class, or bacteria, are of Supreme importance.
It should be remembered by the student that the word bacteria is used
very loosely by many to refer to all the kinds of parasitic fungi. It is
better, however, to restrict it, as I have done, to a single class, to which
is given the name schizomycetes. Bacteria are characterized by their
method of multiplication, which is either by division, or by the forma-
tion of spores.
Yeasts, however, multiply by the budding process; while the moulds
have a more complicated method of multiplication or reproduction, and
are characterized by numerous threads which interlace and form the
mycelium.
It is sufficient for our purpose to describe the different forms of cells
which characterize the bacteria. If the cells are spherical or egg-shaped,
the fungus is called a coccus; if the cells are straight rods, the fungus is
called a bacillus; if the rods are curved, the name vibrio is used; when
the plant assumes a more twisted form, it is called spirilla. These four
terms, then, are used to give an idea of the shape of the plant, a single
cell of which constitutes an individual. These cells may be grouped
together in various ways. If the round or oval cells show a tendency to
grow together in groups somewhat like bunches of grapes, the fungus is
called a staphylococcus, or grape-coccus; if the same shaped cells always
grow in straight chains, like beads upon a string, the plant is called a
streptococcus, or chain-coccus; if there is a tendency for two round or oval
cells to keep close together, but separate from other cells, the fungus is
called a diplococcus.
These remarks make clear the terms used to describe the fungi found
in surgical diseases. The streptococcus pyogenesis, in accordance with its
name, a pus-causing chain-coccus; whereas the staphylococcus pyogenes
is a pus-causing grape-coccus. There may be several kinds of staphylo-
Qoccus or streptococcus, each of which has a distinctive adjective added to
its name. Thus we have the white pus-causing grape-coccus and one of a
golden color which has a similar pathogenic action.
In multiplying, as has been said, schizomycetes, or fission fungi, to
which have been given the name bacteria, divide so as to form two or
more individual cells. Some of them, however, multiply by the forma-
tion of spores, round or oval bodies, which grow within or from the
cells, and subsequently become separate individuals. Some of these
38 I N F L A M M AT I O N .
microörganisms have the power of motion and are called, therefore, motile
forms. The various forms differ from each other in the character of food
which they require; though carbon, hydrogen, nitrogen, phosphorus,
sulphur, magnesium, and potassium are needed, probably, by all. The
presence of water is necessary for the development of fungi; therefore,
thorough drying prevents multiplication of fungi, and, in some cases,
kills them. Some require oxygen, which others can do without. The
temperature to which they are exposed has also an important bearing on
the life and development of nearly all forms. They are killed by boil-
ing, or by a degree of heat very little above the boiling-point, provided
that moist heat is used. Dry heat does not destroy them until it reaches
a point considerably above the boiling-point. The bacillus of malignant
pustule is of all pathogenic microörganisms the most difficult to destroy
by heat. Spores will resist a higher degree of heat and more changes of
condition without loss of vitality than will fully developed fungi.
Bacteria are found in the air, in the water, in the earth, and upon the
external surface of the human body. These organisms in large numbers,
both pathogenic and non-pathogenic, are found under the nails and in the
various folds of the skin, such as the axilla. They are also numerous
upon the mucous membranes which come in contact with the air, such as
the bronchial and intestinal mucous membranes and those of the mouth
and oesophagus. In many instances they do no harm, even if pathogenic ;
because of the resistance of the tissues to their action, which is great
when the vitality of the tissues is unimpaired, or because of the com-
paratively small number which gain access to the tissues. Under favor-
able circumstances, however, multiplication is very rapid, and one indi-
vidual may become many millions in twenty-four hours. -
It has previously been stated that the mere presence of pathogenic
organisms in the blood-current is not sufficient to give rise to disease.
This, according to present pathological views, can only occur when the
circumstances are favorable to their development within the body, and
the resisting power of the tissue to their injurious action is imperfect.
The antagonism of the tissues to microbic invasion tends to prevent
disease, unless the number or dose of infecting germs is too large to be
successfully repelled. The leucocytes may form a wall or barrier around
the bacteria, and, thus hemming them in, prevent their dissemination
through the body; or they may be taken into the interior of the leuco-
cytes and their vitality be destroyed.
VARIETIES.—All forms of inflammation are either acute or chronic.
The acute is rapid in course or severe in symptoms, the chronic slow in
progress or less severe in symptoms. It will thus be seen that the terms
acute and chronic (perhaps improperly) each contain two ideas—one refer-
ring to time, the other to severity. The word subacute is used to express
an intermediate severity between acute and chronic, but has no reference
to time. Hence inflammation, as to time, is termed either acute or
chronic ; as to severity, it is expressed as acute, subacute, or chronic.
Although inflammation is essentially the same in whatever tissue it
may occur, the character of the exudate varies in accordance with the
resistance of the tissue, the intensity of the injurious causative influence,
and the time of action of that influence. These variations in the exudate
may often be found in the same inflammation by examining different
areas of inflamed structure.
Serous Inflammation. — In serous inflammation the exudate is
characterized by a small amount of albumin and few leucocytes, being,
W A. R. I. ET IF. S. 39
indeed, very slightly different from the normal transudate of healthy
tissues. This fluid does not coagulate. Instances of serous inflammation
are seen in pleuritis with effusion, arthritis, hydrocele, and in inflamma-
tory oedema of connective tissue. This form of exudate may be expected
after slight or momentary injuries, in the early stages of more severe in-
flammations, and in cases where the blood is impoverished.
Fibrinous Inflammation.—Fibrinous inflammation gives rise to an
exudate containing larger quantities of albumin and more leucocytes,
and hence more coagulable. It forms, upon free surfaces and in the sub-
stances of organs, that which is clinically denominated “lymph.” Lymph,
then, is an inflammatory product consisting of fibrin and entangled leuco-
cytes. It is sometimes called plastic lymph, to show that it is entirely
different from the fluid called lymph which circulates in the lymphatic
vessels.
The best examples of this form of inflammation are seen in the serous
membranes, such as the peritoneum and pleura, and in the long continued
or chronic inflammations of slight intensity in connective tissue.
At times we find a grade of inflammation intermediate between these
forms, which may be termed sero-fibrinous inflammation.
These varieties of the inflammatory process may end by absorption of
the exudate, which is accomplished by the leucocytes returning into the
circulation by first entering the lymphatic vessels, and by the fibrin and
some of the leucocytes undergoing fatty degeneration previous to such
absorption by the lymphatic system.
Suppurative Inflammation.—In this very common form of inflammation
the exudate contains the same elements as in the fibrinous, but does not
coagulate. No lymph, therefore, is deposited, or, if any lymph has been
deposited by the previous form of inflammation, it is destroyed by the
accession of the suppurative stage. It is thus seen that the so-called
varieties of inflammation are rather stages, or degrees, of the process.
Suppurative inflammation is the result of a more irritative or longer con-
tinued cause than the serous or fibrinous forms.
Acute suppuration is another term signifying the same process. If the
suppuration is circumscribed in an abnormal cavity, the resulting condi-
tion is called abscess; if diffused in the tissues, purulent infiltration. Pus
contained in a normal cavity, such as the pleural sac or knee-joint, is called
a purulent effusion. If suppuration occurs upon a free surface of mucous
membrane the condition is called purulent catarrh, provided the epithelium
of the mucous surfaces is not destroyed; while it is called ulceration if
the epithelium and subjacent tissue are destroyed. Suppuration attack-
ing a cutaneous surface also gives rise to what is called ulceration.
Productive Inflammation.—When the exudate of a serous or fibrinous
inflammation becomes converted into new connective tissue, the inflam-
mation is termed productive, because of the formation of this new struc-
ture. This process is accomplished by the fibrin disappearing and
numerous leucocytes coming into the lymph, after which vascular loops
from the capillary vessels of the inflamed structures penetrate the lymph
and become surrounded by young cells. This new tissue, consisting of
capillary loops and young cells, which have developed within the sub-
stance of the lymph, is called granulation tissue. Granulation tissue may
be converted into connective tissue, often called scar tissue; it may de-
generate into typical tubercles; it may become material looking like
pus, but which is not true pus; or finally, it may actually break down
40 I N F L A M M ATIO N.
into pus, the inflammation assuming the character of suppurative inflam-
mation, which it then is.
The second transformation of granulation tissue gives rise to what is
variously called “chronic” or “cold’ abscess and chronic suppuration
in bone.
MODES OF EXTENSION.—Inflammation cannot spread unless its cause
extends before it; hence, inflammations due to mechanical and chemical
irritants do not spread beyond the point at which the irritation was first
exerted. All those inflammations which tend to spread from the original
site are probably due to microbic causes. It may be taken for granted,
in accordance with the present state of pathological knowledge, that the
spread of inflammation is due to vegetable parasites. Such inflammations
spread in three ways—by continuity of tissue, by the lymph-current, and
by the blood-current. {
When inflammation spreads by continuity of tissue, the bacteria which
have settled there are spread into the surrounding tissues by being carried
thither by leucocytes and by the lymph-channels. This mode of exten-
sion of an inflammatory process is comparatively limited in its action.
When mycotic inflammation spreads by the lymphatic vascular system,
the bacteria are carried along by the current in the lymphatic vessels
until they reach the first gland, where they are filtered out by the ramifi-
cations which the current makes in passing through the interstices of the
gland. After being arrested thus they multiply and act as an exciting
cause of inflammation, producing in the gland a secondary inflammation
which is located at a considerable distance from the primary disease. This
is quite different from the method of extension just described, where the
fungi travel a short distance only in the lymph-current, or are carried
short distances by the white blood-cells, choosing, as they do, the paths of
least resistance. The blood-current may carry bacteria to all parts of the
body, but they are innocuous, as a rule, until they are arrested by ex-
travasation, by clotting of the blood, or embolic plugging of the vessels.
Under these circumstances, secondary or metastatic inflammation occurs.
Pyaemia is a good example of such metastatic inflammation. The inflam-
mation of mumps being carried to the breast and testicle is a similar
example of metastatic inflammation.
PATHOLOGY, SYMPTOMs, AND TERMINATIONS OF INFLAMMATION.
PATHOLOGY-The study of the pathological or essential nature of in-
flammation must be divided into a consideration of the rôles played by
(1) the nerves, (2) the small blood vessels, (3) the blood, and (4) the
tissues. The changes occurring in each of these, though in the main
synchronous, must be investigated separately.
1. Nerves.—The agency of nerves is really unknown. The vaso-motor
nerves may have a causative influence in the dilatation of the vessels, due
to a reflex action following irritation of the part affected; but of this
nothing definite can be asserted. Recent researches show pretty conclu-
sively that inflammatory phenomena depend on a direct injurious influence
upon, and a vital alteration of, the walls of the blood vessels, without the
necessity of any direct nervous agency.
2. Bloodvessels.—As has been previously stated, the essential factor or
lesion of inflammation is the change that occurs in the walls of the small
bloodvessels, by which the friction between the wall and the blood-current
P A TEIO L O G. Y. 41
is increased and the wall is made more porous. In inflammation of non-
vascular tissues, such as the cornea and cartilage, the same vascular
alterations take place in the vessels which surround these structures, and
upon which their nutrition depends. The vascular phenomenon of inflam-
mation is dilatation of the arteries, capillaries, and veins; followed by
acceleration, with subsequent abnormal retardation, of the blood-current.
Mere acceleration of blood-flow not followed by abnormal retardation
does not constitute inflammation, though it may lead to it. The dilata-
tion of the vessels and the abnormal retardation of the current must be per-
manent. A preliminary contraction of the capillaries is at times seen,
but it is not an essential factor.
While vascular dilatation and blood retardation are being established,
the white corpuscles accumulate, especially in the venules, and the red
corpuscles generally in the capillaries, until stagnation or stasis of the
current occurs. This stage of absolute cessation of motion is preceded by
one in which is seen a mere oscillation of the vessel contents synchronous
with the cardiac pulsations. Synchronous with these vascular changes
there occur permeation of the blood elements through the vessel walls and
increased absorption by the lymphatic vessels.
3. Blood.—The white corpuscles (leucocytes) are relatively increased
in inflammatory blood, and show a tendency to keep near the walls of
the vessels. They are less heavy than the red corpuscles, and hence are
thrown to the margin of the blood stream. Inflammatory blood when
drawn shows more fibrin than non-inflammatory blood. This condition
of hyperinosis and the buffy coat, formerly considered diagnostic of in-
flammation, have no diagnostic or therapeutic value. During inflamma-
tion white cells migrate through the walls of the venules, and red cells
are pressed, as it were, through the walls of the capillaries into the sur-
rounding tissues. This escape is supposed to occur through small open-
ings (stomata) resulting from stretching of the walls of the dilated vessels.
There is no emigration from the vessels in which absolute stagnation has
taken place, nor from the arterioles. The escape of the white corpus-
cles usually greatly exceeds that of the red, and the vessels soon become
surrounded and obscured by the crowd of extra-vascular leucocytes.
In intense inflammations in very vascular tissues the red escape in greater
numbers than the white corpuscles, and a resulting hemorrhagic spot is
visible to the naked eye. The number of migrating cells is increased in
the later stages of the inflammatory process. It is possible for the
emigrated leucocytes—(1) to be transformed into tissue cells; (2) to re-
enter the bloodvessels; (3) to enter the lymphatic vessels; (4) to become
pus-cells.
There also occurs an escape or exudation of fluid derived from the blood
liquor and similar to it, which, when associated with the escaped white and
red blood corpuscles and the proliferating cells of the inflamed tissues, con-
stitutes the inflammatory exudation, or, as it has been termed by some
writers, inflammatory lymph or fibrin. The escaping fluid differs from
the simple serous or dropsical effusion, that occurs in congestion or
mechanical hyperaemia, in that it contains more white corpuscles, more
albumin, and is more prone to spontaneous coagulation. It differs from
blood liquor, or liquor sanguinis, in having less albumin and less coagula-
bility. I prefer to call this inflammatory fluid an evudation of lymph, or
simply an evudate, and the escape arising from venous distention a trans-
wdation of serum, or simply a transudate.
This exudate or inflammatory lymph is of paramount importance to
42 IN FLA M M ATION.
the surgeon, for, by its organization and transformation into tissue anal-
ogous to that at the seat of injury or disease, hemorrhage is prevented,
wounds united, abscesses circumscribed and limited, plastic surgery made
possible, and other reparative surgical processes accomplished. At times,
however, it produces morbid conditions, strictures, and adhesions, alters
structure by interstitial deposit, and is exceeding destructive to functional
integrity.
It is well, it seems to me, to apply the term exudate, or lymph, to effusions.
occurring from inflammation, even when they closely resemble the serous
transudate of mechanical venous obstruction. The milder forms of in-
flammation give rise to a fluid containing so little albumin and having so
little tendency to coagulation that it is impossible to distinguish it from
the fluid of a non-inflammatory dropsy. If, however, inflammation exist,
let this be called lymph; if inflammation does not exist, call it a transu-
date or serum.
On mucous or serous surfaces the exudate is readily seen during the
progress of inflammation; in some tissues it is exhibited as swelling; in
the cornea and other non-vascular structures it is found surrounding the
part, because it is the adjacent vessels which present the inflammatory
alterations. The blood phenomena of inflammation, then, are migration and
evudution.
4. Tissues.—The tissues are swollen and infiltrated with the escaping
blood elements, and the proper cells of the tissue involved show disordered
nutrition, such as coagulation-necrosis and fatty degeneration. The im-
pairment of nutrition may result in the formation of inferior tissue, sup-
puration, or gangrene. The peptonizing action of microörganisms has
to do with the inflammatory destruction of tissue, and thus aids the
malign influence of the chemical and physical changes wrought by original
injury and the deluging of the tissues with escaping blood-elements.
Within the tissues there is proliferation or multiplication of the white
blood-cells which have escaped from the vessels; but multiplication of
the proper or native cells of the tissue does not take place, except when
repair or regeneration of tissue is going on coincident with inflammation
of only moderate intensity. This proliferation must not be considered as
a part of the inflammatory process. During inflammation the tissue ele-
ments are obscured by the intermingled white corpuscles and filaments of
fibrin; and the structures are changed in physical consistence, being
sometimes softer than normal, at other times harder.
The tissue alteration of inflammation, then, may be described as dis-
turbance of nutrition associated with proliferation of white blood-cells. t
The phenomena of inflammation may finally be thus formulated:
1. Nerves: Unknown, or possibly vaso-motor influences.
2. Bloodvessels: Permanent dilatation of calibre associated with per-
meability of walls.
3. Blood: Permanent abnormal retardation of current associated with
migration and exudation.
4. Tissues: Disturbances of nutrition associated with proliferation of
white blood-cells. It was formerly held that the native or tissue cells
also underwent proliferation.
SYMPTOMs.-The local symptoms of inflammation are those exhibited
at the point at which the process is going on; the constitutional or general
symptoms are manifested by the patient's organism as a whole and are
observable in functional derangement of the various organs without any
necessary relation to the situation of the inflammatory changes. The
SY M P T O M S . 43
general symptoms imply an existing inflammation, but do not indicate its
locality.
The local symptoms are pain, discoloration, swelling, heat, and disordered
function. It requires the co-existence of a number of these abnormal
manifestations to constitute inflammation, and one or more may be
prominent or entirely absent, according to the variety of the inflammation
and the nature of the inflamed tissue.
Pain is a subjective symptom of inflammation, while the other manifesta-
tions are, for the most part, really objective physical signs. The pain of
inflammation is due to pressure of the exudate on nerve-endings and
possibly to chemical irritation exerted upon them; is persistent; is in-
creased by motion and the dependent position; and must be distinguished
from the paroxysmal pain of neuralgia and spasm. Its severity depends
more upon the tissue affected than the degree of inflammation, and is
often inverse to the amount of swelling possible, because the pressure of
the distended vessels and exudate upon the nerve filaments is increased
when the structures are too dense to allow swelling. Pain may be reflected
by nervous distribution to a part remote from the seat of disease, as occurs
in coxalgia; in such cases it is not strictly a local symptom. Throbbing
pain, which is due to increased tension at each pulsation of the heart, is
usually indicative of the advent of suppuration.
The discoloration usually varies from the shades of red, the usual hue,
to those of purple and blue. It is essential that the alteration in color be
permanent, for the transient hyperaemia of merely physiological causation
also produces redness. In the cornea, arachnoid, and similar non-vascular
structures the change is manifested by a whitish opacity and a loss of
lustre, while the surrounding vascular tissues present the usual inflam-
matory redness. In iritis there is a loss of lustre and a brownish dis-
coloration.
The blackness of gangrenous tissue and the whiteness of necrotic bone
have been erroneously instanced as illustrations of inflammatory altera-
tion of color, but, since inflammation ends at the moment death of tissue
occurs, these are not strictly inflammatory discolorations. The cause of
the red discoloration in inflammation is the abnormal amount of blood in
the vessels, and, perhaps, at times, a real staining of the tissues by the
coloring matter of the corpuscles. As resistance to flow of blood increases
because of change in wall of vessels and pressure from exudate, the parts
become bluish, or mottled and pale.
The temperature of an inflamed part is usually increased. It is fre-
quently above 100°F. There is no production of heat at the inflam-
matory focus, but the increase is due to the increased rapidity of the
arterial circulation. A local increase of heat in chronic inflammation
may be imperceptible; hence, for example, we speak of “cold” abscesses.
Inflammatory swelling is due to the increased amount of blood in the
Vessels and to the migration and exudation which occur. If the exudate
consists principally of fluid the part is said to be cedematous; and a de-
pression made in the surface by pressure of the surgeon's finger is apt to
remain for a few moments as a little pit. This “pitting” does not show
if the tissues are tensely stretched. It is most typical in oedema from
mechanical hyperaemia. Usually the exudate is cellular rather than
fluid and the swollen tissues are too hard to pit. Swelling is always
great in those parts, such as the scrotum, formed largely of loose con-
nective tissue, because there is less resistance to the escape from the
Vessels of inflammatory products. In dense resisting structures and under
44 I N F L A M M A TI O N .
tense fasciae much swelling is impossible; and hence, great pain is exper-
ienced during inflammation in such localities. The tissue-pressure thus
induced may lead to gangrene by totally obstructing circulation, if not
relieved by free incisions to allow escape of fluids and to relax distended
structures. The occurrence of swelling is frequently beneficial by dimin-
ishing the intravascular pressure. If the exudate is small in quantity and
the lymphatics carry it off, no swelling will exist. This occurs in slight
grades of inflammation.
Disordered function is a symptom (sometimes subjective and sometimes
objective) always present, and attracts attention when the other manifesta-
tions of inflammation are more or less in abeyance. The increased or
impaired sensibility of the 'sense organs; the irritability of the hollow
viscera; the modified secretions of the various glands; and the alteration
of nutrition, shown by defective absorption, by atrophy and hypertrophy,
are all well-known instances of functional disturbance arising from in-
flammation. The injury inflicted upon every tissue by the morbid process
readily explains the functional disturbance.
The general or constitutional symptoms of inflammation are grouped
together and called inflammatory or symptomatic fever, because the in-
crease of the general bodily temperature is such a characteristic member
of the group. The terms traumatic fever and surgical fever are some-
times employed as synonyms of inflammatory fever when the inflamma-
tion is due to an injury. Inflammatory fever varies with the intensity,
extent, and locality of the process, and with toxic influences associated
with it, and is practically absent in slight inflammations of unimportant
localities and when microbic infection of the blood is prevented. It de-
pends on the presence in the blood of products of the morbid tissue-
change occurring at the seat of inflammation, or of poisonous principles
manufactured at the seat of injury by microorganisms of a vegetable
nature. The most important duty of the surgeon is to protect all acci-
dental or operation wounds from infection by these vegetable parasites,
which, under the general name bacteria, enter the blood-stream and
are believed to be responsible for all grave degrees of inflammatory
fever. Inflammatory fever, in other words, is usually a poisoned condi-
tion of the blood due to microörganisms. Inflammatory fever becomes
prominent within twenty-four hours after the incipiency of the local
symptoms. There are two types of constitutional disturbance in inflam-
mation : the sthenic, representing excess of force; the asthenic, repre-
senting want of force. The irritative type, so-called, is not a special
form, as all cases are necessarily either sthenic or asthenic. The
respiratory, circulatory, digestive, nervous, secretory, and other gen-
eral symptoms accompanying inflammation show modifications accord-
ing to the type of the constitutional disturbance; hence, as the treatment
must greatly vary in the two conditions, the necessity of an early recogni-
tion of the type is evident. The constitutional symptoms of inflammation,
when asthenic, resemble those of typhoid fever; hence, they are often
said to belong to the “typhoid condition.”
The student must remember, however, that typhoid or enteric fever and
the “typhoid condition,” though presenting similar symptoms, are dif.
ferent entities.
The following table shows the differential diagnosis of typical cases of
sthenic and asthenic inflammatory fever :
T. R. E. A. T M E N T . 45
Sthenić. Asthenic.
Patient . . . . Usually of vigorous constitution. Previously of weak constitution,
though may have been vigorous.
Pulse . . . . . Full, bounding, 90–120. Compressible, weak, 120–160.
Respiration . . Oppressed, hurried. Shallow (?), hurried.
Digestive organs. Constipation, loss of appetite, Bowels, irregular, tendency to
white furred tongue, thirst. diarrhoea, loss of appetite, brown
and dry tongue, Sordes, thirst.
Skin . . . . . I)ry and hot, temperature 100°– Often clammy, temperature 99°–
105°, chill at beginning. 101°, chills and colliquative
sweats.
Urine . . . . Scanty, highly colored, uric acid No marked difference from sthenic
abundant, chlorides diminished. type.
. Nervous system . Restless, headache, active de- Stupor, not much headache, mut-
lirium. tering delirium.
Muscular system. Pain in back and limbs. Twitching of tendons.
TERMINATIONS.—There can be but two terminations of inflammation.
First, gradual return of the tissues to health without destruction of their
elements and functions; and second, death of these tissues, which may
take place molecularly or in masses large enough to be readily seen.
When inflammation terminates in the first manner the walls of the blood-
vessels are restored to their normal condition, the deposits absorbed and
the damaged tissues regenerated. Resolution is then said to have taken
place. In the second instance, if death occur molecularly, that is, if small
particles die, it is called ulceration if in soft tissues, and caries if in
bone; while death in mass of soft parts is termed gamgrene; of bone,
necrosis. It should be observed that pathologists apply the term necrosis
to all forms of tissue-death, whether in bone or soft structures, in mass or
in small particles.
When the surface of an inflamed mucous membrane suffers death and is
covered with a gray, yellowish or reddish membrane, which is tough and
adheres to it, the inflammation is said to be of a diphtheritic character.
Such gangrenous inflammations occur on the conjunctiva or any other
mucous membrane, and may attack wounds. They are infective inflam-
mations and take their name from the disease diphtheria, which often, but
not always, gives rise to a pharyngeal inflammation of this character.
Not all diphtheritic inflammations, however, are diphtheria. These mem-
branes differ clinically from the layer of lymph which ordinarily forms on
inflamed surfaces by the great difficulty with which they are detached.
The results or sequences of inflammation, such as newly organized
tissue, adhesions, effusions, exudations, pus, sloughs, and sequestra must
not be confounded with its terminations. It can only terminate either in
a return to health of the tissues inflamed or in the death of the same.
The parts in the vicinity may continue in a state of inflammation, but the
death of tissue, by either ulceration or gangrene, effectually terminates
the inflammatory process in that particular issue.
Resolution is the termination of inflammation which the surgeon ordi-
marily aims to secure, but in many instances it is impossible to obtain it,
and suppuration, ulceration, or gangrene occurs. Hence, after considering
the treatment to be pursued in the endeavor to obtain resolution, I shall
discuss suppuration, ulceration, and gangrene.
TREATMENT.-The most important precept that can be taught in rela-
tion to the management of inflammation is this: Inflamed structures tend
to recovery as soon as the cause of inflammation is removed. Hence,
when the surgeon can remove the cause the rest of the treatment consists
in merely waiting for the reparative efforts of nature, and in averting any
secondary irritative action that may supervene. When the obscurity of
46 IN FLAM M ATION.
the cause precludes its removal, efforts must be made to avert the advance
and the destructive effects of the inflammation, until the cause ceases to be
operative.
The indications of treatment in all cases of inflammation, then, are to
remove the cause and to establish resolution as promptly as possible.
Removal of the cause is to be effected on general rational principles:
for example, a foreign body is to be extracted from the tissues; the patient
himself is to be transported from unfavorable surroundings; or, if the
cause lie in some vitiated state of the blood, remedies to remove that
state are to be administered. Attempts to remove the cause are not justi-
fiable, however, if they render the patient liable to conditions more dan-
gerous to life than that for which he is being treated, for it must always
be remembered that the surgeon is treating a condition rather than an
entity.
Resolution, if possible, is to be induced by local and constitutional
measures. The latter, of course, includes hygienic and dietetic as well as
medicinal agencies. After injuries and operations the surgeon desires
the presence of reparative inflammation to heal the wounds, and, there-
fore, little is required except attention to prevent the occurrence of inor-
dinate inflammatory action. The prevention and arrest of microbic
infection of wounds is the most important duty of the surgeon in this
connection. The means by which these ends are to be accomplished will
be discussed under Treatment of Wounds.
The local treatment of inflammation is properly discussed before the
constitutional, because many cases of minor severity demand no constitu-
tional treatment whatever. Inflammation is treated locally by (1) posi-
tion and functional rest; (2) cold ; (3) heat; (4) anodynes; (5) blood-
letting; (6) diminishing arterial supply; (7) antiseptics and necrotics;
(8) stimulants and astringents; (9) counter irritation; (10) compression
and friction.
Position and functional rest.—Rest from functional activity and that
position which renders afflux of blood to the part most difficult are
essentials in treating inflammation, especially when acute. Elevation
and immobility of the parts are, therefore, usually to be enforced, sup-
plemented in many cases by confinement to bed.
Cold.—The depressant and sedative action of cold is utilized as a pre-
ventive of inflammation, and, in the earliest stages of the process, to limit
its severity. It should not be employed when suppuration or mortifica-
tion is to be feared, nor, as a rule, in chronic inflammation. Cold and
moisture may be applied by cold baths, rapidly evaporating lotions, or
by irrigation in which a constant application of water, simple or medi-
cated, is maintained by allowing it to drop on cloths laid over the inflamed
part. Dry cold is obtained by using tubes or rubber bags filled with
cold water or ice.
Heat.—Heat is practically always combined with moisture, because all
warm applications soon become saturated with secretions from the skin.
Hot dressings are properly used when there is pain and tension, a tendency
to suppuration, and a probability of mortification. They aid in mortifying
processes by causing separation of the sloughs, thus promoting the suppura-
tive action beneath the dead tissue. Heat is usually indicated when cold
is contra-indicated. It may be obtained by local baths of hot water or
steam, fomentations, poultices, etc.
Any warm or hot application combined with moisture acts as a poul-
tice if evaporation be prevented by rubber cloth, waxed paper, or other
T R E A T M E N T . 47
}
impervious covering. The protracted use of heat is objectionable because
it causes relaxation of tissue. When suppuration is inevitable deep
incision is preferable to poultices, because it relieves pain promptly, pre-
vents destruction of tissue, and hastens cure. It is probable that the
value of moist heat is largely due to its increasing the migration of white
blood cells, which thus, by their numbers, become more powerful in their
antagonism to the microörganisms causing the inflammation.
Anodynes.—The narcotics, especially the preparations of opium and
belladonna, are frequently beneficial by relieving the pain of inflamma-
tion. Extract of belladonna, softened with water and smeared over the
surface, and opium combined with acetate of lead are favorite prescriptions.
Local bloodletting.—The direct abstraction of blood from engorged
vessels and the opportunity of escape afforded deposits infiltrating the
tissues are the means by which puncture, Scarification, incision and wet
cupping act as potent agencies in combating inflammation. At times it
is not practicable to incise the vessels and tissues of the inflamed organ,
and then wet cupping or leeching at an adjacent point is done to relieve
the hyperaemic structures. As a rule the bloodletting should be applied
at the focus of inflammation, and the bleeding encouraged by warm appli-
cations. The advantage of incision over poulticing has been mentioned
previously.
Cutting off arterial supply.—This is done be applying pressure upon,
or by ligating in its continuity, the main artery, and thus diminishing
the supply of blood to the inflamed member. Ligation has seldom been
resorted to, except experimentally; but intermittent digital pressure or
partial compression by compresses is occasionally judiciously employed as
a prophylactic measure after operations on the extremities.
Antiseptics and necrotics are adapted to the treatment of wounds, and
are usually employed as prophylactics to prevent excessive inflammation
liable to occur from pyogenic or putrefactive bacterial infection or from
inoculation of animal poisons.
The use of carbolic acid, corrosive sublimate, beta-naphthol, and
similar agents, will be described in discussing the antiseptic treatment
of wounds. The most efficient necrotics to prevent absorption of the
poison of hydrophobia, snake-bites, etc., are the actual cautery, strong
nitric acid, and acid nitrate of mercury. Immediate excision is prefer-
able when it can be adopted.
Stimulants and astringents.-These local remedies, of which nitrate of
silver and acetate of lead are examples, occupy a high rank in the treat-
ment of inflammation, especially of mucous membranes. The more
chronic the inflammation the stronger must be the stimulant and astrin-
gent impression.
Counter-irritation is applied at a point more or less remote from the
inflammatory focus, and varies in degree from mere redness of the skin
to vesication, suppuration, and complete destruction of the skin as by the
actual cautery. Except in the mildest form, as obtained by sinapisms,
counter-irritation is seldom used in acute inflammation. It probably acts
by abstracting blood from, and lessening the textural excitability of, the
inflamed organ.
Compression and friction.—Compression, by means of muslin or elastic
bandages or adhesive strips, and friction, or manipulation (massage),
either with or without oils and liniments, are most efficient means of
relieving muscular spasm and of producing absorption of deposits in
chronic and the late stages of acute inflammation.
48 I N F L A M M A TI O N .
CONSTITUTIONAL TREATMENT.-The general or constitutional manage-
ment of inflammation comprises: 1. Abstraction of blood by vene-
section. 2. Increase of secretion and elimination by cathartics, dia-
phoretics, diuretics, and emetics. 3. Diminution of vascular tension by
cardiac depressants. 4. Increase of vascular tone by tonics and stimu-
lants. 5. Decrease of nervous excitement by anodynes. 6. Reduction
of temperature by antipyretics and the general application of cold. 7.
Correction of morbid conditions of blood by alteratives and specifics.
8. Regulation of sanitary surroundings and diet.
These measures, however, as well as the local means, are not all to be
employed in each instance of inflammation, for, while some are appro-
priate to the sthenic type, others are adapted to asthenic cases. More-
over, it is to be remembered that many medicinal agents have a com-
bination of activities, being, at the same time, evacuants, anodynes, and
cardiac depressants; hence, one or two remedies will often meet all the
requirements.
|Venesection.—In the early stages of acute sthenic inflammation, when
the after-depression from loss of blood will be less detrimental than the
threatened destruction of the integrity of a vital organ, general blood-
letting is beneficial, Venesection acts mechanically by lessening the
amount of blood in the system, and, therefore, relieves inflammatory
engorgement, which may be the most disastrous factor of the inflamma-
tory process demanding treatment. This is especially true of pulmonary
and cerebral inflammations. Vascular engorgement, however, is the
result, not the cause of inflammation, and removal of blood is not re-
moval of inflammation. Venesection should never, as a rule, be employed
when the pulse is feeble and frequent and the symptoms those of asthenia,
nor when it is probable from the activity of the inflammatory attack, as
in blood-poisoning, that depression will shortly follow. w
Catharties, diaphoretics, diuretics, and emetics, are internal remedies of
value; because they increase glandular secretion, which is arrested in in-
flammatory fever, act as derivatives by attracting blood to other organs,
deplete by drawing away the watery constituents of the blood, expel
irritating substances from the system, and have a refrigerant or cooling
effect. t
Depressants.-Aconite, veratrum viride, and antimony are the cardiac
sedatives most frequently employed to reduce the high vascular tension,
exhibited by the full, bounding, frequent pulse of acute inflammation
occurring in robust, plethoric persons. They are selected when the de-
pressing influence of venesection is considered unwarrantable.
Tomics and stimulants.-Asthenic inflammations, on the other hand,
require from the first, quinia, iron, digitalis, alcohol, and highly nutri-
tious food, to increase cardiac power and sustain life under the depressing
effects of the inflammatory process. The same remedies are usually
needed after the subsidence of active sthenic symptoms, which leave the
patient emaciated and exhausted by the severity of the structural changes
that have taken place.
Anodynes.—Pain, restlessness, and general nervous excitability call for
the administration of opiates, chloral, the bromides, sulfonal, hyoscin,
and kindred drugs, to give physiological and functional repose. The
beneficial effect on inflammatory fever of a few hours' profound sleep is
familiar.
Cold.—Sponging the surface of the body, cold packs, and cold baths
are certainly effectual in diminishing bodily temperature, and are
CONSTITU TI O N A L T R E A T M E N T. 49
employed advantageously in inflammatory affections. Antipyrine, anti-
febrin, and similar drugs with a known ability to lower the general
temperature are often valuable remedies.
Alteratives and specifics.-Certain inflammatory lesions are best com-
bated by specific remedies, which have some alterant or eliminating
blood action and which should be given as soon as the diagnosis is estab-
lished. As examples may be mentioned mercury and the iodides in
syphilitic inflammations, quinia in malarial, and colchicum in gouty
lesions. Mercury, because of its supposed antiplastic action, was long
given in all inflammations to lessen the deposition of lymph, but this
belief has deservedly, I think, lost ground. The removal of inflamma-
tory products in chronic conditions is certainly effected by the so-called
sorbefacients, among which the preparations of mercury, iodine, and
ammonium chloride stand prečminent.
Sanitary and dieletic measures.—Cleanliness of person and of surgical
dressings, freedom from microbic and deleterious atmospheric influences;
regulation of the temperature of the room; proper ventilation; freedom
from noise and anxiety; good nursing and judicious diet are more im-
portant than any one requirement heretofore mentioned under the consti-
tutional treatment of inflammmation. Acute sthenic cases may require
some restriction of diet, but not the starvation treatment of past genera-
tions of surgeons. Asthenic inflammation invariably requires concen-
trated, easily digestible food at frequent intervals.
In conclusion, a recapitulation of the differential therapeutic indica-
tions of sthenic and asthenic and of acute and chronic inflammations
may be instructive.
Sthenic cases present symptoms of overaction, and require depleting,
depressant, and non-stimulant remedies, with restricted diet.
Asthenic cases present symptoms of depression, and require corrob-
orant, tonic, and stimulant remedies, with abundance of nutritious food.
Acute inflammations, being either sthenic or asthenic, require treat-
ment according to their type, with depleting and soothing applications
locally.
Chronic inflammations, being usually more or less asthenic in type and
characterized by much inflammatory deposit, require tonic and alterative
treatment, with stimulating applications locally.
C H A P T E R II.
SUPPURATION.
MENTION of suppurative inflammation has been made in a previous
section, but, so important is the relation of the suppurative process to
operative surgery and surgical pathology, that it is necessary to consider
a little more fully the clinical history of this pathological condition.
Suppuration, or the formation of pus, is due to causes which are sufficiently
intense and sufficiently prolonged in their action to give rise to suppura-
tive inflammation, and which have the peculiarity of preventing the
formation of fibrin in the inflammatory exudate. According to present
pathological views, it is believed that the yellow liquid called pus, laud-
able pus according to the older writers, never occurs except when vege-
table fungi are present. In some other cases there is a liquid found which
is often called pus, but which is not true pus. This kind of fluid is found
in so-called chronic abscesses, in bone abscesses, and under other circum-
stances. It is preferable to call it a puriform liquid, and restrict the
term pus to the creamy discharge that escapes from acute abscesses and
ulcerated surfaces.
Let it be understood, then, that for the clinical purposes of the surgeon
pus never occurs except in association with microörganisms, and, therefore,
does not occur in inflammation of a simple traumatic kind, unless the seat
of the inflammation becomes infected with fungi. There are about twelve
vegetable parasites which are known to cause the formation of pus; those
most frequently found are the staphylococcus pyogenes aureus, the
staphylococcus pyogenes albus, and the streptococcus pyogenes. The
first two are grape coccusses, while the streptococcus is a chain-
coccus; the two former usually produce circumscribed suppuration and
abscess, while the streptococcus is usually the cause of spreading and
diffuse suppuration.
The importance of this connection between organisms and suppuration
is very clear, because it indicates at once that great care must be taken to
prevent infection, in simple traumatic inflammations, with germs from the
hands of the surgeon, his instruments, or dressings.
Pus is a yellow or greenish-white, alkaline fluid, presenting character-
tistics varying with the peculiarities of the inflammation producing it.
It consists of a liquid in which float white corpuscles. The pus liquor is
composed of water, albumin, fats, and salts, and is derived from the blood,
with the liquid portion of which it seems to be almost identical. It con-
tains, however, the pus-forming microörganisms and their chemical
products. The corpuscles are, in fact, the migrated leucocytes referred to
in the section on the pathology of inflammation, which have now lost
their vitality. Some of them are still capable of changing their shape
and migrating, and are considered to be the white blood-cells which have
just escaped from the vessels. As usually seen under the microscope the
corpuscles are dead, and have lost the amoeboid movements of the living
cells.
A B SC ESS, 51
Pus has a tendency to cause liquefaction and disintegration of the
tissues with which it comes in contact. It may itself occasionally be
absorbed after fatty metamorphosis, or be changed into a caseous mass;
as a rule, however, if not evacuated by operation it is discharged through
an opening produced by its disintegrating action on the overlying tissues.
It may be secreted from a free, unbroken surface, as in inflammation of
mucous membrane, and constitutes most of the discharge in all cases of
ulceration.
VARIETIES.—When a granulating surface in a healthy person is pro-
gressing favorably toward cicatrization the pus secreted is of a creamy
consistence, and has a specific gravity of about 1030, yellow color, and
little or no odor. These features, therefore, pertain to what was formerly
called healthy, or laudable pus. The so-called unhealthy pus is fre-
quently, though not always, thin, of low specific gravity, of a dirty yellow
or reddish color, and has often an offensive smell, and a tendency to irri-
tate the skin. It is termed ichorous, or sanious pus. Other adjectives
are used to describe various conditions and appearances of pus; thus
curdy, gummy, scrofulous, Sanguinolent, contagious pus, and muco-pus are
terms often heard, but most of them are indefinite and unscientific. At
the present time the occurrence of pus is believed to be due to infection
of the wound by microörganisms; hence no pus can be called healthy.
Wounds, however severe, will, if kept free from organisms, heal without
puS.
TESTs.-Pus mixed with other fluids can be detected by the addition of
Solution of potassa, with which it forms a gelatinous mass. This and
other tests, however, are inferior to microscopic
examination, which discloses the characteristic FIG. l.
spheroidal semi-transparent corpuscles, from Gr 5
sººth to ºth of an inch in diameter, con- gº tº
taining granules and nuclei. The nuclei are É º • *-*.
made more distinct by the addition of dilute § @ (3)
acetic acid. Some of these corpuscles are iden- Pus corpuscles as seen after
tical in appearance with white blood-cells, and death: a, before, b, after the
are the white cells which have just escaped addition of acetic acid. × 400.
from the vessels. (GREEN.)
Microscopic examination with suitable illu-
mination and sufficiently high oil-immersion lenses will bring to light the
microörganisms to whose presence the suppurative action is due.
ABSCESS.
DEFINITION.—An abscess is often described as a collection of pus cir-
cumscribed by a wall of lymph, or as an abnormal cavity containing
pus; while suppuration occurring within the meshes of the connective
tissue without such limiting wall is called a purulent infiltration, and a
segretion of pus from a mucous, serous, or granulating surface, a purulent
effusion.
These distinctions are frequently ignored, however, for a “diffused"
abscess is an impossibility if abscess means a circumscribed cavity filled
With pus; and certainly the expression, “abscess of the knee-joint,” is
more, common than “purulent effusion in the knee-joint.” It would be
less confusing to define an abscess simply as a cavity containing pus,
52 SU PP U R A TI O N.
without any restrictions as to a limiting wall or to the nature of its sur-
roundings. There is certainly no etymological objection to this use,
which is certainly in accordance with the ordinary signification of the
word. The symptoms, diagnosis, and local treatment of pus in the
normal sacs and cavities, as the pleural cavity and knee-joint, and in
newly-formed spaces in the connective tissue are the same; and they are
practically, in both cases, abscesses.
VARIETIES. Acute abscess.--When pyogenic organisms are arrested
in the tissues they multiply and cause coagulation-necrosis in the cells.
To prevent the injurious effects of these organisms a large number of
leucocytes appear in the region affected, and, by their endeavor to prevent
encroachment of the microörganisms upon other tissues, form a wall
around the group of germs.
The antagonism between the organisms and the leucocytes is kept up
until the Wall of granulation tissue created by the action of the white
blood-cells is too dense for the microörganisms to penetrate. It is thus
that the suppurating focus is circumscribed ; within this wall the tissue
cells break down, and under the peptonizing influence of the micro-
organisms the formation of fibrin in the exudate is prevented. The
cavity of the abscess, therefore, contains dead leucocytes, microörganisms,
and their chemical products, and destroyed tissue cells, in addition to in-
flammatory exudate. These constituents make up the creamy liquid
which is called pus.
The tendency of the pus contained in this cavity is to soften the sur-
rounding tissue and to spread in the direction of least resistance until it is
discharged through an opening upon a free surface. This is called the
pointing or spontaneous opening of an abscess, Such a spontaneous
opening relieves the tension, which has been one of the causes of the
continuance of the inflammation, and permits the pus and microörgan-
isms to be evacuated. The collapse of the walls of the abscess and the
adhesion of the opposite surfaces readily complete the cure, if the admis-
sion of putrefactive bacteria is prevented.
In the event of putrefaction taking place, suppuration continues for a
comparatively long time, according to the situation and the character of
the abscess. Healing of the abscess may be hastened by the surgeon open-
ing the cavity and evacuating its contents long before the pus reaches
the surface; but, in this event, it is equally important that the operation
should be dome antiseptically, since the admission of putrefactive and
pyogenic germs would keep up the inflammation and the Suppuration, as
it would after spontaneous evacuation.
Very rarely the pus of an acute abscess may become encapsulated and
undergo caseation or calcification; the mass in a sort of Sac may then
remain in the tissue as an innocuous tenant for many years, though it
forms a spot of least resistance at which inflammation may readily be set
up at any future time.
Diffused suppuration frequently occurs and causes what is often
called diffused abscess. The process is of similar pathological nature
to that just described, but the pus is not enclosed in a distinctly limited
cavity. The condition is due to a more intense inflammation, and is
usually believed to be due to the presence of the pyogenic strepto-
coccus, which has a more intense peptonizing influence on the cells than
the mycotic causes of such suppurations as are limited by a distinct barrier
of cells. Sloughs and shreds of gangrenous tissue are often found
commingled with the pus of diffused suppuration.
A BSC ES S. 53
The acute or phlegmonous abscess necessarily corresponds in symptoms
with acute inflammation, of which it is a result. The advent of suppur-
ation in the progress of acute inflammation is often marked by rigors and
great constitutional disturbance; after which the throbbing local pain,
the shining red skin, and the acuminated appearance indicate that an
abscess is being formed. The pus usually produces softening of structure,
and tends to escape toward a free surface. The consequent elevation of
the overlying tissues is distinctive of an abscess about to point, and, as
the skin becomes thin over the advancing pus, the characteristic yellow
color becomes apparent, after which a small slough is separated, leaving
an orifice through which the pus is discharged. The walls of the abscess
then collapse, and the cavity is filled up like an ulcer by the granulating
process; in fact, an abscess within the tissues has been called a “closed
ulcer.” Deep abscesses may produce very little change upon the surface,
except a localized Oedema.
Metastatic abscesses are essential elements of pyaemia, and will receive
consideration under that heading.
The so-called chronic or cold abscess, which is probably usually a lesion
of tubercular inflammation and is, therefore, slow in progress, does not
exhibit very active local symptoms. It is apt to occur in connection
with bones and lymphatic glands and in persons of the so-called scrofulous
habit, but may be found in any region and in any patient. There is no
heat of skin, little or no cutaneous redness, no pain, and generally no
tendency to pointing. The skin becomes thin over the puriform collec-
tion and an orifice by which the contents escape may form after a long
time; but, instead of the pointed elevation of an acute abscess, there is
seen a general rounded protrusion of thin and purplish integument.
The puriform liquid is confined by a thick wall, forming a tough sac lined
with velvety elevations, and is usually thin in consistence, containing
cheesy masses, ill-formed corpuscles, and cholesterin crystals. It is not
pus in the strict sense, and should be discriminated from that which is
found in acute abscesses. Chronic or tubercular abscesses often become
very large, because they do not tend to spontaneous evacuation. If we
do not consider the fluid in these so-called chronic abscesses to be pus, and
it certainly differs from pus, the term abscess is inappropriate. The term,
however, is still retained because of its convenience.
DIAGNOSIS.—Acute abscesses are diagnosticated by the history of pre-
ceding acute inflammation, the superficial oedema, the throbbing pain, the
appearance of pointing, the sense of fluctuation, and in cases of doubt by
the use of an exploring needle or by the withdrawal of some of the pus
with a hypodermic syringe or aspirator. Chronic abscesses are distin-
guished by the absence of symptoms pointing to aneurism, cystic tumors
or malignant growths, by the negative history, the possibly depraved
constitution of the patient, oedema, fluctuation, and by aspiration.
Fluctuation is the wave caused by the displacement of fluid when pressure
is suddenly made upon the swelling. It shows the existence of liquid
Contents, but gives no indication of their character. It may be obtained
by placing the fingers of the two hands on opposite sides of the suspected
abscess and making intermittent pressure or striking sudden taps. In
small collections it is better to grasp the swelling between the thumb and
fore-finger of one hand, and make the parts tense, while intermittent
pressure is made by the fore-finger of the other hand. The transmission
of the impulse proves that the contents are fluid, but other symptoms
54 SU P. PU R A TI ON .
must be investigated to determine whether pus, serum, or blood is con-
tained in the tumor.
The opening of an abscess must always be an aseptic procedure. After
the incision the interior of the sac should be thoroughly scraped out
with a curette and made perfectly aseptic by means of irrigation. This
removes all pus and microörganisms. The cavity, if small, may then be
sewed up so as to bring the walls together and allow healing. If the
abscess be a large one it may be needful to provide for drainage by the
use of drainage-tubes. This is especially necessary in large cavities that
cannot be thoroughly scraped and disinfected. Dressings should be
antiseptic in character, as a rule, and should exert some pressure so as to
cause collapse of the walls of the cavity.
TREATMENT.-Since abscess is the result of mycotic inflammation, the
local and constitutional means previously described, as appropriate for
the cure of inflammation by resolution, should be adopted when suppura-
tion is threatened. A blister is often very serviceable, and seems to dissi-
pate the suppurative inflammation. If it is found that resolution is im-
possible, rapid maturation and evacuation of the abscess are to be obtained,
and restoration of the parts to a normal condition promoted. Hot and
moist applications, such as poultices, soften tissue and encourage rapid
migration of leucocytes; hence, they are, perhaps, proper when resolution
and absorption seem hopeless. Poultices are very little used since the
advent of the antiseptic era, and more early operative interference than
formerly is usual. To relieve the pain and tension, and prevent disfigur-
ing scars and destruction of tissue, early evacuation, by means of a free
incision made with a sharp knife, is imperatively demanded in all cases of
acute abscess. Incision made before pus has actually formed will often
cut short the suppurative process, and, if made sufficiently free to relieve
tension, always lessens the pain. If there is danger of wounding large
vessels the abscess may be opened on a grooved director, or it may be
torn open with a blunt instrument after incision of the skin. Sometimes
this last procedure is well done by inserting the end of a pair of closed
forceps and forcibly opening the ends of the blades. In all cases where
the cavity is large the orifice should be kept open by a tent made of a
piece of antiseptic gauze, or by a drainage tube; and permanent pressure
should be applied by means of a bandage, in order to hasten contraction
and granulation of the sac of the abscess. Counter-openings may be
necessary when the pus infiltrates the connective tissue or burrows or
gravitates into pouches which prevent its ready escape.
In tubercular abscess the treatment is the same. The evacuation of
many fluidounces of puriform liquid may, by exposing the wall of the
abscess to the air with its septic influences and by the sudden relief of pres-
sure to which the surrounding capillaries were accustomed, lead to rigors,
exhaustive fever, and grave constitutional symptoms. Hence, as the
fluid is sometimes, though very rarely, absorbed, and chronic abscesses
may remain without pointing for indefinite periods, it was formerly the
custom with many to abstain from operative interference. This is inju-
dicious, for, withdrawal of the so-called pus by the aspirator, and the
application of firm pressure, or incision and disinfection under the strictest
antiseptic precautions, are now believed to be the best surgery.
Hyper-distention of large abscess cavities with antiseptic solutions
forced in by means of a syringe tightly fitting a small opening, is often a
good procedure to be adopted as soon as most of the contents have been
allowed to escape. Thus air is excluded, the customary pressure main-
U L C E R A TI O N. 55
tained, and constitutional symptoms lessened. These various antiseptic
measures are useful in acute abscesses, but are even more essential in
large chronic abscesses. Supporting remedies and anodynes are important
in all cases of severe or prolonged suppuration.
The local treatment of all abscesses, then, whether acute or chronic,
should be early and free incision with strict antiseptic precautions. The
best watery solutions to use in washing out small abscess cavities are
corrosive sublimate (1 : 1000 to 1 : 5000) and betanaphthol (1 : 2500).
As there is some risk of poisoning if large quantities of the sublimate
solutions remain in large and irregular cavities, that drug must be used
with caution. Betanaphthol is not poisonous, but is not so active a
germicide. Solution of iodoform in ether (1 : 50 to 1 : 500) is a good
material for injecting the cavities of tubercular abscesses. In all cases
the solution, of whatever character, is subsequently allowed to flow from,
or is pressed out of, the abscess cavity.
SINUS AND FISTULA.
When an abscess has been evacuated it may not contract and heal
completely, but, especially when the muscles prevent perfect rest, may
leave a long, narrow, and sinuous canal through the tissues. This is lined
by a membrane having somewhat the character of mucous membrane,
from which unhealthy pus is discharged. If the canal has only one
orifice it is called a sinus; if more than one, a fistula or fistule. The
term fistula in surgery is sometimes limited to such a canal communicat-
ing with one of the hollow organs, as the bladder, rectum, or lachrymal
sac. The orifice of a fistula or sinus is usually surrounded by exuberant
granulations projecting as a papilla. Sinuses and fistules are cured by
destroying the adventitious lining membrane and setting up acute inflam-
mation, in order to cause healthy granulations to take place from the
bottom. This may be done by irritating injections, the actual cautery,
curetting, or by laying the track open with the knife or elastic ligature
which thus controls all muscular contraction; and in many cases still
better by dissecting the whole canal out and approximating the healthy
wound so made with sutures. Any source of irritation, such as diseased
bone or foreign material, must be removed at the same time.
The term fistule is also applied to a communication between two
hollow viscera, due to injury or sloughing. Such abnormal openings are
cured by plastic operations. 4.
ULCERATION.
When inflammation does not terminate by resolution in a return to
health, death of the part by either ulceration or gangrene must take
place. Ulceration is death in small particles or molecules; gangrene is
death in masses large enough to be seen. Similar processes in Osseous
tissue are called caries and necrosis, and will be described under diseases
of bone. The causes of ulceration are the same as the causes of inflam-
mation, to which ulceration always owes its existence. It may occur
Superficially, as in the skin and cornea, or deeply, as in the substance of
organs, for abscesses and sinuses are practically but the results of ulcera-
tion. The ulcerative process is more common in skin, mucous mem-
branes, cartilages, lymphatic glands, lungs, and bone (called caries), than
56 SU PP U R A TI ON .
in fibrous, serous, or muscular tissue. Ulceration consists in softening
and disintegration of structure, followed by the removal of the débris by
absorption and ejection. When removal of tissue is effected by absorp-
tion alone, as is seen in erosion of tissue from aneurismal pressure, the
term interstitial absorption is applicable, since ulceration causes removal
chiefly by discharges.
Ulceration and suppuration are closely allied, since some of the pus
owes its existence to the destruction and disintegration of tissue. Sloughs
and foreign bodies in the tissues are usually thrown off by ulceration and
suppuration occurring around them.
Ulceration, then, is the molecular death of soft tissues, and produces
on a free surface the anatomical lesion called an ulcer or open sore.
ULCERs.
DEFINITION.—An ulcer is a breach of continuity of surface, covered by
granulations and usually accompanied by a discharge of pus. The nature
of the granulations and of the pus determines the character of the ulcer.
The solution of continuity may be due to the process of ulceration, to
gangrene, or to a wound; for in gangrene the slough is separated by
ulceration, and wounds that do not heal by first intention become ulcers
as soon as granulation is instituted. A solution of continuity called an
ulcer is usually deeper than the epithelium ; if not, the terms abrasion,
desquamation, or excoriation are commonly applied. Among exceptions
to this rule may be mentioned superficial ulcers of the cornea.
Surgeons are called upon to treat ulcers of the skin and mucous mem-
brane, and to these alone are the following paragraphs meant to apply.
VARIETIES.—All ulcers are direct consequences of the inflammatory
process, which is due to either constitutional or local causes. The causa-
tion is an important factor in the treatment of ulcers, but does not require
any change in the classification of them.
Ulcers are healthy or unhealthy. The healthy ulcer is typically illus-
trated by the Sore produced when granulation has begun in a wound
made by cutting out a portion of tissue. The edges are regular and
smooth, and slope gradually toward the granulations, which are red, pain-
less, do not bleed under gentle pressure, secrete a serous non-purulent
fluid, and never protrude above the surface of the skin. The granula-
tions at the circumference are being covered by or converted into a bluish-
white cicatricial pellicle of epithelium, while the skin surrounding the
ulcer is purplish and somewhat hardened by inflammatory infiltration.
All ulcers must be brought to this condition before cicatrization can
occur, and so long as the ulcer continues healthy, healing goes on spon-
taneously and steadily, if the surface be only protected from injurious
contact. Protection is best effected by applying a piece of aseptic rubber
tissue or oiled silk covered with an aseptic or antiseptic gauze dressing.
Some surgeons prefer antiseptic ointments, such as carbolized oxide of
zinc ointment, boric acid ointment, and ointment of petroleum ; or
lotions or powders containing some germicidal agent.
Unhealthy ulcers are those accompanied by some condition which pre-
vents their exhibiting the characteristics above mentioned. If undue
inflammation be present, as shown by great heat and pain, Oedematous
surroundings, engorged granulations, and discharge of pus mixed with
blood, it is an inflamed ulcer. If this process be violent and rapid, de-
U L C E R S. 57
struction of tissue and extension of ulceration occur, a pellaceous mass
is seen covering unhealthy-looking granulations, and the edges become
irregular and sharp-cut. This constitutes a “sloughing” ulcer, which is
a rather contradictory term. The devitalized skin or muscle is often
found in the discharge from such an ulcer, as shreds and tags of tissue.
When the granulations are exuberant and project like excrescences be-
yond the level of the skin, the ulcer is called a fungous ulcer. The
callous or indolent ulcer is deeply excavated, has indurated whitish and
undermined or inverted borders, is surrounded by thickened and con-
gested skin of a bluish color, shows imperfectly-formed pale granulations
covered with a foul-smelling thin pus, and is usually insensible to painful
contact. Such ulcers are of long duration, and may well be termed
chronic. Ulcers may be complicated or may depend upon the existence
of varicose veins, impeded circulation,
diseased bone, or may be the seat of FIG. 2.
hemorrhage or of malignant processes. sº- —r—i.
Other circumstances may contribute ºr *
to the production of complicated or
unhealthy ulcers, but it is not neces-
sary to give a distinctive name to each
Oſſlé.
Ulcers, otherwise healthy, are often
the seat of a purulent discharge, be-
cause of pyogenic germs having been
allowed to come into contact with the y
ulcers' surfaces. Such a suppurating -
ulcer is usually denominated a healthy §§ *
ulcer, though the term is not strictly
applicable.
TREATMENT.-The criterion in the
treatment of all ulcers is the condition Method of cutting skin-grafts by
of the edges. If the borders are pink- means of needle and scalpel.
ish and smooth, and gradually slope
down to florid granulations, or perhaps are separated from them by a
narrow line of bluish-white epithelial cicatricial tissue, it is certain that
the ulcer is in a healthy state, and only requires protection from irritation.
Hence, it may be dressed with any bland non-irritant application. Car-
bolized ointment of the oxide of zinc is, in my opinion, one of the best, if the
ordinary aseptic protective silk, or rubber, and gauze dressing is not used.
Cicatrization usually takes place from the edges toward the centre, and
therefore in large ulcers, even when healthy, the action of the cutaneous
cells at the margins may be insufficient to complete the process, or if able
to do so, may be very slow in causing healing of the entire ulcerated sur-
face. Centres of cicatrization may be established upon the ulcer at any
number of points by applying aseptic grafts of skin (Fig. 3).
Skin-grafting is best performed by thrusting the point of an aseptic
ordinary sewing-needle under the epidermis of the inner surface of the
arm or thigh, previously made aseptic, and, after putting the skin on the
stretch by raising the needle, cutting out a minute portion of the true
skin, with a sharp scalpel or scissors. The graft taken in this almost
painless and bloodless manner is then to be gently pressed upon the
healthy granulations with its epidermic surface upward and a gauze dress-
ing applied. Any number may be engrafted. The grafts at first shed
their cuticle and become almost invisible, but in a few days bluish-white
M
g
&
ë
&
à
3%
*
2%
N

58 SU P. P. U R A TI ON .
spots of cicatricial tissue are seen at the points where some grafts have
taken root. These islands grow eccentrically by epithelial cell prolifera-
tion, and stimulate the periphery of the ulcer to similar activity, so that
the cicatrizing process is greatly expedited by the new points of cutifica-
tion, which gradually coalesce with one another and with the marginal
skin. The process is not attended with much success unless the ulcer be
healthy. Long and thin shavings of skin cut from the patient by means
of a sharp razor may be used in a similar way. This method causes
much more rapid healing, but the pain is rather severe when the shavings
are cut. Skin may be taken from a living frog's abdomen and laid upon
the ulcer. Plastic operations may be performed to hasten the healing of
intractable ulcers by the transfer of healthy integument to their surfaces.
ºr g
3. ; : *
J. ſ: 3. § yº.
% § sy §
t Rº º
*ś , ºf 3
º *…
Skin-grafting in traumatic ulcer of the Scalp. (LEVIS.)
The treatment of all unhealthy ulcers must be directed to transforming
them into healthy ulcers, and is both constitutional and local. If they
depend upon syphilis specific remedies, such as mercury, iodoform, and the
iodides, must be given internally; if the tuberculous diathesis exist,
iodine and its derivatives, cod-liver oil and tonics, are required. In all
cases digestive and other constitutional vices must be investigated and
treated. Any local exciting cause, such as bone disease and varicose
veins, must be removed, or at least palliated, after which local treatment
is to be regulated by the condition of the ulcer. An ulcer accompanied
by acute inflammation must be managed on the principles already laid
down in the treatment of acute inflammation. Antiphlogistic internal
remedies are demanded, while elevation and rest of the part, Scarification,

MO RTIF I CATION, OR G A N G R ENE. 59
lead water and laudanum, warm water dressings, or weak astringent solu-
tions are used locally. When the inflammation is severe enough to cause
sloughing ulceration, supportive treatment and poultices to hasten separa-
tion of the sloughs, or other mild applications are demanded. The local
irritability and pain which characterize many ulcers are often greatly les-
sened by the application of solid nitrate of silver, or strong solutions of
the same (gr. xx to fjj of water). Submitrate of bismuth is an excellent
local remedy. A moist antiseptic gauze dressing, covered with oiled silk
or rubber tissue to prevent evaporation, is far better than the old-fashioned
poultice. It is, in fact, an antiseptic poultice.
Fungous ulceration is treated by caustics, such as deliquesced chromic
acid, or by the surgeon cutting away the exuberant growth with the
knife, or scraping it away with a sharp spoon. Ulcers exhibiting pale,
oedematous, semi-transparent granulations require stimulating applications
of nitrate of silver and sulphate of copper, in solution or undiluted.
Callous or indolent ulcers are the most rebellious to treatment. The
hard elevated edges must be softened and depressed, and the accompany-
ing venous congestion, shown by the livid skin surrounding the sore, re-
moved. My own plan is to apply pure carbolic acid, nitric acid, or some
other chemical cauterant, to the insensitive edges and to the foul and
semi-devitalized tissue covering the depressed and unhealthy granulations.
Then a moist antiseptic dressing is applied for a few days to separate the
slough thus produced and to soften the callous borders. Subsequently
scarification around and through the ulcer relieves the engorged venous
capillaries. The pressure of strips of adhesive plaster properly adjusted, or
of an elastic bandage smoothly applied from the distal extremity upward,
prevents a repetition of the congestion, and stimulates absorption of deposits
and cicatrization of the ulcer. Instead of using the caustic, I frequently get
rid of the callous margins by paring them away, and then treat with anti-
septic dressings and pressure, or the whole ulcer may be scraped away with
a curette and treated as a recent wound. Astringents and disinfecting
lotions may be used beneath the elastic bandage. Chronic ulcers of
small size may be frequently cured with rapidity by dissecting them out,
freeing the surrounding skin from its deeper attachments, and uniting
the edges of the wound by sutures.
Peroxide of hydrogen is said to render a foul ulcer aseptic by oxidizing
the devitalized and putrefying discharges.
Tubercular ulcers do well when treated with powdered iodoform.
As soon as unhealthy ulcers approach the healthy condition cicatriza-
tion begins, and may be hastened by skin-grafting. In order to maintain
a healthy state of the sore and prevent occlematous and fungous granula-
tions, slightly stimulant lotions of chloral (gr. v . or x to fºj), sulphate
of copper (gr. iij-v to fj), sulphate of zinc (gr. v to fj), or nitrate
of mercury or submitrate of bismuth in solution, ointment, or powder
should be employed. When in a few days or weeks the ulcer gets accus-
tomed to the effect of one agent and becomes “inactive,” the dressing
must be varied, for a new impression will be beneficial. Mucous ulcers
are to be treated like cutaneous sores.
MoRTIFICATION, OR GANGRENE.
5
DEFINITION.—Mortification, or local death, is the complete and per-
manent cessation of vital functions in a part, and differs from ulceration
in the devitalized portion being more extensive. Ulceration is molecular
60 SU PP U R A TI O N.
death, while mortification is death of appreciable areas of tissue, that is,
of tissue in mass. The two processes are, however, allied, and may
co-exist, as in hospital gangrene or sloughing phagedaena, where ulceration
is too rapid for disintegration to take place. The dead tissue is called a
slough or eschar. Necrosis is often used by pathologists to signify death
of animal tissues in mass without reference to the character of the
structures, but in surgery, necrosis is usually applied to bone and carti-
lage; and mortification, gangrene or sphacelation to soft tissues.
CAUSES.–Mortification is due to defective nutritive supply and to
destruction of cellular activity. The former condition may be caused by
obstruction in the arteries, as from ligation, rupture, embolism, plugging
by great numbers of bacteria, or diseased arterial walls; obstruction in
the veins, as from tight bandaging; obstruction in the capillaries, as from
pressure of tumors, or inflammatory deposits; cardiac weakness, which is
merely an accessory cause, decreasing the activity of the circulation; in-
flammation, by its intensity inducing permanent arrest of circulation,
or by its specific mycotic cause having a special tendency to cause destruc-
tion or devitalization of tissue.
The causes which induce mortification by destroying the vitality and
activity of the cellular elements are: injuries, which disorganize tissue;
chemical agents, such as acids and alkalies; the ptomaines of putrefactive
or other bacteria acting as irritants; and excessive heat or cold. Morti-
fication is often due to a combination of several of the causative influences.
Defective innervation has been considered a cause of mortification, but it
is probable that it acts only indirectly by diminishing circulatory activity,
or by rendering parts less cognizant of the contact of irritating agents.
The power of the cells to resist gangrenous causes varies in individuals
and in tissues.
VARIETIES.–Mortification may be moist or dry, according to the causa-
tion and circumstances attending the process. If the parts contain much
fluid, as is the case when the mortification is associated with venous
obstruction and when evaporation is prevented by the integrity of the
cuticle, the process resembles the ordinary putrefaction of animal sub-
stances as seen in dead bodies. This is called moist gangrene. The local
symptoms are due to the fact that ordinary putrefaction is occurring
because putrefactive fungi have gained access to the dead tissue through
the skin. If the gangrene is due to slowly progressive arterial obstruc-
tion while venous and lymphatic absorption is not decreased, or if rapid
evaporation occurs on account of the destruction of the cuticle, the parts
become shrivelled and dry, and dry gangrene is said to exist. Acute gan-
grene is usually moist, because it dies quickly when full of blood, while
chronic mortification is generally dry. Soft and vascular tissues mortify
much more rapidly than dense, non-vascular structures, such as tendons
and cartilages.
The infarctions found after embolism of renal and other arteries, the
caseous change that occurs in scrofulous products, and similar pathological
conditions, are examples of what has been called coagulation-necrosis,
which is a change of protoplasm into a material resembling the fibrin of
the blood. With this form of mortification surgical pathology has little
COD COI’I). º
SYMPTOMS.–The constitutional symptoms of gangrene are almost in-
variably asthenic, probably because the blood becomes deteriorated by
the admission of septic products derived from the sloughing tissues.
MOR TIFICATION, O R G A N G R ENE. 61
The feeble circulation and general nervous depression accompanying a
very limited area of mortification are often remarkable. º
The local symptoms of moist and dry gangrene differ and must be dis-
cussed separately. In the moist variety the parts become green, bluish,
or black, lose their normal sensibility and temperature, and become
softened and covered with blebs containing reddish-brown fluid. The
epidermis is easily rubbed off, leaving a dark, smooth surface. Pressure
causes a crackling sound, due to the presence in the tissue of the gases
generated by putrefactive decomposition. The gases, which are prin-
cipally sulphuretted hydrogen, ammonia, and carbonic acid, cause great
local emphysema and puffiness of the parts, and with the other products,
such as butyric acid, give the characteristic odor of putrefaction. The
red streaks along the course of the vessels in the incipiency of gangrene,
and the deep color of the parts during its existence are due to the
transuded coloring matter liberated by the destruction of the blood
corpuscles.
Fig. 4.
*:S ºr ‘º
§§ & \ sº tº
º' §N * :
... sº, § º §. s
*...*.* \\\\\\ Wºº,"
§§ º #3% |#ffff; §W. Hº
§ §º % ſ º: º
º º *.*. % ºft#. ºfliº.
Senile gangrene of arm.
In dry gangrene the appearance of a small brown or black spot, espe-
cially upon the toes, where the affection is most frequently seen, is often
the first sign of disease ; though at times cramps, and stinging pain, and
feeble local circulation are premonitory symptoms. The discolored point,
instead of being brown may be a mottled white, and sometimes a vesicle
forms at the beginning of the disease. The darkened area becomes
blacker and slowly extends with very few accompanying inflammatory
symptoms. The dead tissue is dry, without offensive odor, and gradually
becomes shrivelled and hard. The loss of sensibility and the lowered
temperature of the dead tissue present in moist gangrene, of course,
exist here. This form of mortification is frequently called senile gan-
grene, but improperly so, since it may occur from chronic ergotism with-
out reference to the patient's age, and because moist gangrene may occur
in the aged in similar regions of the body.
In all forms of mortification, if the patient survive long enough, the
dead tissues are separated by the process of ulceration from those whose
vitality resists the destructive influence. The living structures become
reddened at the line of junction with the slough, and thus constitute the
line of demarcation which indicates the extent to which the devitalizing
process has been able to exert its influence. Sometimes a row of vesicles
forms along this margin. The line of demarcation soon becomes con-
Verted into a groove which is lined by granulations secreting pus. This
is practically a linear ulcer, and is called the line of separation, because
the ulcerative and granulating processes gradually push off the dead
tissues by a species of natural amputation and leave an ulcer to heal
by cicatrization. Hemorrhage is prevented by coagulation within the




















62 S UP P U R A TION .
arteries and fibrinous deposition due to the inflammatory action. The
inflammation accompanying mortification often gives rise to great pain,
which, of course, is located in the living or partially devitalized struc-
tures. This increases the general depression due to septic influences of the
gangrenous parts. When mortification occurs in deep structures, the
slough is thrown off through fistulous orifices, as occurs in carbuncle, and
as is attempted by nature, though often unsuccessfully, in necrosis of bone;
or, it may become encapsulated and thus be separated from the surround-
ing living structures. The latter mode of separation is seen in infarc-
tions of the internal organs,
TREATMENT.-The general treatment of all forms of gangrene, to be
judicious, should be directed to fulfil two indications: first, to remove
the cause and thus arrest the progress of the gangrenous action ; and,
secondly, to sustain the patient until separation of sloughs has occurred.
Unfortunately, the constitutional cause is often difficult of removal, but
an effort should be made to bring the system into that condition which
will render the causative factors as inoperative as possible, and limit the
mortification. If the peripheral circulation is poor because of a feeble
heart and degenerated arteries, remedies such as quinia, iron, opium,
digitalis, strychnia, alcohol, etc., should be administered and the patient
protected from cold and other depressing influences. When there is a
tendency to a sthenic type it is possible that slightly depressing agents
may be advantageous, but these are seldom needed and should be used
with great caution, since the advent of gangrene is soon followed by
nervous and circulatory prostration.
During the stage of separation of sloughs the flagging powers of the
patient must always be supported by active medication with tonics, stimu-
lants, and concentrated nutritious diet. Depressing antiphlogistic reme-
dies are never justifiable; and if nervous irritability and pain exist opium
in full doses is to be employed. Cleanliness, disinfection, and ventilation
are necessary hygienic measures. The local treatment of mortification is
very important.
If gangrene is threatened on account of the tension produced by rapid
and intense inflammatory swelling, it may often be averted by free inci-
sions several inches in length through the skin, subcutaneous and fascial
structures. This treatment relieves local tension by permitting gaping
of the wound and affording a free escape of blood and inflammatory
products. Much tissue destruction is thus avoided by removing the
obstruction to capillary circulation. Parts prone to slough from deficient
circulation should be kept normally warm. When gangrene has occurred
disinfectant lotions of carbolic acid of an unirritating strength (1:20
or 30), corrosive sublimate (1:1000 or 3000), chlorinated soda, chloride
of zinc (1:50 or 100), or desiccating powders of a disinfectant nature,
should be used to destroy the fetor of the parts. These should be com-
bined with antiseptic gauze dressings, perhaps made moist and covered
with oiled silk or waxed paper, in order to encourage and hasten separa-
tion of the devitalized tissues. The sloughs may be removed in pieces
with the forceps and scissors after the line of separation has divided the
vascular attachments. Tendons and fibrous tissues, as they contain no
vessels of importance, may be carefully cut, for in this manner the de-
composing masses can be removed somewhat earlier. No special dressing
is to be applied to the line of separation. The ulcer left after the slough
has been detached is to be dressed with mild applications, such as carbol-
ized oxide of zinc ointment, ointment of petroleum and boric acid, or
H OS PIT A L G A N G R E N E . 63
antiseptic gauze, as in ordinary ulcers. Cicatrization is to be encour-
aged.
*When mortification depends on a known local cause, such as Crushing of
the parts, or ligation or rupture of the main artery, amputation should be
performed, except in cases due to frost-bite or burns above the location
of injury, without waiting for the line of demarcation. If the gangrene
is due to constitutional causes, such as deficient circulation, or ergotism, or
to the presence of an embolus whose location is unknown, the surgeon
must wait until the line of separation is well marked before attempting
operative interference, since the extent of the gangrenous influence can-
not otherwise be estimated. In traumatic cases where gangrene is inevit-
able, amputation should be promptly performed.
HOSPITAL GANGRENE.
Hospital gangrene, or sloughing phagedaena, is a peculiar form of
rapidly spreading mortification or gangrenous ulceration, which attacks
wounds or injuries where the epidermis is broken, when patients are sub-
jected to the foul air of overcrowded hospitals and the wounds infected by
certain bacteria. It is exceedingly contagious and infectious, and may at
times begin as a vesicle if the parts are not much denuded of cuticle.
The ulcer resulting is painful, covered with grayish sloughs, and dis-
charges excessively fetid, brownish fluid. The edges of the ulcer, as a
rule, are sharply cut. The connective tissue is rapidly invaded, and pro-
fuse hemorrhage may occur. The constitutional symptoms, which are
secondary, are markedly asthenic. The disease is of local origin, due to
wound infection, and must be treated as such. The patient should at
Once be removed to uninfected quarters, such as a tent, or pavilion hos-
pital, and all the instruments, dressings, and sponges be sterilized or
destroyed. The sloughs should be lifted off, if possible, and the entire
wound saturated with undiluted nitric acid, bromine, or other powerful
cauterant to destroy the septic germs. The caustic must corrode the
healthy tissue in order to get beyond the gangrenous influence. The
actual cautery is probably valuable in such cases. Tonics, stimulants,
and other supportive treatment generally combined with opium are
required internally. e
Fortunately, the aseptic and antiseptic methods of modern surgery
have made hospital gangrene practically unknown.
C H A P T E R III.
ERYSIPELAS, SAPRAEMIA, SEPTICAEMIA, ETC.
IERYSIPELAS.
DESCRIPTION.—Erysipelas is an acute febrile affection, usually of a low
type, due to some mycotic blood contamination, and accompanied by a
rapidly spreading inflammation, which has no tendency to limit itself by
the exudation of plastic matter. It is most frequently met in the tegu-
mentary structures, but may attack mucous and serous tissues as well. As
seen by the surgeon it generally occurs as a complication of wounds, but
may arise idiopathically. , Simple or cutaneous erysipelas involves the
skin alone, while in the phlegmonous or cellulo-cutaneous variety the sub-
cutaneous tissue is also inflamed. If the inflammatory process spreads
through the cellular or connective tissue without invading the skin, it is
called diffuse cellulitis or cellular erysipelas.
It is an infectious and contagious disease, and is particularly liable to
attack those debilitated by bad hygienic surroundings or depressed by
intemperance or by renal and hepatic affections. The septic germs con-
tained in putrefying dead bodies have some occult influence in the induc-
tion of erysipelas. It appears to be allied to septicæmia, and also follows
bites of venomous reptiles, etc. It is uncertain whether it is due to a
special vegetable parasite, or results from the streptococcus, which causes
diffuse suppuration. Many believe that suppuration occurring in the
course of erysipelas is indicative of a secondary infection with pus fungi.
SYMPTOMS.–The constitutional symptoms may be of a sthenic type,
but unless the disease is very mild and short in its course, they soon
present the characteristics of asthenia. Fevers, rigors, nausea, vomiting,
coated tongue, constipation, and perhaps delirium, are the early symptoms,
which are not lessened by the appearance of the eruption, and are followed
by frequent quick pulse, muttering delirium, dry tongue, sordes and often
by diarrhoea, and not very infrequently by death. In the cutaneous and
cellulo-cutaneous forms the burning or throbbing pain, the Scarlet, or
dusky-red, shining skin, with a distinctly elevated margin, the Oedema-
tous or brawny character of the swollen part, the tendency to spread,
and the lymphatic glandular involvement, make the diagnosis sufficiently
distinctive. Vesicles may form and be succeeded by a brawny desqua-
mation. Sometimes in the cellulo-cutaneous variety suppuration or
gangrene of the connective tissue occurs; then the skin is apt to become
less scarlet in color, and the parts have on palpation an Oedematous or
boggy feel. There is no sign of pointing, but incision discloses a diffuse
form of abscess in the areolar tissue, and gives escape to shreds of gan-
grenous tissue and unhealthy, foul-smelling pus,
When erysipelas attacks a wound the pus from it becomes lessened, the
granulations degenerate, the union breaks down, and the local symptoms,
mentioned above are presented about the wound. Cellular erysipelas,
often called diffuse cellulitis, resembles the cellulo-cutaneous variety, but
usually arises secondarily to a wound, and presents fewer characteristics
of inflammation of the skin. Its evident relationship to erysipelas is
SA PR AEM IA, S E PTIC AEM IA, A N D PY A. M.I.A. 65
admitted, but the term cellulitis seems preferable to cellular erysipelas.
This variety of erysipelas may attack the areolar tissue in the pelvis and
other internal regions if they be opened by a wound. The probability
of causing puerperal Septicaemia by inoculation from erysipelatous cases
must always be borne in mind by the obstetrician or surgeon.
An attack of erysipelas lasts from one to two weeks, and in persons of
fair health previously, is usually followed by recovery. The subcutaneous
forms have a much more unfavorable prognosis than the cutaneous.
TREATMENT.-Preventive measures consist in ventilation and steriliza-
tion of instruments and dressings. At first a purge should be given and
light diet ordered, but, as a rule, depressing treatment is inapplicable,
because the disease soon assumes a low type. Hence ten minims of tinc-
ture of iron every two or three hours, combined, perhaps, with two grains
of quinia at each dose, is the best treatment. Opiates and stimulants
may be demanded. Milk and beef essence, or meat juices, are the best
articles of diet. A mixture of one part of laudanum, one part of lead-
Water, and two parts of water, a combination of lime-water and sweet
oil, or a non-irritating antiseptic lotion or ointment, should be applied
locally. If suppuration and gangrene threaten, or if great tension is
present, numerous incisions, which will gape widely, should be made
aseptically, and be followed by antiseptic gauze dressings. When pus
burrows, as in the subcutaneous forms of the disease, the cavities should
be injected with carbolized water (1 : 40), or solution of corrosive subli-
mate (1:2000), and drainage-tubes inserted and counter-openings made.
SAPRAEMIA, SEPTICAEMIA AND PY.EMIA.
DEFINITION.—There are four conditions often confused which ought to
be distinguished; though it is admitted that a clinical diagnosis is fre-
quently impossible.
They are:
1. Aseptic wound-fever, arising in connection with aseptic wounds, and
due, probably, largely to poisoning by the so-called fibrin ferment.
This is given off during the disintegration of leucocytes which occurs in
inflammation at the time the exudate coagulates. The inflammatory fever
usually seen is, however, one of the forms of septic poisoning mentioned
below, and is due to imperfect asepsis. If the wound is absolutely aseptic
the wound-fever is always inconsiderable.
2. Sapraemia, putrid poisoning, or septic intoxication, which is a febrile
condition, due to the chemical products or ptomaines developed by putre-
faction of animal tissues, either in the wound or entirely away from the
body of the patient. This poison may gain access to the blood by its devel-
opment and retention in insufficiently drained putrescent wounds; or, it
may be obtained experimentally and be injected hypodermatically. The
poison is the result of mycotic action, of course, for putrefaction is due
to fungi of putrefaction. The symptoms of sapraemia occur immediately
after inoculation, but it requires a comparatively large dose to produce a
toxic effect. *
3 Septicºnia, or septic infection, a fever due to infection by putrefac-
tive microörganisms which enter the blood by the mucous membranes or
by a wound, usually by the latter, and do not produce symptoms until
they have had time to multiply. The clinical symptoms are similar to
those of Sapraemia, but a most minute dose is sufficient to lead to violent
5
66 SA PRAS MIA, SEPTIC A. M IA, AN D PYA M I A.
symptoms. The condition formerly called hectic fever corresponds with
what is now called sapraemia and septicaemia.
4. Pygemia, a condition in which the general febrile disturbance, similar
to septicaemia, is due to pyogenic germs, and in which secondary foci of
inflammation or suppuration, called metastatic abscesses, are formed in
the lungs, liver, and other organs. These abscesses in distant organs are
due to the transportation in the blood-stream of emboli infected with pus-
causing bacteria. Pyaemia is probably simply a multiple suppurative
inflammation. The old theory that pyaemia is a condition in which the
blood contains pus is untenable, though the derivation of the word
pyaemia still suggests it.
The relations of sapraemia, septicæmia, and pyaemia are not perfectly
understood. They may, therefore, be considered together, at least until
their clinical relations and pathology are further investigated. Some
authors believe pyaemia to be identical with what I have called septi-
caemia, except that the poisoning is more intense.
PATHOLOGY..—The peculiar poison, which by introduction into the
blood causes sapraemic conditions, is associated with putrid decomposition
of albuminous fluids, and is connected with the production of ptomaines
by the bacteria causing the putrefactive process. Septicæmia and pyaemia
are due to infection by microörganisms themselves; the former by the
microörganisms of putrefaction, the latter by the microörganisms of sup-
puration. It is usually necessary that there exist some abnormal state of
the tissues, such as inflammation, before the presence of such microbes
can induce these conditions. The occurrence of septicæmia and pyaemia
is promoted by such conditions as favor the contact of wound surfaces
with particles of decomposing animal tissue, or of dust containing pyo-
genic bacteria, such as necessarily circulate in ill-ventilated apartments
containing numerous surgical patients. Septic and infective substances
thus introduced into animal fluids encourage therein putrefactive changes
and the generation of infecting organisms. It is necessary, however,
in order to infect the system, that the poisonous principle be absorbed.
A recent wound, or one covered with unhealthy granulations, allows
rapid absorption of the poisonous substances, while healthy granulations
seem to act as a barrier to septic infection. The blood in septicæmic con-
ditions is less coagulable than in health, and the red corpuscles show a
tendency to congregate in irregular masses, and to undergo ante-mortem
disintegration. In addition, congestions of organs and Stasis of the
blood-current are frequently observed. The autopsy frequently shows
softening and degeneration of viscera, ecchymosis and even inflamma-
tion of the serous membranes, and changes in the glands and mucous
membrane of the intestines.
Pyaemia may be provisionally considered as septicæmia with the addi-
tion of disseminated spots of inflammation and suppuration. These con-
sist of metastatic abscesses in lungs, liver, spleen, and other viscera, due
to embolism and bacterial infection, and suppuration in joint cavities or
inflammation of cellular and serous tissues, caused either by embolism or
the blood-change. Metastatic abscesses commence as small, reddish, and
usually pyramidal sections of solidified tissue, which are found most fre-
quently near the periphery of the lungs, liver and spleen. These soon
break down into pus, producing abscesses, which are always small, and
which are surrounded by indurated tissue. These multiple or metastatic
abscesses result from the process of embolism as follows: At the seat of
the original inflammation coagulation takes place in the vessels, and on
SAP RAE MIA, SEPTICAE MIA, AND PY A. M.I.A. 67
account of puriform softening of these clots or thrombi, due to septic in-
fluences, small particles of the thrombi, are washed into the circulation,
carrying along with them pyogenic bacteria. These emboli lodge in the
capillaries of the lungs or other viscera, cause impairment of circulation,
and by their mycotic nature give rise to numncous suppurative points
called metastatic or embolic abscesses.
FIG. 5.
|
i
FIG. 6.
Diagram of thrombus in a vein. a. Cen- Embolus (E) impacted at the bifurcation
tral end of a venous thrombus projecting of a branch of the pulmonary artery. Sec-
into a large trunk. b. Small branch. The ondary thrombi (t and t'), behind and in
blood flowing from Small branch may front of embolus, extending to the first
readily detach a part of the thrombus. collateral branches. (VIRGHow.)
(BILLRoTH.)
Pyaemia is probably not an actual disease, but simply a transference of
suppuration by means of emboli and their accompanying pus-causing
germs. It is a complication, or variety, then, of suppurative inflamma-
tion, due perhaps to putrefactive germs having caused softening of the
thrombi. Hence the frequent association of Septicaemic conditions and
pyaemia.
CAUSEs.-The exciting cause of septicæmia is the peculiar poison
already described as usually generated by the mycotic decomposition of
albuminous fluids. The poison, under the name of sepsin, is believed
to have been isolated; but our knowledge of the nature of the agency
inducing septicaemic conditions is very limited. Any condition which
tends to produce septic material in the patient's body may be called a
predisposing cause. The most frequent of all is the existence of a wound,
though it is possible that septicæmia may result from septic changes in
the fluids of the body, due to agencies introduced by absorption through
the mucous membranes. Hemorrhage, protracted shock, erysipelas, osteo-
myelitis, puerperal lesions, overcrowding of patients affected with suppu-
rative diseases, and bad hygienic surroundings are important predisposing
Causative factors. %–

68 SAP RAE MIA, SEPTIC A. M.I.A., AND PY A. M.I.A.
SYMPTOMS.—The first symptom of septicæmia or of pyaenia is often
a sudden rigor preceded or accompanied by a rise in temperature, which
is followed by exhaustive sweating with rapid lowering of bodily ten-
perature. These phenomena resemble those of malarial fevers, but the
hot stage between the rigor and the sweating is less marked. The tem-
perature during the chill may rise to 104°-107°, and during the sweating
period may fall, though rarely, to normal or below. The rigors and
great temperature changes are repeated at more or less irregular inter-
vals. The pulse is increased in frequency, but diminished in force, beat-
ing 90–120 per minute; and respiration is similarly affected, being more
frequent and less deep. The breath and emanations from the body have
a sweetish odor which is of some diagnostic value in septicaemic states.
The tongue is usually furred, while nausea, vomiting, and diarrhoea are
frequently present. The skin, which has a pale or yellowish hue, due to
pigment from disorganized corpuscles, may present Sudamina, and even
an ecchymotic or a pustular eruption. Albuminuria is not infrequent
and delirium is common. As the disease progresses the symptoms assume
the asthenic or typhoid character as shown by rapid emaciation, great
exhaustion, twitching of the tendons, drowsiness, low muttering delirium
or coma, dry and brown tongue, sordes upon the teeth, colliquative
diarrhoea and sweating. The wound during this time usually, but not
always, assumes an unhealthy character of granulations and discharge.
In most cases the discharge of pus decreases, and it may entirely disap-
pear. About the sixth or tenth day, if pyaemia and not mere septicæmia
exist, the formation of metastatic abscesses and the occurrence of other
inflammatory foci give rise to jaundice, cough, pain which is often intense
in the joints, and suppurative or inflammatory signs in the viscera and
elsewhere.
The lobular pneumonia, hepatitis, pleuritis, pericarditis and other in-
flammations that at times occur, give rise to their characteristic symptoms.
The prognosis is always unfavorable, as in acute cases death takes place,
as a rule, in from one to two weeks, and in chronic cases in from one to
two months. Recovery, however, does at times occur after a protracted
convalescence. It is often impossible to discriminate between cases of
septicæmia and pyaemia until the autopsy proves or disproves the existence
of metastatic abscesses. The symptoms have, therefore, been grouped
together as representing conditions which are often indistinguishable
during life.
DIAGNOSIS.–Septicæmia or pyaemia may be confounded with malarial
or typhoid fever. The suddenness and intensity of the rigor and of
the temperature rise, the irregular occurrence of these phenomena, the
great fall in temperature, which seldom reaches the normal before the
occurrence of another rise, the profuse Sweating which follows the rigor
without the intervention of a marked hot stage, and the association of
these symptoms in many instances with a wound, usually serve to render
a differential diagnosis possible. Quinine will usually modify malarial
conditions but not septic ones. Ordinary inflammatory fever differs from
septicæmia because it usually ceases when suppuration begins. Rheum-
atism is at times distinguished with difficulty from chronic pyaemia, but
the acute forms of the diseases differ, because rheumatic effusion into the
joint cavities is seldom purulent as in pygemic synovitis. Again, the sour
odor of acute rheumatism is replaced by the sweetish smell often noticed
about septicæmic cases. The rapidity of emaciation and the fatal issue
SA PR AEM IA, SEPTIC A. M IA, A N D PY AEM IA. 69
in the majority of cases of septicæmia or pyaemia, as well as the evident
existence of secondary inflammations and metastatic deposits in the latter
disease, proclaim the nature of the affection with no doubtful voice. It is,
however, difficult at times to certify that visceral symptoms are really
due to metastatic abscesses, and not to simple inflammatory lesions.
Many of the symptoms of typhoid fever resemble those of septicæmia,
because the intestinal lesions of the former disease lead to septic infection
of the patient,
TREATMENT.-The indications of treatment are to remove the exciting
causes of Septic conditions by general local prophylactic measures, and
to support the system until the poison is eliminated. An abundance of
fresh air, sequestration of pyaemic, erysipelatous and similar patients,
sterilization of clothing and instruments that possibly contain Septic
germs, and the aseptic or antiseptic treatment of all wounds, are im-
portant factors in preventing the occurrence of the disease in hospitals.
These are general measures to preclude the advent of the disease among
patients with operative or accidental wounds who are to be subjected to
the influences of hospital wards. It is especially necessary, moreover,
so to treat every patient that he may not be liable to self-infection from
generation of the septic poison in the discharges of his own wound.
Hence, union by first intention, or by rapid and healthy granulation, is
to be obtained as quickly as possible. The surgeon must be on his guard,
however, lest in this endeavor he allow purulent accumulations and
burrowing to occur; for pus contained in irregular cavities exposed to
the air soon decomposes, and putridity is the fertile source of septic
infection. Hence, free incisions, counter-openings, and perfect drainage
of the lowest depths of the wound, with copious antiseptic affusions,
are absolutely essential. Free laying open of irregular, lacerated, and
dirty wounds, even before suppuration occurs, especially if serous cavities
be involved, is often the most scientific treatment, although, to the inex-
perienced mind, it seems like protracting the cure by increasing the
wound surfaces. Such wounds should be thoroughly washed out with
Sublimate solution (1 : 500 to 1 : 5000), carbolized water (1:40), solu-
tions of chloride of zinc (1:100 or 1 : 50), or some similar antiseptic
lotion, before suturing or dressing. In very large wounds corrosive sub-
limate may cause toxic symptoms if used in strong solution. Shreds
of devitilized tissue, decomposing blood-clots, and unhealthy pus confined
in any portion of such wound will cause septic or pyaemic symptoms with
great readiness. All abscesses forming in the neighborhood of the
original wound must be opened promptly. The method of dressing
Wounds must be that known as the aseptic or antiseptic method, of
which there are many variations fulfilling the same conditions. Mopping
the surface with undiluted carbolic acid may, perhaps, become an im-
portant preventive agent in certain cases, where infection is feared, as it
probably seals the vessels and hinders septic absorption.
To support the system after septic infection has occurred, tonics, stimu-
lants, and nutritious food must be employed. There is no specific remedy
available. At first a laxative may or may not be required. The appear-
ance of the tongue and state of the bowels indicate or contra-indicate its
use. Quinia (gr. j) and tincture of chloride of iron (m. xx) every .
three or four hours; brandy in amounts varying from two to six fluid-
ounces daily, and opium, if pain demands it, in one or two-grain doses
every second or fourth hour, will be the line of medication suited to the
majority of cases. Frequent administration of cream, milk, and animal
70 S A P R AE MIA - S E PTIC AE M IA, A N D PY AE MIA .
5 )
broths, given in small amounts, day and night, is absolutely essential. An
astringent combined with opium (as for example, tannic acid gr. j, opium
gr. j, capsicum gr. 3); atropia Sulphate gr. Tº ; turpentine m, X, or some
other remedy, may be needed at varying intervals, to combat diarrhoea,
profuse sweating, or dry tongue and tympanites. In fact, symptoms must
be met by appropriate remedies, since no specific to eliminate the poison
is of recognized value, though many have been advocated.
O H. A. P. T. E. R. I. V.
SCROFULA AND TUBERCULOS [S.
DEFINITION.—Scrofula, or struma, was formerly believed to be a consti-
tutional condition in which there existed an abnormal tendency to inflam-
mations of unusual chronicity, and in which the inflammatory products
were not readily absorbed, but infiltrated the tissues and underwent
cheesy degeneration. These inflammations occurred either idiopathically
or after slight injuries, and were especially prone to attack the lymphatic
glands, the skin and mucous membranes, the serous membranes, and the
bones and joints.
We now know that scrofula is simply tuberculosis, usually of the infil-
trated and not of the modular form ; and that it is due to the bacillus
tuberculosis. The structures mentioned above are obviously those into
which the parasitic plant most readily penetrates. Microscopical exami-
nation of scrofulous lesions shows the presence of typical tubercles and the
bacillus. It is a well-known clinical fact that miliary tubercles may
result from scrofulous lesions. Lupus, also, is probably simply an example
of cutaneous tuberculosis. It is thus seen that these three conditions,
which formerly were considered separate diseases, are now, according to
recent pathological research, included in one category.
Tuberculosis is an infective disease due to a bacillus. Its lesions may
be so numerous as to justify the term general tuberculosis, or there may
be a single lesion, when it is known as local tuberculosis. The original
infection, of course, is usually a single lesion, but it is often the focus
from which further infection originates, causing lesions in distant parts of
the body.
Chronic inflammation due to the bacillus tuberculosis may give rise to
small nodular masses, or may assume the infiltrating form. The inflam-
matory lesions due to the antagonism of the tissue to the microbic irrita-
tion, are small masses of granulation tissue called tubercles, because
they usually make small shot-like protuberances. Tubercles are de-
scribed from their color as gray and yellow ; the latter, however, are
simply a later stage of the former, because the gray tubercles usually
finally undergo cheesy degeneration.
Tubercles are found in the skin, the subcutaneous tissues, the mucous
membranes, the serous membranes, the cancellated structure of bones,
the lymphatic glands, the lungs, the liver and testicles; in fact, in al-
most every structure, though most frequently in those just mentioned.
PATHOLOGY..—Gray or miliary tubercles are, according to my concep-
tion of prevalent pathological views, minute inflammatory shot-like
tumors or growths, not larger than a millet-seed, consisting of granulation
tissue and resulting from infection of the system by the bacillus tuber-
culosis. The general infection occurs through the blood and lymph-
atic currents, and is due to the transfer of the organisms from some
local tubercular inflammation which may have remained many months
Without infecting the rest of the body. The gray tubercles undergo
72 S C R O F U L A A NI) TU B E R C U L OSIS.
cheesy degeneration, as, indeed, may any structures which have little vas-
cularity and great abundance of cells, and become yellow tubercles.
Miliary tubercles may not only be
Fig. 7. due to some previously existing
caseous tubercular centre, but be-
come caseous themselves. The term
yellow tubercle is often applied to
cheesy masses, without much refer-
ence to their causation. Gray tuber-
cles show microscopically a network
of large, branched, many-nucleated
cells, called giant-cells, associated
with a small-celled structure resem-
bling adenoid tissue. Differences
occur, however, with variation in lo-
cality of the tuberculous lesions.
Tubercle bacilli in giant-cell. Specimen The bacilli al"e found within the tu-
from tuberculosis in a horse. (GREEN.) bercle, and especially in the giant-
cells. Persons who may have an
inherited proneness to inflammatory affections, characterized by chronicity
and by products containing many cells and tending to caseation, would
be most liable to afford a suitable soil for the tubercle bacillus, and thus
become tuberculous. They are those who were formerly called scrofu-
lous or strumous. Cheesy or calcareous degeneration, encapsulation of the
bacilli by fibroid or scar tissue, and breaking down into puriform fluid,
causing the so called chronic abscess, may occur as secondary changes.
CAUSEs.-It was formerly taught that the tendency to such inflamma-
tions was often inherited, constituting hereditary scrofula, but that
a chronic inflammation might cause infection and tuberculosis in one
who had not previously shown any caseous degenerative changes, and who
had no inherited predisposition thereto. This was denominated acquired
scrofula. A chief cause of inherited scrofula was thought to be syphilitic
ancestry, which established the tendency to chronic and cellular forms of
inflammation. The acquired tendency to scrofulous affections was at-
tributed to improper nutrition, often, perhaps, due to feeding infants on
the milk of tuberculous cows, to impure air, exposure, and overwork.
We now know that it is infection by a vegetable parasite which causes
these anomalies, and that the fungus produces its effects most surely when
it finds a suitable soil for its germination. Such a soil is furnished by
the ill-nourished, the weak, whose tissues prove least resistant to my-
cotic invasion. Scrofula and tuberculosis exist much more frequently
among children and young adults, but no age is exempt from such
affections.
SYMPTOMs.-The affections which are apt to occur among those called
tuberculous are characterized by protracted inflammation and degenera-
tion of the tissue, often giving rise to a puriform liquid. The products of
this chronic inflammation, instead of being rapidly absorbed, accumulate
and often become cheesy. Enlarged lymphatic glands, which may de-
generate into caseous masses, or soften and give rise to thin curdy puri-
form fluid, are frequent. Other lesions are chronic catarrh of the various
mucous membranes; cold abscesses which burrow, and, discharging, leave
ulcers with livid, ragged edges, that in turn are followed by irregular and
puckered cicatrices; phthisis, synovitis, and arthritis; caries and necrosis;
corneitis; and ulcers and cutaneous inflammations, often called scrofulides.

S C R OF U L A A N D TU B E R C U L O S I S. 73
Attempts to define the physical and mental characteristics of those liable
to suffer from strumous disease are valueless, because all temperaments
may, as we now know, become tuberculous from infection with the bacillus
tuberculosis.
TREATMENT.-Inherited predispositions to tubercular infection must be
so treated as to prevent the possibility of infection ; when infection has
occurred the original lesion must be so managed as to obviate general
infection. The best possible condition of nutrition must be obtained by
good diet, warm clothing, and out-of-door life in equable climates, com-
bined with bathing and friction of the skin. The digestion must be care-
fully watched, and regulated by alkalies, laxatives, mineral acids, tonics,
and proper exercise. Each case demands especial study. Cod-liver oil,
syrup of iodide of iron, quinia, iodide of potassium, iodoform, iodine,
arsenic, mercury, chlorate of potassium, and rarely alcohol, are the medi-
cinal agents usually required, but they are secondary to the hygienic
measures mentioned. To hasten the cure of the chronic inflammations,
local measures, such as recommended under that heading, are required.
Early and complete excision of the tubercular lesion is often the safest
course. The pus of abscesses is sometimes absorbed, but it is better to
evacuate it with a knife or aspirator than to have the deformed cicatrix
due to spontaneous evacuation. Glandular masses, if small, may be
enucleated. To avert an impending scrofulous or tuberculous general
infection, excision of bone, arthrectomy of a joint, or even amputation of
a limb, may be necessary. Such operations, however, must not be done
too hastily, though in certain cases their expediency is unquestioned as a
factor in preventing or ameliorating an acquired tubercular habit. The
deformity due to irregular cicatrices after abscess of cervical glands may
be relieved by dissecting out the elevated masses, and by sliding skin over
the depressed scars so as to make a level surface with a single white linear
SCall".
C H A P T E R V .
SYPHILIS.
DEFINITION.—Syphilis is a constitutional disease resulting from a
blood poison, of unknown nature, introduced by inoculation or by heredi-
tary transmission. The acquired form has a period of incubation, and
appears to be self-protective—that is, a person who has once been inocu-
lated is not liable to be affected by subsequent exposure to the virus. The
words venereal disease are often used to include syphilis, chancroid dis-
ease (improperly called local syphilis), and urethritis. The term should
be rejected because these affections are by no means always acquired
through sexual intercourse, and are so mutually distinct that any classi-
fication of them under one heading induces mistaken ideas of pathology.
While discussing syphilis and its primary lesion, hard chancre, I shall
speak incidentally of chancroid disease, or soft chancre, which is a dis-
tinct affection, resembling the first manifestation of syphilis, but not
resulting from constitutional infection. This disease, as well as urethritis,
or gonorrhoea, will be fully considered under local diseases of the genito-
urinary apparatus, where they properly belong; though chancroid is by
some described in this connection because of its important differential
diagnosis from syphilis.
CAUSES.–Syphilis, when not congenital, can only be produced in
healthy individuals by inoculation with the specific virus. Inoculation
may occur directly, from contact usually, of an abraded surface, with the
secretions of primary or secondary manifestations of the disease situated
upon another person, or indirectly by the discharges of such lesions being
transferred by means of drinking-cups, surgical or dental instruments,
tobacco-pipes, towels, etc. In the vast majority of cases of acquired
syphilis, inoculation occurs during sexual intercourse, from chancres or
mucous patches upon the genitals. Inoculation may occur from the
blood of syphilitics, taken during the eruptive period of the disease, being
introduced into the system by vaccination, skin-grafting, and, perhaps,
also by contact with the menstrual blood of women infected with consti-
tutional syphilis, who have at the time of coitus no lesion of the genital
organs. It is doubtful whether the saliva, milk, and semen can cause
syphilis, unless mixed with the discharges and blood coming from mucous
patches or other lesions. The discharge from tertiary ulcers or gummy
tumors is not capable of inoculating other persons. It is not absolutely
necessary that a break or abrasion of the skin or mucous membrane exist
to permit admission of the virus. A woman, previously healthy, may,
it is said, become infected from carrying a foetus which is syphilitic from
the semen being furnished by a syphilitic father. The woman, if this is
true, is infected by the man, not directly, but secondarily through the
medium of the foetus and the placenta.
A prolific cause of syphilis is heredity. Two syphilitic parents are
almost certain to have, if repeated abortions do not interfere, children
who subsequently exhibit symptoms of constitutional syphilis. If only
SY M P T O M S. 75
one parent is syphilitic the child is less liable to infection, particularly if
the diseased parent is the father. Hence marriage of syphilized subjects
is to be discouraged ; though if the acquired disease was mild and well
treated and no lesions have appeared for one or two years, the risk of con-
taminating the wife or husband and of producing children with syphilitic
constitutions is reduced to a minimum. Scrofulous or tuberculous chil-
dren are frequent witnesses of such marriages which have not in truth
produced true hereditary syphilis; but have brought forth a posterity
liable to chronic inflammations, caseation, and tubercle infection.
The cause of syphilis is almost certainly a microörganism, though up
to this time it has not been definitely and certainly found.
CLINICAL HISTORY..—A study of the symptoms of syphilis reveals the
existence of:
1. A stage of incubation lasting two or three weeks, followed by
2. A primary stage, marked by chancre and bubo, which, at the end of
two or three months, is followed by
3. A secondary stage, characterized by eruptions and inflammations of
the mucous membranes, which, at the end of six or twelve months or a
longer period, is succeeded by
4. A tertiary stage, exhibiting itself by ulcers and other severe cuta-
neous lesions, bone diseases and gummy deposits, and which often is fol-
lowed, if the patient marries, by what may be called
5. A quarternary stage, exhibited in his children. The quarternary
form, or hereditary syphilis, presents lesions similar to the secondary and
tertiary stages of acquired syphilis.
SYMPTOMS.–The stage of incubation is the period between the time of
contact with the virus and the appearance of chancre. It waries greatly,
but lasts, on the average, two or three weeks. It often is represented by
the patient to be longer than this, because he fails to recognize the advent
of a small chancre.
During any portion of the incubation period local inflammation of the
parts may arise, due to simultaneous contact with irritating discharges
(chancroid, etc.), or to injury, which has no pathological relation to the
syphilitic chancre that is subsequently developed. The local disease may
persist even after the stage of incubation has passed and the initial lesion
(chancre) is exhibited.
If the syphilitic inoculation was effected at the same point at which the
inflammatory ulceration, due to irritating discharges, is in progress, the
patient will have the two lesions combined at that locality. This fact has
induced many observers to believe erroneously that chancroid may be
followed by syphilis.
Primary stage.—The initial lesion of acquired syphilis is always chancre,
which is soon followed by lymphatic involvement, causing adenitis. The
inflamed and enlarged glands constitute a swelling or tumor, called bubo.
It must be remembered that when chancre appears the patient has already
been syphilitic for two or three weeks; that is, during the time of the
incubation stage, The chancre is the result of his syphilitic condition,
and is not a local sore, which generates the poison that infects the system.
The chancre, which must not be confounded with the chancroid sore
(chancroid, soft chancre, non-infecting chancre), presents different appear-
ances, according to its situation and the depth of the tissue involvement.
Very frequently it is a small, superficial papule, having a reddish color
and a circularly or eliptically ulcerated apex. Sometimes there is no
ulcer whatever, but it is rare that some ulceration does not appear. It is
76 SY PEIIL I S.
probable that the ulceration is usually due to infection of the surface of
the syphilitic lesion by pus bacteria. Abrasion, perhaps, removes the epi-
dermis from the papule, and pyogenic organisms infect the part so that
suppuration and ulceration occur. When the ulcer exists it is not much
excavated, and secretes a serous fluid, containing epithelial and other
particles, but no pus, unless active inflammatory processes have been
developed by irritation. The papule, with or without ulceration, has at
its base a thin layer of hardened tissue, which is sharply defined, and
resembles to the touch a disk of cartilage or parchment, buried under the
skin. This induration is less apparent when the chancre is located on a
mucous than when on a cutaneous surface, and in some cases does not per-
sist long. At other times the chancre is a deep ulcer, with elevated edges
and a surface covered with a sloughing material; still the discharge is
not purulent, but watery and, perhaps, slightly sanguinalent. The indu-
ration is deep and slightly outlined, and gives the sensation of a split pea
between the finger-tips. This hardening lasts a long time even after the
ulcer has been healed; but, finally, when cicatrization and absorption
have occurred, there remains a cicatrix with comparatively little depres-
sion. The ulceration does not destroy the tissue of the part as much as it
appears to do, since it is the newly-formed inflammatory lymph that disin-
tegrates.
Both these forms are true chancres, but the deep ulcer seems to be due
to a more virulent infection, as it appears sooner after inoculation than
the superficial chancre, and, as a rule, does not follow inoculation from
secondary syphilis, which is more apt to cause superficial chancre, such as
described above. Either form of chancre may assume phagedenic action
under local irritation, or on account of a depressed state of the system of
the patient, such as struma and scurvy.
The secretions from these indurated, hard, or infecting chancres, whether
superficial or deep, will not produce similar sores when applied to other
parts of the patient's body, for he is protected against further syphilitic
inoculation. How long this protection lasts is not definitely understood.
On this account chancre is single, unless inoculation at several points has
occurred at the same time.
Coincident with the stage of induration of chancre, enlargement and
induration of the nearest lymphatic glands appear, constituting the syphi-
litic bubo. These bubos are usually situated in the groin, because the
common location of the chancre is upon the genitals. Bubos, however,
are found in the axilla, above the internal condyle of the humerus, under
the jaw and elsewhere, according to the position of the chancre. If the
initial lesion is near the middle line, a bubo will, probably, be found on
both sides. If the lymphatic vessels from the inoculated spot lead to
internal lymphatic glands, as in uterine chancre, no external bubo will be
manifested. Induration of the glands is, probably, always present in
syphilis, but cannot occur unless chancre has preceded it. Syphilitic
bubo appears, about three weeks after inoculation, as a chain of hardened
and enlarged glands, which are painless, or nearly so, and show no
tendency to suppuration. The inflammation affects the glands only, and
not the surrounding tissue, hence they retain their characteristic almond
shape, and do not suppurate unless there be some cause of pyogenic infection,
such as co-existing chancroid disease, or an infected wound. Then the Sup-
puration is not syphilitic, though, if due to chancroid, the pus may have
the contagious properties of that non-syphilitic sore. If it be due to other
inflammatory causes, the pus is as innocent as the pus from common acute
SY M PTO M. S. 77
abscesses, or ordinary so-called sympathetic suppurating buboes; that is,
it contains pus organisms, but not the syphilitic poison.
The chronic and indurated bubo of syphilis may continue for many
months after the chancre has disappeared. The clinical history of true
syphilitic bubo is very different, as will hereafter be seen, from that of
bubo following chancroid disease. .
Secondary stage.—About six weeks after the appearance of the chancre,
the patient becomes more or less feverish, has, perhaps, headache and
general uneasiness of an indefinite character, and then discovers, in the
course of five or six days, the existence of an eruption, Sore-throat, mucous
patches, cervical adenitis, falling of the hair, or iritis. These are the
symptoms of the Secondary stage, which usually occurs at the time men-
tioned, and is preceded by the prodromes described. It may be delayed
until the sixth month, and often overlaps the period of primary syphilis,
which is prolonged by imperfect resolution of the chancre and bubo.
The cutaneous lesions of syphilis are called syphilides or syphiloderms,
whether occurring as symptoms of the secondary or tertiary stages. In sec-
ondary syphilis, the eruption is usually macular or papular in form ; though
the scaly, vesicular, pustular and tubercular syphiloderms may occur. The
last two varieties are more common in the later periods of secondary syphi-
lis, or in the tertiary stage. Syphilitic skin affections usually become some-
what brownish in color about the time of their disappearance, are accom-
panied by very little itching, often present several varieties at the same
time, and are not confined to a single portion of the patient's body.
Mucous tubercles or patches are flattened and elongated elevations, a
quarter or half an inch in diameter, found on the mucous surfaces, at the
muco-cutaneous junctions or where the skin is very delicate, and covered
by a whitish exudate. They appear at first as reddish elevations, from
which the cuticule is removed, and upon which the exudate soon occurs,
giving the surface an appearance similar to that produced by touching
mucous membrane with nitrate of silver. The sore mouth and throat of
Secondary syphilis are due to these mucous patches, to superficial inflam-
mation and ulceration, or to a combination of these lesions.
Inoculation of syphilis occurs more frequently from these mucous patches
about the genitals and mouth than from the secretions of chancre itself.
Inflammation and chronic enlargement of the lymphatic glands, especially
of those situated along the posterior margin of the sterno-mastoid muscle,
are very frequent symptoms of the secondary stage. These have no
necessary relation to the existence of marked cutaneous lesions in the
neighborhood. Falling of the hair of the scalp and other regions, and
inflammation of the iris are frequently present in secondary syphilis. The
papular eruption often occurs as an accompaniment of the iritis. Other
Symptoms may present themselves in the secondary stage, but the most
Common have been mentioned.
Tertiary stage.—There is no distinct separation between the secondary
and tertiary stages, but the latter is characterized by more chronic and less
contagious lesions, which affect, as a rule, the deeper tissues of the body.
It is convenient to consider lesions originating after the lapse of six
months as tertiary symptoms. Tertiary symptoms are not exhibited in
all cases, because the disease may be so mild or so judiciously treated that
it subsides or becomes latent with the disappearance of the secondary
troubles. Very often, however, the disease remains in abeyance for many
months or years, and then tertiary lesions supervene.
The lesions produced by tertiary syphilis may be classified under the
78 SY P H II, I S.,
following heads: 1, Fibroid degenerations; 2, gummy deposits; 3, changes
in the arterial walls. The fibroid indurations occur in limited areas sur-
rounded by normal tissue, and are found in periosteum, sheaths of nerves
and of organs, and in muscle. Gummy tumors or deposits are yellowish
masses of firm consistence, due to degenerated cell-products, surrounded
by a fibrous area, which is in turn encircled by a cellular and vascular zone
intimately adherent to adjacent structures. They are the most character-
istic formation of syphilis and occur in the tegumentary structures, mus-
cles, fasciae, bones, and internal organs. They may become caseous, but
often in a manner not well understood, cause suppuration around them-
selves, break down and cause the deep intractable ulcers of tertiary
syphilis. The change in arterial walls occurs in the inner coat and causes
diminution in calibre, which interferes with circulation and may induce
degenerative changes. The tertiary syphiloderms are usually pustular,
tubercular or ulcerous. The ulcerations and suppurations found in syph-
ilis are probably the result of the low vitality of the cells, affording a
place of least resistance for the harmful localization of pyogenic fungi
circulating in the blood-stream. The germs cause suppuration there, when
to healthy tissues they would be unable to do injury. The rupial ulcer
with its acuminated scab is especially characteristic, as are the deep
ulcers due to destructive changes in gummy tumors. Similar lesions of
the oral and other mucous membranes are frequent. Periostitis; oste-
itis, modes due to lymph or gummy deposits under the periosteum, and all
causing bone-pains (osteocopic pains) especially at night; caries and
necrosis; iritis, retinitis and choroiditis; falling of the hair; onyxitis;
orchitis; cerebral and spinal inflammations; and, in fact, inflammation
of any organ or tissue may be induced by constitutional syphilis. Many
of these lesions depend on the deposition of gummy material, others are
due to the fibroid and arterial changes mentioned.
FIG. 8.
Upper incisors of boy with symptoms of
inherited syphilis from infancy. Typical
notchcs.
Quarternary stage.—This seems to
me a good name to apply to heredi-
tary syphilis, though I admit that
syphilitic children may be born to
parents who have not yet advanced
beyond the secondary stage. It is
unnecessary to discuss the method
Notched teeth of hereditary syphilis.
Boy, ten years, who had periostitis of
tibia. Lower teeth show normal sex rations
of second dentition, and are elongated,
probably because the imperſect upper teeth
do not oppose them.
by which children inherit the syphi-
litic cachexia, but it is recognized
that the disease is more certainly
derived from a syphilitic mother
than from a syphilitic father, and
from two more certainly than from
one syphilitic parent.
The child may not present any distinctive symptoms until a few weeks
after birth, when its unhealthy looking and shrivelled skin, its aged


IDIA G. N. O S I S. 79
appearance, the nasal catarrh and stomatitis due to the inflamed mu-
cous membranes, and the possible discovery of cutaneous eruptions or of
mucous patches about the anus and genitals will point unequivocally to
its syphilitic parentage. The syphilis so exhibited is of the secondary
form; and by its ability to inoculate other subjects, and its greater or less
protective power against further inoculation of the same subject, it
proves its identity with ordinary acquired syphilis.
If death does not remove the child, further secondary and tertiary
symptoms will in time follow. Interstitial keratitis, periostitis, bone dis-
ease, and many tubercular affections will in time be developed. The low
cell-vitality of syphilitic children makes easy the assaults of the tubercle
bacillus. The resistance of healthy tissues is wanting. The peculiar
notched condition of the upper central incisor teeth of the permanent
set, first described by Hutchinson, of London, is often seen.
These two teeth, and at times others, are poorly developed; having a
conical shape and a cutting edge, which is marred by an irregularly
bevelled anterior surface, or even distinctly notched by the breaking away
of the central portion. This notched condition must not be confounded
with the normal serrated edge of newly extruded teeth of healthy chil-
dren. The teeth of syphilitic children are often irregularly placed, and
look like the end of a screw-driver or are mere pointed pegs. Syphilitic
women are liable to abort frequently because of the diseased condition of
the placenta, and it is only after the woman has regained a fair degree
of health that the foetus is carried until full term.
DIAGNOSIS.—The diagnosis of syphilis rests upon the general clinical
history of the disease rather than upon any one symptom or upon the
statements of the patient. The distinction between chancre and the local
affection called chancroid disease is often difficult, and at times impos-
sible, unless time be given to watch the progress of the symptoms. The
diagnosis is to be founded upon the following characteristics:
Chancre.
Time.—No noticeable lesion until two or
three weeks after exposure.
Number.—Single unless several points in-
oculated at time of exposure.
Character.—Papule, superficial abrasion,
or an elevated ulcer, with edges sloping
towards center, which coalesces with ad-
jacent tissue and discharges a scanty,
serous, non-purulent fluid. Permanent,
indolent, non-inflammatory induration
at base of sore, feeling like a disk of
parchment or a split pea beneath the
integument. No tendency to phage-
daema. Heals spontaneously.
Bubo.—Always present, involves a chain
of glands, is indurated, usually bilateral,
and seldom suppurates. If it does sup-
purate pus is not inoculable.
JPalhological mature.—Due to a constitu-
tional disease, which is soon manifested
by other symptoms. Protects the patient
from subsequent inoculation; hence,
Surgeon cannot produce another chancre
on him by inoculation with the dis-
charge from the suspicious sore.
Chancroid.
Irritation early and sore developed within
a week after exposure.
Multiple, because pus is auto-inoculable
and produces other ulcers.
Ulcer, with edges steep as iſ a piece of
tissue had been punched out or ragged
and irregular; does not coalesce with ad-
jacent tissue and is covered with a drab-
colored deposit. The secretion is puru-
lent, very copious, and inoculates sur-
rounding surfaces, thus producing mul-
tiple chancroids. No induration. Liable
to phagedaema. No tendency to heal.
Often absent, involves but one gland and
one side Very prome to suppuration,
furnishing pus which readily inoculates
and produces other chamcroid ulcers.
The suppurating bubo is practically a
chancroid.
A local affection never followed by consti-
tutional symptoms and, therefore, does
not protect against Subsequent inocula-
tion ; hence, surgeon can produce many
other chancroids by inoculating patient
with pus from original sore.
This table gives the usual clinical history of the two affections, but it
must be remembered that the time of appearance and the physical char-
80 SY PH I L I S.
acteristics may vary somewhat. Thus, a chancre may be so infected by
pus fungi as to furnish a purulent secretion; and a chancroid may have
a slightly indurated base by reason of repeated applications of caustics.
Chancre is to be distinguished from epithelioma by the earlier glandular
involvement it causes, the effect of anti-syphilitic treatment, and the con-
comitant constitutional symptoms. Many doubtful cases of cancer and
of chaneroid can be diagnosticated by the collateral evidence obtained
from confrontation of the patient and the person by whom he is supposed
to have been inoculated.
Secondary and tertiary syphilitic lesions are to be differentiated from
non-specific affections by the history, the co-existence of multiple patho-
logical changes, the exclusion of other causative factors and the response
to anti-syphilitic remedies. t
TREATMENT.-Syphilis is a constitutional disease and demands general
treatment. Cauterization or excision of the chancre is valueless, since
constitutional symptoms are not the result of the chancre, but the latter
is a lesion due to general infection dating from the time of inoculation.
Hence, the local treatment of chancre should consist of measures that
prevent the irritation of the ulcer, such as is caused by rubbing against
the clothing and infection with pyogenic microbes. Antiseptic protection
of the primary induration before the epithelium is abraded is eminently
proper. Cleansing with soap and water and a dry dressing of sublimate
gauze, so applied as to permit urination, is judicious treatment. Iodo-
form dissolved in collodion (gr. X to faj) is a convenient application, as it
makes an impervious coating. It should not be applied until the sore is
made aseptic by washing with soap or sublimate solution. If the
chancre becomes phagedaemic, which is rarely the case, strong caustics,
such as undiluted nitric or carbolic acid or nitrate of mercury, may be
employed to arrest the destructive action. The actual cautery destroys
the microörganisms better than any of these. It must be applied to every
crevice of the sore. Bubo, as a rule, demands no local treatment, for it
is painless and merely an expression of the constitutional implication.
Moreover local treatment is useless because it, as a rule, effects no result.
If suppuration occurs about the indurated glands, the pus should be
evacuated as if the abscess were non-specific, which, indeed, it really is.
The special constitutional remedies for syphilis in all its stages are
mercury and iodine; of these mercury is probably the more important
and efficient. The manner of using these drugs is important, but the
preparation employed may vary with the fancy of the surgeon and the
convenience of the patient. It is absolutely essential that the effect of
the remedy be maintained for one or two years, if the tendency to sec-
ondary and tertiary manifestations is to be eradicated. Mercury is the
better remedy for the primary and secondary lesions, and iodine probably
the better one for the tertiary affections; though this dictum may at times
be invalidated by individual experience. In the later lesions I usually
employ a combination of both drugs.
As soon as the diagnosis of syphilis is established, mercurial treatment
is to be instituted, and, even in doubtful cases, I should probably give the
patient anti-syphilitic remedies. Many, perhaps most, syphilographers
prefer to wait until the diagnosis of a doubtful sore is absolutely estab-
lished by the occurrence of secondary symptoms. The green iodide of
mercury (often called the protiodide) may be given in quarter-grain pills
three times daily after meals; or a corresponding amount of blue pill or
calomel may be substituted. If it is found in the course of a few days
T. R. E. A. T M E N T. 81
that unusual looseness of the bowels is produced, one or two grains of
tannic acid or a sixth of a grain of opium may be added to each pill.
This amount of mercury will probably be tolerated for several weeks
without causing tenderness of the gums or undue salivary excitation. As
soon as either of these effects is induced the amount must be decreased or
the drug entirely suspended for a week. In cases where the disease is
violent in its first manifestations, an early decided mercurial impression
is necessary. Blue pill in one to three grains daily, or calomel to the
amount of one-half to two grains daily, or a similar amount of green
iodide continued until evidences of moderate constitutional effects become
evident, is judicious treatment. If no beneficial effect is observed from
ordinary small doses, and the condition of the gums will warrant it, the
dose must be increased. In this tentative manner the maximum quantity
which the patient can take without causing gastric, intestinal, or oral
irritability is determined. This he must continue during nearly two
years, occasionally omitting treatment for one or two weeks, but never
suspending it entirely, even if no further constitutional symptoms have
shown themselves. There is no danger of taking these small or tonic
doses of mercury for too long a period in this way, but there is often a
tendency to tire of what seems unnecessary tediousness of treatment.
If it is preferred, some of the other mercurial preparations may be
used, or the agent may be introduced into the system by inunction, fumi-
gation, hypodermic injection, or suppository.
For inunction thirty or forty grains of the officinal ointment of mercury
may be rubbed into the thin skin of the inner side of the arms or thighs
at bedtime. Fumigation is accomplished by volatilizing a half drachm
of calomel by means of a lamp placed under a metal plate upon which
the drug is spread. Any apparatus which will allow this arrangement,
and at the same time furnish an atmosphere warmed and filled with
steam, is all that is required. The patient is divested of clothing, and
surrounded by a rubber cloth extending from his neck to the floor.
Under this covering the generator of mercurial vapor and of steam is
placed, and thus the moistened cutaneous surface is subjected to the reme-
dial influence.
Such fumigation may be repeated every day for fifteen minutes, and is
especially available in syphilitic skin affections. Internal treatment may
be used in conjunction with these mercurial baths. The corrosive chlo-
ride of mercury in doses of from one-thirtieth to one-tenth of a grain may
be given hypodermically. All these methods, however, are too incon-
venient for prolonged use, and will never supersede the ordinary mode of
administration, except in especially selected cases. At certain times, be-
cause of the inefficiency or undesirability of mercury, the preparations of
iodine must be utilized. The iodides of potassium, sodium, and ammo-
nium are usually adopted because of their cheapness, convenience, and
efficiency. Iodoform is too offensive in odor, and many other prepara-
tions are too expensive or bulky. The iodides seem more valuable in
the late lesions of syphilis than in the primary and early secondary
affections. They are to be given in ten to thirty grain doses three or four
times daily, after meals, and preferably, perhaps, in alkaline solutions.
The sodium iodide will often produce less coryza and mucous irritability
than the commonly employed potassium salt, though the remedial power
of the drugs is about equal. Upon some persons the iodides act as a
Poison, and in very small doses produce coryza, conjunctivitis, cough, and
a papular eruption. Usually, however, these disagreeable effects can be
6 &
82 SY PHILIS.
obviated by combining a small amount of morphia with each dose, or by
resorting to some other preparation of iodine.
Before leaving the constitutional treatment of syphilis, it is necessary
to remind the reader that many patients are so broken down by the effects
of the syphilitic poison, or by previous conditions of ill health, either ac-
quired or hereditary, that the use of corroborant remedies is imperatively
demanded. Such cases require quinia, iron, mineral acids, stimulants,
cod-liver oil, and concentrated food. It is often possible to keep up this
line of action, while administering the small doses of mercury, or the
iodides. If these remedies seem to interfere with digestion and produce
anaemia, they must be suspended or reduced in amount for a time, and
the reliance of the surgeon be upon the tonic and supporting regimen.
It is a mistake, however, always to consider the prolonged course of mild
specific medication a depressing agency, for in the majority of cases it is
the syphilis that depresses, and the specifics which neutralize this poison
are really the proper drugs to increase the health equation. Agents
which tend to eliminate morbid matters from the blood are doubtless
valuable; hence, Turkish baths and secretory stimulants probably are
beneficial in the treatment of syphilis.
Again, it is very often of advantage to combine the mercurial and
iodine treatment when either agent alone does not beget favorable results.
In very late lesions, unusually large doses of iodide of potassium, such as
a half drachm or a drachm, largely diluted and taken after food three or
four times daily, will occasionally work astonishing cures of painful con-
ditions due to periostitis and nerve lesions. I usually give about thirty
grains of the potassium iodide before each meal, and a half to one grain
of the green iodide of mercury with a grain of tannic acid after each
meal. These remedies should not be taken at the same time, as red iodide
of mercury might perhaps be formed and poison the patient.
Hereditary syphilis must be treated with mercury and iodine, combined
with or occasionally replaced by tonics, in the same manner as acquired
syphilis. The syrup of iodide of iron in twenty or thirty drop doses is
often an eligible preparation. Warm clothing, good diet, and hygienic
surroundings of the best character are important factors in bringing
syphilitic children to adult life. It is probable that the subjects of in-
herited syphilis are more or less protected against inoculation with syph-
ilitic virus.
Any incidental symptoms that occur during the progress of either ac-
quired or hereditary syphilis must be managed on general principles.
Thus, impaired digestion, constipation, fever, sleeplessness, and such con-
ditions, may require laxatives, astringents, refrigerants, or hypnotics.
The local treatment of syphilitic lesions is important, but far less so
than the general treatment, except in the case of iritis. In iritis it is abso-
lutely essential to drop immediately into the eye a strong solution of atropia
(about four grains of atropia sulphate to the fluidounce of water); because,
if this is delayed, the iris will become glued to the anterior capsule of the
lens, and the permanently contracted pupil be occluded by the deposit of
inflammatory lymph. Hence, wide dilatation of the pupil must be ob-
tained at once, after which, or indeed during the same time, constitutional
remedies are administered.
Mucous patches and ulcerations should be touched with fused silver
nitrate or a solution of nitrate of mercury (1 : 10). Cutaneous ulcers
will heal more rapidly if slightly stimulated with diluted ointment of
nitrate of mercury (1 : 10), or with some astringent, such as copper sul-
T R E A T M E N T , 83
phate, silver nitrate, nitrates of mercury, iodoform, or chloral. The various
remedial measures described under ulcers are applicable.
The falling of the hair, technically called alopecia, may require stimu-
lating applications to the scalp, such as alcohol, ointment of the nitrate
of mercury, tincture of cantharides, tannic acid, and ammonia, suitably
diluted.
Iymphatic glandular involvement may be benefited at times by pres-
sure, absorbent plasters and lotions, and by interstitial injections of
alcohol or iodine.
Periostitis, which often causes excruciating pain, may be relieved by
blisters, or by subcutaneous incision of the periosteum, which relieves
tension.
Other operations may, at times, be required for the removal of diseased
bone or irrevocably degenerated members.
O H A P T E R V I.
RICKETS OR RACHITIS.
DEFINITION.—Rickets is a diathetic affection, and, therefore, should
mot be described under disease of bone, but in the present connection. Its
characteristic is an abnormal deposition of cartilaginous material, with
incomplete Ossification. The effects of this constitutional condition are
shown in softening and distortion of bones, and in changes resembling
amyloid degeneration in the liver, spleen and other organs.
PATHOLOGY..—Rickets seems to depend upon malnutrition, which
causes deposition of abnormally large areas of soft, cartilaginous tissue
which cannot be at once perfectly ossified by calcific transformation.
Hence the bone is thickened by soft, subperiosteal, cartilaginous deposits,
which do not add to its strength, because the medullary cavity is simul-
taneously increasing. The bones are, therefore, easily bent out of shape.
The epiphyseal cartilages, in a similar way, are enlarged, and, becoming
imperfectly ossified, allow deformity in the vicinity of the joints. Marked
deposition is apt to occur about the edges of the cranial and other flat
bones. After a time excessive deposit of bone salts occurs, and sclerosis,
or abnormal hardening, of the bones takes place. The visceral changes
resemble amyloid or waxy degeneration.
CAUSES.–The etiology of rickets is unknown. Heredity, food deficient
in organic salts, and the presence of lactic acid or phosphorus in excessive
amounts have been named, but not established as causative factors. Defi-
ciency in amount of fresh food is an important factor in its production.
SYMPTOMs.-Rickets is a disease of childhood, and appears about the
second or third year of life. The premonitory symptoms are not distinc-
tive, and no definite diagnosis can be made until the enlarged extremities
of the long bones, the nodules at the junction of ribs and costal cartilages,
and the bending of the bones by muscular traction and the weight of the
body in walking, point out the rachitic condition. The child may be
restless, sweat profusely about the head, show digestive derangement,
exhibit irregularity in dentition, and complain of muscular pain upon
moving or being handled. There is often no febrile movement. The
liver and spleen are often enlarged, and the child listless, emaciated and
somewhat sluggish in mental development. Osseous deformities of the
limbs, anterior thoracic region, spine and pelvis are commonly exhibited
in tuberous enlargements and curvatures. Partial or complete fracture
may occur. The fontanelles close slowly, and the occipital bone may be-
come thinned. These symptoms may abate, as if convalescence was at
hand, and be followed by recurrence of symptoms. It is not usually a
fatal disease, but recovery slowly supervenes, accompanied by abnormal
induration of the distorted skeleton.
TREATMENT.-The treatment must consist of feeding with the most nu-
tritious food, as mother's milk, cow's milk, broths, etc., and the adminis-
tration of cod-liver oil (fºss—ij three or four times daily), syrup of iodide
of iron (mx-xxx), quinia (gr. i-ii), compound syrup of phosphates
T R E A T M E N T . 85
(m, x-faij), or syrup of lacto-phosphate of lime (m, x-fºj). Fresh air,
bathing and frictions are valuable adjuvants. “lºſſ
During the stage of softening, deformity of the bones should be averted
by prohibiting locomotion, and by the application of splints or plaster-of-
Paris dressings. After convalescence, slight curvatures will often be cor-
rected by muscular action during the growth of the child. If the deformity
is great and permanent, osteotomy may be demanded to relieve lameness
or to improve appearances.
C H A P T E R V II.
TUM.O.R.S.
DEFINITION.—A tumor, or morbid growth, is a circumscribed enlarge-
ment of living tissue, abnormal to the part and having no physiological
function, which, in its growth, is independent of the adjacent structures,
and which is not the result of an inflammation. It is an atypical new
formation. Most cysts are not strictly tumors. Condylomata are inflam-
matory formations, not tumors.
CAUSES.—The cause of all morbid growths is abnormal activity of the
cellular elements from which they originate, but the factors or primary
causes inducing this morbid activity of prečxisting cells are not easily
discoverable.
It is probable that the cause of tumors is local rather than general, for,
although blood alterations and hereditary conditions may influence their
progress, the development of such morbid growths seems to depend on
peculiarities of the tissue-cells. These peculiarities may be due to in-
herited cellular eccentricity which readily responds to any existing cause,
or to local irritation from injurious impressions or from the immigration
of foreign elements coming from primary morbid growths situated at a
distance. Many efforts have been made to prove the dependence of
tumors, especially malignant growths, upon microörganisms, but thus far
unsuccessfully. The most tenable theory for benign growths is that there
has been left imbedded in the tissues a few embryonic cells, not em-
ployed in the development of the animal in the prenatal stage of ex-
istence, which, in after-life, assume activity and develop into tumors. It
has been suggested that the occurrence of carcinomas is due to the normal
resistance of connective tissue being reduced until epithelium, which has
an active power of growth, invades it.
PATHOLOGY..—Tumors are always developed from cells which have pre-
viously existed, either at the present seat of the growth, or at some
distant spot from which they have been transported to the locality occu-
pied by the tumor. The tumor in the former case is a primary, in the
latter a secondary, morbid growth. The histological structure and de-
velopment of every tumor resemble, in a greater or less degree, some
normal or physiological tissue—that is, all pathological formations belong
to some physiological type. The resemblance is not exact, however; they
are atypical. These axioms may be clearly illustrated by saying that no
tumor can be formed from cloth or straw, but in its construction and
growth must resemble some animal tissue. The original elements from
which tumors are developed are cells of connective tissue, of epithelium,
of glands, of muscle, or of nerve. The morbid growths originating from
muscle- and from nerve-cells are rare, those arising from epithelial and
glandular origins quite common, and those developed from a connective-
tissue basis exceedingly frequent.
A tumor whose structure is similar to the part from which it originated
or in which it lies, is called homologous; one which differs from the tissue
that gave it birth, or in which it is situated, is termed heterologous.
P A T H O L O G Y . 87
These terms are somewhat relative ; for example, a cartilaginous tumor
growing from the larynx would be homologous, but if appearing in the
testicle it would be heterologous. Heterology is especially characteristic
of malignant growths because they spread into tissues different from their
original site, and are even transported, by the blood and lymph currents,
to distant parts of the organism, such as the internal viscera.
An important point in regard to the relation of the new growth to the
adjacent tissues is the presence or absence of infiltration. If the tumor
blends with the surrounding parts so that the microscope discloses tumor
cells involving the muscular and cellular tissue of the neighborhood,
infiltration exists and the tumor is diffuse. This infiltration is very
common in malignant tumors, but may not be apparent to the unaided
eye. A circumscribed growth is one which is definitely separated from
the adjacent structures, which it has pushed apart during it development.
It is often isolated from them by a capsule of condensed fibrous tissue.
Such growths may, during their progress, become diffuse. Microscopic
examination is the only test of the absence of infiltration even in growths
which appear to be encapsulated.
Tumors occasionally disappear by atrophy or absorption, and at times
reach a certain bulk and remain stationary; but usually they increase in
size. This increase frequently occurs rapidly even though the patient is
losing weight. They may undergo changes, such as fatty degeneration,
calcification, pigmentary, colloid and mucoid degeneration, inflammation,
ulceration, and mortification, in a manner similar to tissues not patho-
logical in their origin. Tumors have no nerves.
The tendency which certain morbid growths have to be reproduced,
either at the original site, after excision, or in other regions by infiltrating
or infecting the tissues, is designated malignancy. Hence, tumors are
malignant and non-malignant. Malignant tumors, as previously stated,
are capable of infiltrating neighboring tissues with their cells; and by
this and perhaps other means they influence such abnormal activity in
the part that similar growths arise at the circumference of the original
tumor. Hence, it is not unusual to see a neoplasm surrounded by a
series of small nodules.
When the surgeon removes a malignant tumor he may leave tissue
which has recently been infiltrated with the tumor cells, but which appears
to be normal. These cells, either by their own proliferation or by in-
fluencing proliferation in the native cells of the part, cause a similar
tumor to appear at the cicatrix and its vicinity. The development of
Secondary tumors from malignant growths may occur in another way. The
lymphatic circulation through the original disease may carry cells of the
tumor to the nearest lymphatic glands, where they are arrested, and, as in
the former case, induce secondary growths similar to the primary. A
third manner of inducing secondary tumors is a similar transference of
cellular elements by means of the blood current passing through the
growth. These tumor cells are arrested by arteries or by veins in some
distant capillary system, often the nearest, and, as in the lymphatic method
of infection, induce secondary growths.
Thus, it is evident that malignant tumors produce others like them-
selves by infiltration and by lymph and blood infection. Other methods
may at times, though rarely, be operative. Tumors often show a decided
preference for one or other of these methods of reproduction. The sec-
ondary growths may, in the same way, act as parents and produce a
progeny with characteristics similar to their own. This transference of
88 T U M O R. S.
cellular elements explains the circumstance that malignant tumors are
frequently heterologous,
It must not be forgotten, as it often is, that multiple tumors, even when
malignant, may not be secondary to another, but may be synchronous or
due to the same original cause.
From the description given of the processes by which reproduction of
malignant growths is accomplished, it is evident that the most malignant
growths would be those containing the greatest number of cells, the most
juice, and the greatest abundance of lymphatic vessels and blood vessels.
The reverse of this picture would give non-malignant or benign tumors,
which, as they approach the characteristics of the other group, become
more or less malignant in nature. In fact, there is no absolute line drawn
by nature dividing the malignant from the non-malignant; although it is
admitted that tumors with one histological structure are usually malig-
nant, and others usually benign, either class may occasionally assume the
clinical nature of the other.
CLASSIFICATION.—Tumors are classified according to their histological
structure, which, as I have previously stated, always resembles, in a
greater or less degree, some physiological tissue either of adult or foetal
life. The imperfect knowledge that we possess of the development of
many tissues, and the varying degrees of relative importance attached by
pathologists to the microscopic elements seen in the growth, prevent a
universal acceptation of a single classification. I have accepted that given
by Green (Pathology and Morbid Anatomy), which is convenient for
reference, and more familiar to the American profession, perhaps, than
any other.
CLASSIFICATION OF TUMIORs.
I. Tumors whose general structure or type resembles one of the modifications of fully
developcd connective tissue.
Special types:
1. Fibrous tissue. Fibrous tumor. Fibroma.
2. Adipose tissue. Fatty tumor. Lipoma.
3. Cartilage. Cartilaginous tumor. Chondroma.
4. Bone. Bony tumor. Osteoma.
5. Mucous tissue. Mucous tumor. Myxoma.
(not mucous membrane.)
6. Lymphoid tissue. Lymphatic tumor. Lymphoma.
II. Tumors whose general structure or type rescimb/cs that of one of the higher or more
comple:c tissues than fully developed connective tissue.
Special types:
1. Muscular tissue. Muscular tumor. Myoma.
2. Nervous tissue. Nerve tumor. Neuroma.
3. Blood vessels. Vascular tumor. Angioma.
4. Lymphatic vessels. Lymphatic vessel tumor. Tymphangioma.
III. Tumors whose general structure or type is that of the undeveloped connective tissue
- of the embryo. *
Sarcomas.
These are named according to the shape and size of the predominant constituent cell
(round-cell, giant-cell, etc.); according to the character of the stroma (osteo-sarcoma,
myxo-sarcoma); or according to the retrogressive changes that occur in the tumor
(melano-Sarcoma, calcifying Sarcoma).
IV. Tumors whose general type is that of epithelial tissue.
1. Papillae of skin or mucous membrane. Papilloma.
| Adenoma.
9 (§ - º
2. Glands. Carcinoma.
T R E A T M E N T . 89
Under carcinomas, then, are :
1. Acinous carcinoma.
a. Scirrhoma, or chronic carcinoma.
b. Encephaloma, or acute carcinoma.
2. Epithelial carcinoma.
a. Squamous epithelioma.
b. Columnar-cell epithelioma; often called adenoid carcinoma.
3. Colloid carcinoma.
W. Congenital miced tumors or terofonata.
Tumors due to inclusion and imperfect development of one foetus within another, or
abnormal development of a single foºtus. Dermoid cysts belong in this division.
CLINICAL HISTORY..—Tumors present innumerable varieties as to size,
form, consistence, number, situation, and other physical characteristics.
These clinical attributes have much to do with the symptoms of the
growth; for example, a small tumor passing on a nerve-trunk will pro-
duce more pain than a large one in another locality; one overlying an
artery will receive transmitted pulsation, another pressing upon a vein
will cause mechanical dropsy. Certain tumors, especially the carcinomas,
have a tendency to ulcerate and become the seat of hemorrhage.
Those growths whose clinical history is conspicuous because of their
infiltration of adjacent structures, recurrence after removal, and repro-
duction in distant regions of the body, are called malignant. The car-
cinomas and many of the sarcomas usually present this feature of malig-
nancy; the other groups, as a rule, are not malignant. There are, how-
ever, occasional exceptions, for sarcomas and even carcinomas sometimes
act as non-malignant growths, while others, ordinarily benign, at times
assume a decidedly malignant expression.
CAUSES OF DEATH.-Death may occur from morbid growths on account
of hemorrhage; asthenia due to excessive discharge; nervous irritation;
mechanical interference with nutrition ; asphyxia; and profound involve-
ment of the nervous centres. Many tumors have no tendency to impair
the general health. This is especially true of the non-malignant growths.
TREATMENT.—The treatment of tumors depends on their character.
Malignant growths, and those suspected to have that character, should,
as a rule, be removed by operation as early as possible. The excision
should extend far beyond the apparent outlines of the tumor, because
infiltration has probably taken place, though not appreciable to the eye
of the surgeon. Benign growths may be allowed to remain if they neither
interfere with the functions of the part nor cause indirect deterioration of
health. If they show indications of probable future injurious influences
they should be removed while still small, provided the excision can be
done without great risk. If the tumor is more serious in its present or
future aspects than the operation, operation is justifiable; but when the
Operation is more serious than the probable effects of the undisturbed
tumor, operation is not justifiable.
In excising tumors involving deep structures and having firm attach-
ments, the operator should endeavor at once to become master of the situ-
ation by coping at first with the most troublesome portions of the
growth. It is unsurgical to spend time freeing superficial adhesions and
tying vessels which will in a moment be cut again at a lower level. It
is far better to work under the deeper portions of the tumor, as soon as a
free cutaneous incision has been made, and thus control the primary
Sources of hemorrhage. This method of operating enables the surgeon
90 T U M O R. S.
to appreciate more accurately the character of operative procedure de-
manded for the extirpation of the growth.
When tumors cannot be removed, relief of pain may often be obtained
by open or subcutaneous division of the fascias binding them down, or
by excision or stretching of nerve-trunks.
Excision of insignificant tumors is often proper because of the unsight-
liness produced by them, and the mental perturbation induced by their
eXIS ten Ce.
SPECIAL TUMoRs.
I. Tumors whose general structure or type resembles one of the modifica-
tions of fully-developed connective tissue.—Growths of this class are non-
malignant, for when any of them, such as fibroma, enchondroma, and
Osteoma, occasionally assume a malignant expression, it is found on micro-
scopic examination that they are wholly, or in part, sarcomatous. This
accords with the well-known fact that a tumor may present in its different
parts the structure of more than one variety of morbid growth.
FIBROMAs, OR FIBROUs TUMoRs.—These growths may be divided
into soft and hard fibromas. The former grow somewhat rapidly, are
smooth, rather soft and elastic, and often pedunculated; they are at times
diffuse, though often circumscribed and encapsulated, and give rise to no
pain or inconvenience except from their weight. On section they occa-
sionally exude a large amount of serous fluid. The hard fibrous tumors
are of slow growth, are smooth, very firm, usually single, generally
movable unless having bony attachments, painless, and encapsulated.
Fibromas, as a rule, have few vessels, but they are occasionally very
FIG. I 0. FIG. 11.
||
§
º!A
º,
|s
|*
}
y|\
N
\
Section of fibroma, showing typi- Section of lipoma, showing nucleated oil-
cal fibrous character. In this portion cells andsome crystals of margarin. × 220.
of tumor no cells were Seen. X 220. (Holm ES.).
(Hol.MEs.)
vascular, and then, as the fibrous surroundings of the vessels prevent re-
traction and contraction, severe hemorrhage may follow their removal.
Eibrous tumors originate from the fibrous tissue of the skin, connective
tissue, subcutaneous and submucous tissue, periosteum, fascias, nerve-












C HON DRO MAS, OR C A RTIL AG IN O US TU MO RS. 91
sheaths, and other structures; and are found in many situations. They
constitute one form of epulis, a variety of naso-pharyngeal polypus, and
the so-called false neuroma. The last is a fibroma developed from the
connective tissue in the nerve and having nerve fibres spread over its sur-
face. Such tumors are often multiple, and are painless. The painful
subcutaneous tubercle is considered by some a fibroma which has no
demonstrated connection with nerve-fibres; others think it is a true
neuroma, or nerve tumor. Uterine fibroid tumors are usually myomas.
Fibrous tumors may undergo softening, calcification, ulceration, and cystic
degeneration.
Microscopically, fibroid tumors consist of fibrous tissue more or less
conpactly interlaced, associated with a few fusiform or star-like cells
which are often indistinct. Rapidly developed fibromas usually present
a greater proportional abundance of cells, and are soft in consistence.
Some fibromas closely approach the sarcomas in their microscopical and
clinical features. -
The treatment of ordinary fibrous tumors consists in non-interference,
unless their bulk or situation demands removal. They are non-malig-
nant.
LIPOMAS, OR FATTY TUMoRS. – A circumscribed accumulation of
adipose tissue is called a fatty tumor. They occur anywhere, though
especially about the back and shoulders. I once saw one removed from
the palmar aspect of the hand; I think it was in the tissues of the ball
of the thumb. Such tumors are of slow growth, though they may reach a
very large size; are soft, doughy, and sometimes slightly fluctuating.
Often they are distinctly lobulated and frequently cause a dimpling of the
integument at the situation of the fibrous septa attaching the skin to the
deep fascia; they may become pendulous, and even change their position
under the skin by the action of gravity; they are painless and seldom
undergo degeneration, softening, or ulceration.
They consist of indistinctly nucleated cells distended with fluid fat and
Connected by a variable amount of connective tissue. As these cells in-
crease in number by proliferation they are filled with fat, and thus the
growth acquires bulk. The mass is usually surrounded by a capsule of
condensed connective tissue. It is their localization that distinguishes
fatty tumors from ordinary obesity. If lipomas require treatment they
are to be removed by means of a free incision through the skin, which
enables the surgeon to turn them out of the capsule with great ease. No
portion of the tumor should be left behind to reproduce the growth.
CHONDROMAS, OR CARTILAGINoUs TUMoRs.—These growths are found
especially among young patients, and are frequently connected with the
bones of the fingers. They are rarely developed from prečxisting carti-
lage. They occur also in glands, such as the parotid, testicle and mamma,
and occasionally in the lungs. When connected with the phalanges of
the hands or feet they are usually multiple, otherwise they are single.
Cartilaginous tumors are smooth, hard and elastic, and often lobulated
masses; of slow development, usually surrounded by a capsule, and non-
malignant. -
Occasionally, however, they are much softer than usual, grow rapidly,
have no capsule, recur after removal, infect distant tissues by cell trans-
ferrence, and present decidedly malignant characteristics. These tumors
usually show, especially at their circumference, sarcomatous structure in-
filtrating adjacent tissues; hence they are not to be considered true
chondromas.
92 T U M O R. S.
There is a form of tumor called osteo-chondroma, which consists of
bone associated with cartilage and originates under the periosteum near
the articular extremities of the long bones. They may become trans-
formed into true Osseous tissue.
FIG. 12.
| #d
**
zºs §º sº.
* - * ~. $ N!!!"
WZ
$4% º
Multiple enchondroma of fingers.
Chondromas, or enchondromas, as they are also called, are in structure
almost identical with the varieties of cartilage, and yet they rarely
FIG. 14.
º
º
sº
º
FIG. 13.
* º
g **
Sº Hº: º
- § Sz-Śºs \%.
£2° ** º
Hyaline enchondroma, showing cells Section of an exostosis covered with a
with nuclear contents lying in a hyaline layer of cartilage. The cartilage is seen at
matrix. X 200. (GREEN.) top of figure. X 220. (Hol.MEs.)
originate from cartilage. They exhibit cells with nuclear and granular
contents enclosed in a matrix which varies from a hyaline to a fibrous
















MYXO M AS, O R. M UC O U S TISSUE TU M O RS. 93
or mucoid character. They are usually developed from the bone or from
connective tissue, and not from cartilage; very occasionally they originate
from costal, laryngeal, and other cartilages in the same manner as exos-
toses grow from bone. It has been proposed to call these overgrowths
enchondroses.
Changes of a calcareous or ossific character quite often affect cartilagi-
mous tumors. Sometimes portions soften in the interior of the growth
and cause an appearance resembling cystic degeneration. If the size of
enchondromas does not render them objectionable or dangerous, they may
be left undisturbed. Under other circumstances excision of the growth
or amputation of the affected bone is demanded. In the sarcomatous
enchondromas prompt operation is probably the best treatment.
OSTEOMAs, OR BONY TUMoRS.—These growths, which must be distin-
guished from calcareous degeneration of tissue, are hard, painless, of slow
development, and frequently immovable because of their firm attach-
ment to bone. They do not acquire a great bulk, but may be multiple.
Falls may cause fracture of such tumors. Inflammation of periosteum
and bone will frequently give rise to Osseous masses, as is seen in long-
standing periostitis and when callus is formed after fractures. These are
not usually regarded as true tumors, but the line between them and other
bony growths is not very definite, Bony segments are occasionally
formed in fibroid and cartilaginous tumors, because of Ossific degenera-
tion; and at times we have sarcomas associated with bony masses. These
last may show signs of malignancy, and hence must be distinguished from
true Osteomas, which are benign: Irregular masses of spongy bone are
often Ossified chondromas.
On section Osteomas resemble bone, showing lacunae, Haversian canals,
and canaliculi. Some consist of cancellated or spongy bone surrounded
by a thin layer of compact bony tissue, others are much more compact;
while still others are so dense that they show no spongy structure, and
are hence called ivory-like Osteomas.
Bony tumors may originate from bone or its accessories (cartilage and
periosteum), when they are denominated exostoses, except when they pro-
ject into the medullary cavity and are called enostoses. The projections
of bony tissue found associated with diseased joints and inflamed bones,
usually called osteophytes, are not tumors, but inflammatory formations.
The former are frequent upon the interior or exterior of the skull, the
jaws, great toe, humerus, and femur; the latter about diseased joints, mus-
cles, and other structures undergoing inflammatory process. Osteomas
occasionally arise from the medulla of bone. Bony tumors are non-
malignant, but may require removal because of deformity, interference
With motion, pain, or ulceration of the overlying integument. Excision by
bone-cutting forceps or saws, or grinding away with the burr of the surgical
engine is the proper method of accomplishing removal. Subcutaneous
Sawing or drilling followed by fracture may be valuable by affording
relief of symptoms without entire excision.
MYXOMAs, or MUCOUs TISSUE TUMoRs.—The most familiar growth
of this class is the mucous tumor or polypus found in the nasal cavities.
yxomas are soft, often fluctuating, smooth or somewhat lobulated, pain-
less tumors, of slow growth, and surrounded by a thin capsule. On sec-
tion they are yellowish-white or pinkish in color, and exude an abundant
glairy fluid, which examination shows to be mucus. The gelatinous con-
Sistence and intercellular mucous fluid are the physical characteristics of
the growth, which consists of mucous tissue, such as is found in the
94 T U M O R. S.
vitreous body of the eye and in the umbilical cord. Mucous tissue,
which must not be confounded with mucous membrane, is a form of con-
nective tissue which is translucent and possesses between its cells a fluid
containing mucin. This resembles very much the connective tissue of
the embryo, and, therefore, some authorities class myxomas with
S&LI'CODO fl.S.
Mucous tumors are always developed from some connective tissue, such
as adipose tissue, bone marrow, or the connective tissue of the nervous
structures and other organs. They may exist in combination with fatty,
cartilaginous, sarcomatous, and other growths, and may undergo cystic
change. On the other hand, various neoplasms may present a mucoid
degeneration in spots which gives them the semblance of myxoma. Some
tumors called colloid carcinomas are myxomas.
The microscopical examination discloses oval, stellate, and spindle-
shaped cells, which are generally nucleated and often possess elongated
projections which mutually interlace. The intercellular substance is
more or less hyaline, and is homogeneous. It is this that gives the mucous
tumors their jelly-like nature and furnishes the mucous fluid, so charac-
teristic of them.
Myxomas, if not associated with sarcoma, are benign ; and if entirely
removed, seldom, if ever, recur. Where there is a group of pendulous
myxomas, as occurs in the nose, the removal of a large one may, by re-
lieving pressure, allow smaller ones to increase, and thus reproduce the
old symptoms; but this is not a recurrence of the original growth.
FIG. I 5.
FIG. I. 6.
J.N-ºxº~~Yºr. *: ºt, º, .
sºčº 32% Nº $º§º:
S--> * ... tº 2,2tº ...tº;" Q_{\ tºº. 3
§ºgºś.
- * ** -
Y. --~~
…}}<>} & ***.*- §§
ºššº º #jš.
2-ºº:
º
-ºš §
_2, ...Sººº. " -
2 (§3,):
jº
Section of myxoma, showing cells and Section of a hard lymphoma, showing
interlacement of prolongations. X 200. thick network and few small cells.
(GREEN.) X 200, (GREEN.)
LYMPHOMAS, OR LYMPHATIC TISSUE TUMoRs.—These tumors are
composed of lymphoid tissue similar to that which is found in lymphatic
glands, Malpighian corpuscles of the spleen, Peyer's patches and solitary
intestinal glands, the tonsils, thymus, pleura, marrow of bones, etc. They
occur most frequently in adolescents or young adults; if of rapid develop-
ment they are soft and often become very large, while if of slower
growth they are hard and seldom attain any considerable size. Lymphomas
may be found in almost any situation because, as is now known, lymphatic
tissue exists physiologically in many localities formerly considered desti-
tute of this structure. The usual original site, however, is the lymphatic
glands of the neck, axilla, groin, thorax, or abdomen, whence the growth
may extend by infiltration to other structures. The ordinary inflam-







MYOM AS, OR M USC U L A R T UMO RS. 95
matory enlargement of lymphatic glands gives the same microscopical
appearance, and such swellings may be considered lymphomas if they con-
tinue to increase in size, and even when they merely persist without
diminution of bulk.
Lymphatic tumors may be lobulated because of successive involve-
ments of a group or chain of glands; they are usually painless and do
not tend to suppuration or degenerative changes.
The microscope reveals a network of fibrils containing in its small
meshes lymph corpuscles which are identical with white blood-cells.
These cells sometimes show one or more nuclei, and sometimes are
granular with no visible nucleus. At the points where the fibrils of the
network or stroma cross, nuclei are occasionally seen. In rapidly developed
lymphomas the cells are abundant and large and the stroma not very
marked. These are the softer in consistence, and allow considerable
milky juice to be scraped from a cut surface. When the tumor has
grown slowly the network or reticulum is found to be well-developed and
the cells small and relatively few in number. These are the hard variety
of lymphatic tumors.
Lymphomas are, as a rule, non-malignant, but those growths which are
of rapid growth and richly endowed with cell elements sometimes infil-
trate adjacent tissues and exhibit a malignant tendency. They are allied
to the sarcomas. Lymphomas do not show a tendency to caseation or
softening as do tuberculous lymphatic glands.
Multiple lymphomas constitute an essential clinical feature of Hodg-
kin's disease, which is a peculiar affection accompanied by intense
anaemia. In leukaemia also we have lymphatic growths among the patho-
logical changes present, but in this disease there is an increase of the
white and a diminution of the red blood-cells, which conditions do not
pertain to Hodgkin's disease. *
The removal of lymphatic tumors may be undertaken if the growths
are accessible and the patient in fair health. When the blood alterations
associated with the existence of the tumors are evidently profound, as in
Hodgkin's disease and leukaemia, no operation would be advisable or
justifiable.
II. Tumors whose general structure or type resembles that of one of the
higher or more complea: tissues than fully developed connective tissue.
MYOMAS, OR MUSCULAR TUMoRs, are growths consisting of non-striated
muscular fibres usually combined with more or less connective tissue.
Very rarely muscular tumors are formed of striated muscular tissue
(rhabdo-myomas): these have been usually, if not always, congenital
tumors. Myomas are of slow growth and are usually circumscribed by
a sort of capsule, though at times they are not distinctly bounded; not
infrequently they become pedunculated. They possess considerable firm-
iness and solidity, are often multiple, and are benign. Their most common
location is in the uterus, prostate gland, and digestive tube; hence, they
show the characteristics of involuntary muscular tissue. From the
abundance of connective tissue found associated with the bundles of
muscular fibres, especially in long-standing tumors, these growths, when in
the uterus, are often termed uterine fibroids or fibro-myomas. Myomas
may undergo calcareous and cystic degeneration.
Under the microscope are seen long fusiform cells of involuntary
muscle, with their characteristic rod-like nuclei, arranged in bundles or
irregularly disseminated through the tumor. There is seen also, except
in Some recent tumors, a good deal of fibrous tissue. Myomas are inno-
96 ‘T U M O R.S.
cent, but should be removed if it is possible to do so, when their location or
their production of uterine hemorrhage demands operative relief. When
such uterine tumors are developed near the lining mucous membrane,
especially if pedunculated, they may be removed by forceps or écraseur.
They are occasionally expelled by inducing uterine contraction with ergot.
It may be necessary and advisable to remove the entire uterus by
abdominal incision when such growths cannot be enucleated from the ab-
dominal surface of the womb.
NEUROMAs, OR NERVOUs TISSUE TUMoRs.—All tumors connected
with nerve-trunks are not neuromas, for they may be fibromas, myxomas,
etc.; nor are nervous tumors necessarily painful tumors, as might be sup-
posed by some readers. A neuroma is a rare form of growth and consists
principally of ordinary white or medullated nerve-fibres. Gray nerve-
tissue may be found in neuromas, but it is exceptional.
Such tumors are small, slow of growth, sometimes multiple, perhaps
painful, and always develop in the course or at the end of a cranial or
spinal nerve. A not infrequent situation is the end of a nerve-branch
that has been divided in a previous amputation ; here they may be com-
pressed in the cicatrix and give rise to much pain. The so-called painful
subcutaneous tubercle is a fibroma, not a neuroma.
Under the microscope nerve structure with some connective tissue is
seen. Nervous tissue tumors are never malignant, but may require excision
when painful.
ANGIOMAs, OR WASCULAR TUMIORS.–Tumors consisting of newly-
developed vessels, bound together by cellular tissue, are angiomas; hence
dilatations of existing vessels, such as are present in varicose veins and
varicose arteries, often called cirsoid aneurisms and aneurisms by anasto-
mosis, are not properly termed angiomas.
Simple angiomas consist of structures resembling normal vessels with
unusual tortuosity and may have a predominance of venules or arterioles.
The color of the growth varies on this account from pink to dark-red or
purple. Such tumors are apt to be
FIG. 17. congenital and small; and, some-
times, present no elevation of the
skin, being mere stains. They con-
stitute the well-known maevus mater-
nus or mother's mark.
Cavernous angiomas are tumors
which are made up of erectile tissue.
This consists of a series of chambers,
lined with endothelium and filled
with venous blood, which circulates
freely through these mutually con-
nected spaces. The walls of the
chambers are fibrous septa. The
structure is similar to that of the
cavernous portion of the penis, and
gives such tumors an erectile char.
acter, which is often accompanied
Cavernous angioma of mouth and check by distinct pulsation.
in a child of two and a half years. Cavernous angiomas are usually
- of a blue tint; vary in size according
to the amount of engorgement, though ordinarily giving rise to distinct
prominence; often grow rapidly, especially in cutaneous and loose areolar

M Y O M A S, OR M USCU L A R T U M O RS. 97
tissue; and are not markedly congenital. Injury to cavernous angioma
is followed by profuse hemorrhage.
Lymphatic vessels sometimes communicate with cavernous spaces,
similar to those described as occurring in cavernous angiomas. A tumor
is then formed, which is called a cavernous lymphangioma. There is
also a form of lymphangioma which consists simply of a mass of lym-
phatic vessels; being, in fact, similar to the simple angioma above de-
scribed.
The treatment of vascular tumors will be described in the section de-
voted to diseases of the bloodvessels more fully perhaps than here. They
are non-malignant; but some forms may tend to produce death by hem-
orrhage, occurring from slight abrasion of their surface or from ulcer-
ation.
No treatment is demanded for angiomas which do not increase, nor
threaten life from ulceration and hemorrhage, unless the deformity or
personal disfigurement is a source of anxiety. Sometimes, though rarely,
they atrophy spontaneously. Capillary dilatations situated solely in the
skin, causing the pink discolorations often called port-wine marks, may
be removed by puncturing with red-hot needles or electrolytic needles, or
by applying caustics, such as chromic acid. These marks are often unac-
companied by any increase in the bulk of the part. Under such circum-
stances they can scarcely be called, with propriety, vascular tumors.
Some of these superficial congenital discolorations gradually increase in
thickness, and become true angiomas.
Purely subcutaneous angiomas present themselves as spongy, doughy
tumors, from which pressure expels the blood more or less completely,
leaving in the fingers a much smaller tumor. If largely composed of
arteries, they have a pulsatile character, and a murmur which causes
them to resemble aneurisms. The pulsation, however, partakes rather of
the character of a thrill than of a beat synchronous with the heart move-
ments. The spongy consistence and the fact that pressure on one artery
does not obliterate the thrill and murmur aid in diagnosis. The angioma,
moreover, is, probably, not located in the course of an artery. Angiomas
in bone resemble malignant tumors.
Vascular tumors, which involve both the skin and the subcutaneous
tissue, are easily diagnosticated. They may cause great deformity, and
even erosion or displacement of the bones. The treatment of the subcu-
taneous angioma and of this last form is identical, except that in the
former case the skin should be lifted up in one or more flaps and preserved
if excision or strangulation of the tumor is practised.
The three methods of dealing with these tumors, which are sometimes
called thick naevi, are injection of coagulating liquids, strangulation and
excision. I believe the last to be the best in nearly all instances. Injec-
tion is accomplished by introducing the needle of a hypodermatic syringe
into the centre of the growth, and after tearing the tissue somewhat by
Q-and-fro movements of the needle-point, forcing twenty minims of the
liquid into the meshes of the tumor by means of the piston. Tincture of
the chloride of iron, or a watery solution of similar strength, or chloride
ºf zinc (gr. x to the fluidounce of water), are proper agents to employ, if
...this treatment is adopted. There is, however, danger of causing disfigur-
!"; Scars from sloughing following the induction of too high a grade of
inflammation. Fatal embolism has also occurred from fragments of the
$9.8gulated blood being washed into the general circulation. This may
° guarded against to some extent, by previously encircling the tumor
7
98 T U M O R. S.
with a ligature, or with a ring of metal or rubber, which is kept in place
for a few minutes after the injection. The temporary ligature may be
adjusted and kept from slipping, with more ease, by transfixing the tissue
under the base of the tumor with a pin, under the ends of which the liga-
ture is passed.
Strangulation may be accomplished in three ways: An acupressure
pin is thrust through the tissues under the base of the tumor, after which
a stout cord is carried once around the mass under the ends of the pin,
and is then tightly tied. Sufficient force should be used in making the
knot to cut off all access of blood to the tumor, which soon sloughs off,
leaving an ulcer to heal.
It is often well to puncture the constricted tumor with a needle before
making the second tie, in order to let the blood and serum imprisoned
therein escape. The tumor thus be-
comes more flaccid and shrunken,
and the string can, probably, be tied
more tightly, Two pins thrust through
FIG. 18.
2& -
£ at a right angle to each other are better
{ & salii than a single pin, unless the naevus is
|− º h' Small. If the string has cut a groove,
in which it will lie without slipping
over the top of the tumor, the pin or
Strangulation of vascular tumor by a pins may be pulled out after the knot
pin and ligature. has been tied ; otherwise, the pin must
be left in position until the parts have
sloughed. A second method is to pass a double ligature under the base
by means of a large ordinary needle, or one with a handle having an eye in
the point. The two halves of the tumor can then be constricted by cutting
the string and tying on each side.
FIG. 19.
Ligation of vascular tumor in halves by a double ligature passed under it.
If the tumor has an extensive area, the double ligature, of which one-
half should be stained black with ink, may be carried repeatedly through
the tissues by a large ordinary needle. Between each puncture of exit
and entrance a long loop of the double string must be left. By cutting
with the scissors the stained threads on one side, and the white threads on
the other, a series of ends are made which can be tied together to stran-
gulate the tumor in sections. The adjacent ends of the separate portions
of the ligature may be twisted around each other before the loop's arcs
are tied, if there is danger of bleeding from the tying pulling the edges
of the needle's punctures apart.
Occasionally constricting a portion of an angioma has set up sufficient
inflammation to obliterate the whole. The subcutaneous ligation of the
whole, or of sections of the tumor, may be done by carrying a wire around
the growth in the same way as described in the treatment of varicose veins.


MYO MAs, OR M USCU LA R TU M O Rs. 99
This plan is well adapted, perhaps, to subcutaneous angioma, which may
possibly atrophy without causing ulceration and scarring. The needle
must, of course, be reëntered every
time at the orifice of exit. FIG. 20.
The third method of strangulation
is a combination of the other two.
First thrust a pin under the mass,
then pass a needle carrying a double
ligature under the pin and at a right
angle to it. The two halves of the
growth can then be tied, and the
ligature will not slip over the sloping
edge of the tumor. All of these
operations must be carried out with
antiseptic care.
Excision of angiomas is, as a rule,
I think, the best treatment. The
tumor is thoroughly eradicated, the
wound, if aseptic, heals more rapidly
than the ulcer left after ligation, and
there is not the offensive sloughing Ligation of large vascular tumor in sec-
mass that remains unseparated for tions. The corresponding loops of the
many days after ligation. Hemor- black and white threads are tied to
rhage of a serious character is avoided gether.
by making the incision beyond the
margins of the growth. When the Spongy mass of vessels is removed,
sutures are applied and the wound treated as after removal of any other
tumor. The method much used by Levis, of Philadelphia, to prevent
hemorrhage during the removal of these and other tumors, when even
FIG. 22.
Ligatures inserted subcutaneously Method of ligating a vascular tumor
around the base of a vascular tumor in halves by means of a pin and liga-
before being tied. (BRYANT.) lures. (BRY ANT.)
º bleeding is undesirable, is worthy of notice. Before making
his first incision he introduces deeply through the tissues surrounding the
growth, and at some distance from it, numerous long acupressure pins,
* *
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100 T U M O R. S.
and then constricts the tissues and afferent vessels by strong cords tied
around the ends of these pins, as in the pin or harelip suture. If the
location is not convenient for using the pins, he carries strong cords
through the tissues by means of specially made needles six or eight
inches long, and ties the ends of the cords on the surface of the skin.
The access of blood to the region of operation is thus more or less com-
pletely prevented. After the incisions have removed the tumor, the pins
or strings are removed one at a time, and the bleeding arteries ligated
systematically. This method is easily applied, and requires no special
skill for its successful employment if the surgeon only place the pins or liga-
tures at a sufficient distance from the growth to allow room for incision
to be made entirely outside of its limits. The cord must be strong, and
tied with much force. I have broken strong fishing-line in tying a knot
before operating in this manner.
LYMPHANGIOMAS may be treated by ligation and excision, as described
for the removal of arterial and venous tumors, if their extirpation is de-
manded.
PAPILLOMAS, OR PAPILLARY TUMoRS.–These growths resemble, and
are usually, hypertrophies of the papillae of the part, and are covered by
the variety of epithelium which belongs to the region. They seem to
owe their origin to direct inflammatory irritation, and are of slow growth,
though they may attain considerable bulk by coalescence of several
smaller masses. When the epithelium is abundant enough to cover the
numerous papillae and fill in the crevices between them, the tumor is
somewhat smooth; but usually the various papillae and their branching
outgrowths are separate, and give the growth a ragged or cauliflower
appearance. Papillary tumors occur upon cutaneous, mucous, and
serous surfaces, and present characteristics depending upon location.
Sometimes they become pedunculated, and constitute one form of poly-
poid tumor. Warts, as well as many horny growths and corns, are
cutaneous papillomas. These have a hardened epithelium, except when
kept moist, as soft corns are, and possess limited vascularity. The
papillary tumors found about muco-cutaneous junctions and upon mucous
membranes are larger, non-vascular, and softer. They occur especially
about the anus and genitals, where irritating discharges cause their ex-
hibition, and are also found in the bladder, larynx, etc. Serous papil-
lomas are met upon the synovial membrane of inflamed joints. The
soft variety of papillary tumor may become the seat of ulceration or
hemorrhage. Many such excrescences about the anus and genitals were
formerly described as syphilitic, but they have no specific origin, except
in so far as the irritation of the mucous membrane may in some cases be
the result of a venereal discharge. Any other chronic irritating secretion
will induce similar growths.
A papilloma consists of a projection of connective tissue, usually quite
full of small round-cells, surrounding a loop or plexus of capillaries, and
covered by a layer of epithelium. Papillary tumors are benign, having
the epithelium only on the surface, and not distributed through the mass,
as in epitheliomas. They may become malignant, however, by transforma-
tion into epithelioma. Warts of a pigmented kind occur frequently in
the aged. They should not be irritated, as they may thus be excited to
assume malignant tendencies.
Papillomas on mucous surfaces may give rise to hemorrhages; and in
the bladder and urethra may obstruct urinary evacuation.
Papillomas should be treated by removal with caustics, ligatures, or
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A DEN O M AS, OR GL AND U L A R T U M OR S. 101
excision. Occasionally the hemorrhage which follows excision will be
severe. Powdered tannic acid smeared over the bleeding surface is a
good styptic, especially if combined with pressure for an hour or more.
ADENOMAS, OR GLANDULAR TUMoRS.–Glandular tumors consist of
such tissue as is found in secreting glands (the simple tubular glands of
the mucous membranes and the compound, or racemose, glands, such
as the mamma and parotid); but the tissue is not capable of performing
function as a gland. They must not be confounded with lymphatic gland
tumors, which have a very different structure and are called lymphomas.
The tubular adenoma is found originating from mucous membrane, as of
the vagina, rectum, stomach, and is often so closely allied to epithelioma
that a distinction is well-nigh impossible. Racemose adenomas occur in
the breast especially, and are often associated with fibrous and sarcomatous
tissue, thus forming compound tumors.
Adenomas are of slow growth, may be lobular in form, are quite firm
unless undergoing cystic. degeneration, are usually surrounded by a cap-
sule, and, when uncomplicated with other morbid growths, are benign.
They sometimes undergo, in places, fatty or cheesy transformation.
Glandular tumors of mucous membrane sometimes become pendulous and
thus constitute a form of polypoid tumor.
FIG. 23.
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Sections of adenoma showing acini. (BRY ANT.)
Tubular adenomas show under the microscope tubules, resembling the
follicles of the intestine, lined with epithelial cells; racemose adenomas
exhibit a series of pockets, or acini, lined with one or more rows of epi-
thelium. Between the acini is connective tissue in varying quantity,
Sometimes containing numerous cells.
True adenoma is benign, but its frequent association with sarcoma,
and its tendency at times to become epitheliomatous, render its extirpa.

















102 T U M O R. S.
tion usually desirable; especially is this the case because of the liability
of error in clinical diagnosis.
III. Tumo's whose general structure or type is that of the whdeveloped
tissue of the embryo (Sarcomas).-Tumors consisting of connective tissue
similar to that found in the human embryo are called sarcomas, and pre-
sent variations according to the peculiarities of the cells and intercellular
substance. The connective tissue of the embryo, before it is developed
into the mature connective tissue of the foetus, consists of numerous small,
round cells, with a very small quantity of soft and homogeneous material
between them. As the connective tissue becomes more mature, the cells
decrease in number and assume an elongated shape, while the intercellular
material spoken of becomes fibrous. This maturing connective tissue
finally develops into the perfect connective tissue, fibrous tissue, cartilage,
and bone of the foetus and child.
Sarcomatous growths are formed then of embryonic connective tissue,
which, instead of maturing, continues to exist and to reproduce itself,
thus causing progressive increase of the tumor. Small portions of the
tumor occasionally reach a higher development and become fibrous tissue,
cartilage, or bone, thus producing a mixed tumor; but this is not general
or usual. The cells of sarcomas may be round, spindle-shaped, or very
large and irregular. They are closely packed together with very little
intercellular substance, which varies from a homogeneous fluid to a some-
what granular or fibrillated material having considerable firmness, but
which usually intervenes between all the cells, and does not allow them to
Congregate together in groups.
FIG. 24.
Round cells. X 350. (GREEN.) Spindle cells. X 350. (GREEN.)
These cells may all occur in one tumor, but the form which pre-
dominates gives name to the variety, viz.: round-cell, spindle-cell, and
giant-cell sarcoma. ... The round cells are either identical in appearance
with white blood-cells, or they may have an indistinct nucleus and bright
nuclei.
The spindle or fusiform cells are oblong, terminate in fibrils, and have
a long elliptical nucleus, with or without a nucleolus. The large irregular
or giant cells, called myeloid cells because they resemble the cells of foetal
marrow, are very much larger than the others, and are irregularly spherical
with perhaps several prolongations, and contain many oval nuclei with
bright nucleoli. They may not actually predominate in the tumor, but
their presence is so evident that they give name to the variety in which
they are seen. The blood vessels in Sarcomas are numerous, and on
account of the small amount of matrix are scarcely separated from direct
contact with the cells.

SA R C O M A S. 103.
Sarcomas always develop from connective tissue; hence, they have a
general distribution and are found originating from muscular fascias,
periosteum, lymphatic glands, and marrow of bones, as well as from the
ordinary connective tissue beneath the skin and the cellular tissue of the
viscera. They infiltrate the surrounding structures and thus extend by
cellular invasion. There may be a sort of capsule, though the growth is
usually diffuse. Fatty, cystic, calcareous, and other degenerations are
liable to occur in portions of the growth; and sometimes sarcoma may
be combined with other forms of tumor. This assumption of, or combi-
nation with, sarcomatous elements accounts for the malignancy of certain
tumors which are usually classed as benign. This has been referred to
when speaking of Osteomas and chondromas.
FIG. 26.
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Giant or myeloid cells. (GREEN.)
Sarcomas are not as common in old age as in the earlier period of life.
Many sarcomas are very malignant, infiltrating adjacent parts, recurring
after removal, and finally producing secondary growths in the lungs and
other regions. The round cell and the large spindle-cell growths are
much more malignant than the small spindle or giant cell tumors. Soft
and very vascular sarcomas are to be looked upon as being probably
highly malignant. Sarcomas do not often affect the lymphatic glands,
While the carcinomas do so with great frequency. The fact that the
bloodvessels in sarcomas are in close relation with the cells accounts for
the occasional rapid development of secondary tumors without lymphatic
involvement. The cells readily penetrate the thin vessel walls and are
garried along with the blood-current. In carcinomas, as will be seem
later, the bloodvessels run in the fibrous network, or stroma, at a distance
from the cells, which lie grouped in alveoli or pockets. Hence, dissemi-
nation usually proceeds along the lymphatic channels before infection by
the blood-current takes place.
Round cell sarcomas present round cells which are similar to granula-



















104 T U M O R. S.
tion cells, which are larger than leucocytes and have an indistinct nucleus
with nucleoli. These round cells are seen lying in a soft homogeneous or
FIG. 27.
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Small, round-cell sarcoma, showing vessels
with mere embryonic wall. X 400.
granular intercellular substance
or matrix. The structure is, in
fact, that of the primitive tissue
of the embryo.
Round-cell sarcomas are soft,
and gray or pinkish in color
upon section ; furnish a juice
when scraped; are very vascular,
and hence, are often stained by
rupture of vessels and are liable
to contain blood cysts. They
rapidly infiltrate neighboring
parts, give rise to distant sec-
ondary growths, may even in-
volve lymphatic glands, and in
many other characteristics re-
resemble clinically the form of
carcinoma called encephaloid.
The microscopic appearances
serve to distinguish them from encephaloid with its stroma and grown-up
cellular elements. Round-cell Sarcomas are, of course, as seen by their
above-mentioned tendencies, very malignant. Glioma, the round-cell
tumor found in the brain, retina, and cranial nerves, is a sarcoma. There
is a round-cell sarcoma which shows an excess of intercellular structure
in certain portions of the growth, so that there is a resemblance to the
stroma of carcinomas. This has been called the alveolar sarcoma.
Spindle-cell Sarcomas.—These are the most frequently found of the
sarcomas, and consist of elongated cells with distinct oval nuclei and
IFIG. 28.
Large spindle-cell Sarcoma. Some cells
teased apart. (VIRGIIow.)
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Giant-cell sarcoma. X 280. (Hol.M.E.S.)
nucleoli. The cells lie close together in parallel rows with little interven-
ing substance, and sometimes give rise to a fibrous appearance until they
have been teased apart to show their characteristic shape. If the spindle
cells are small the growth is rather hard and probably is surrounded by












C A R C IN O M A. S. 105
a capsule. Although it will recur after removal and will spread by in-
filtration of surrounding tissues, it has little disposition to infect the
internal organs and possesses much less malignancy than the large spindle-
cell variety, which is soft, more vascular, and exceedingly liable to give
rise to distant secondary tumors. Sometimes the cells are so broad as to
be really oval in form. The small-cell growths are the recurrent fibroid
tumors of the older writers.
Sometimes spindle-cell sarcomas contain pigment granules deposited in
the cells. This occurs especially when the tumor arises from a tissue
containing pigment, as, for example, the choroid coat of the eye. These
melanotic sarcomas are very liable to induce secondary pigmented growths
in the internal organs, and are, therefore, very malignant, even if they
have less disposition to local extension than some other forms. This
tumor a few decades ago was often denominated black cancer.
Calcareous and Osseous degeneration occasionally occurs; then the term
osteoid sarcoma is used. This is very different from the benign growth
called Osteoma.
Giant-cell or myeloid sarcomas.-These tumors usually arise from bone
and especially from the marrow. They contain large multinucleated
cells, like those of foetal marrow, associated with spindle cells, and show
little substance between the cells. The nuclei of the myeloid cells con-
tain bright nucleoli. Myeloid sarcomas are usually quite hard, may be
vascular, and frequently contain cysts. When they grow from the me-
dullary canal the bone is expanded before them, and therefore manipula-
tion of the tumor may cause a crackling noise. They frequently occur
in the extremities of the long bones and in the jaws. They are less ma-
lignant than the round and spindle-cell varieties of sarcoma.
IV. Tumors whose general type is that of epithelial tissue (Carcinomas.)
—The carcinomas consist of a fibroid network or stroma within the
meshes or alveoli of which numerous cells of an epithelial type (epithe-
lioid cells) are crowded together without any intermediate substance. A
carcinoma may be readily illustrated by a piece of sponge (the stroma)
within the cavities (alveoli) of which numerous grains of sand (cells) are
grouped. A sarcoma, on the contrary, is represented by a quantity or
mass of sand of which the grains (cells) all lie
closely together with no sponge or stroma to form FIG. 30.
distinct spaces (alveoli) for their reception. & -.
The cells of carcinomas are about five times \º
as large as a red blood-corpuscle, have a variety & Nº
of shapes on account of their mutual pressure, ~
• ,s:
*
possess large, well-marked nuclei and nucleoli, tº ſº º) ſº
and, though there is no intercellular substance & Sº, (9) jº
between the cells, have some fluid filling the $º &\\ gº
spaces between them. The cells frequently show § 2 &
molecules of fat within them due to fatty de- cells from a scirrhous
generation, and indeed the cells may be entirely carcinoma of breast. × 350.
destroyed, so that only the free nuclei remain.
It must be borne in mind that similar cells are
Seen in these morbid growths as in normal tissues. It is the characteristic
arrangement of the cells, the variety of their shape and the stroma that
distinguish carcinomas. There is no special carcinoma cell.
The fibrous network or stroma of carcinoma is a more or less fibrillated
Structure so interlaced as to leave numerous communicating irregular
Spaces called alveoli, within which the cells already described are impris-
(GREEN.)


106 T U M O R. S.
oned. The amount of stroma varies very much and with its abundance
the hardness of the tumor increases. It sometimes, especially if of rapid
development, contains in its own structure a few cells. In the stroma,
forming as it does the walls of the alveoli, the bloodvessels ramify. Hence
FIG. 31.
|
y;
gY
º
lſ
the cells of carcinoma are sepa-
rated from the vessels and do
not as readily as in sarcoma
enter the blood-current and
cause rapid dissemination of the
growth. The lymphatic vessels,
however, which accompany the
bloodvessels in the stroma, open
into the alveoli, and thus readily
allow entrance of cells into the
lymphatic stream. This accounts
for the early involvement of the
neighboring lymphatic glands
in cases of carcinoma, and its
more frequent occurrence than
in Sarcomas.
Carcinoma cells originate from prečxisting epithelium, and therefore
carcinomatous growths occur only where epithelium exists, as in the glands
and cutaneous and mucous structures. This at least seems to be the
opinion with most authority in its favor. After a time the epithelial cells
burst through the epithelial basement membrane from which they origi-
nated and thrust themselves among other tissues. This has probably given
rise to the opinion that they developed from other than epithelial struc-
tures. The stroma of carcinoma is partly newly developed tissue and partly
the previously existent connective tissue of the part.
The degenerative process occurring in carcinomas most frequently is
fatty transformation which is always observable in a greater or less
degree. It sometimes converts the tumor into a pulpy mass. Cystic de-
generation sometimes occurs. Abscess may, though rarely, occur.
The structure and clinical characteristics of the carcinomas have caused
their division into these varieties:
Acinous Carcinoma :
a. Scirrhus, or Chronic Carcinoma.
b. Encephaloid or Acute Carcinoma.
Epithelial Carcinoma :
a. Squamous Epithelioma.
b. Columnar Cell Epithelioma.
Any of these may undergo colloid degeneration and become the so-called
Colloid or Gelatiniform carcinoma.
The clinical characteristics of the carcinomas are important. They are
exceedingly malignant, though epithelioma is usually less so than encepha-
loid and scirrhus. They differ from sarcomas in that they generally infect
the neighboring lymphatic glands and do not produce secondary tumors
in the internal viscera until after the lymphatic glands in the vicinity of
the primary growth have been affected for a considerable time. Sarcomas,
on the other hand, rarely involve the lymphatics, but rapidly appear in
the viscera, because of their dissemination by means of the bloodvessels,
which have thin walls and ramify among the cells instead of running in a
Stroma. #
Epithelioma much less rarely reproduces itself in the viscera than the
Stroma from carcinoma. X 220. (Holy(ES.)


C A R C IN O M A. S. 107
other forms of carcinoma, though it ulcerates earlier. It usually, how-
ever, infiltrates the adjacent tissue and involves the neighboring glands.
The more rapid and the more vascular a carcinoma is, the greater are its
malignant qualities; hence, encephaloid may be considered as having
the greatest degree of malignancy. The secondary growths produced
by carcinomas are usually of the same varieties as the primary tumor. If
a carcinoma is incised, a comparatively abundant whitish juice can be
scraped from the cut surface. This consists of the fluid and cellular ele-
ments of the growth.
Ulceration, sometimes attended by hemorrhage, is of frequent occurence
in carcinomatous disease. Pain, of a darting character, is a not infrequent
symptom.
The word “cancer’ was formerly much employed to designate malig-
nant growths. This was before the days of accurate pathological and
microscopic investigation. Now, some authors attempt to limit the term
to the class “carcinoma.”. This produces an unnecessary confusion, for
“cancer’ has and can have no accepted scientific definition. It has no
greater etymological value in the scientific surgery of the present time
than has “hives” in dermatology, or “amaurosis” in ophthalmology.
The word, therefore, should not be retained in surgical literature.
Scirrhus, or chronic or hard carcinoma, grows very slowly, is very
hard, is apt to be nodular, seldom attains a large size, and occurs usually
in rather advanced adult life. At first it is unconnected with the over-
lying skin, but soon becomes attached to the integument, and causes
puckering and retraction thereof. As the disease advances the lymphatic
glands in the vicinity become enlarged and ulceration of the skin over
the primary growth occurs, producing an ulcer with ragged and nodulated
irregular edges, secreting a foul mixture of sanious pus and blood. The
pain in scirrhus, when present, is of a shooting or neuralgic character.
Scirrhus is most frequent in the female mammary gland, and in the various
parts of the alimentary tract. When the internal organs are involved
secondarily, it may assume the form of encephaloid. Section of a scirrhous
mass causes creaking as the knife divides the hard fibroid tissue, and
shows a whitish shining surface, usually traversed by fibrous lines, and
often concave on account of contracting influences.
FIG. 33.
Section of Scirrhus taken from newly developed por- Section from interior of Scirrhus,
tº tion of tumor. X 200. (GREEN.) showing atrophy of cells and
diminution in size of alveoli.
X 200. (GREEN.)
Microscopic examination reveals a very large amount of stroma. This,
by contraction and hardening, finally causes atrophy and disappearance
of the epithelial cells, and almost obliterates the alveoli. Hence, the
*erior, or older portion of a scirrhoma, approximates in appearance

108 - T U M O R. S.
fibrous tissue, while the exterior or newly developed structure shows the
alveoli and the groups of epithelioid cells.
Encephaloid, or acute or soft carcinoma.-This morbid growth is soft,
having the consistence of brain tissue, grows rapidly; is very vascular,
frequently showing large veins traversing the overlying integument, and
when it ulcerates, gives rise to a fungous protrusion which is the seat of
hemorrhage. Sometimes pulsation is perceptible, on account of the numer-
ous large arteries in its structure. Encephaloid is not as frequent a
growth as scirrhus, and it is found usually in the viscera as a secondary
growth following a primary scirrhus of external parts. It does occur,
however, primarly at times, especially in the testicle and breast. Many
tumors of the eye and of the bones occurring particularly in young adults
or children, formerly described as encephaloid disease, are now recognized
as sarcomas. On section encephaloid tumors show a brain-like pulpy
substance stained by blood extravasations and sometimes quite fluid from
fatty degeneration.
Encephaloid can scarcely be described as an entirely distinct growth
from scirrhus; but its softness, its greater rapidity of growth, its less
amount of stroma and absence of con-
tractile tendencies, its vascularity, and
its abundance of cells rapidly undergo-
ing fatty degeneration warrant its desig-
nation by a separate name.
Under the microscope the observer
finds large alveoli, surrounded by a
limited amount of stroma, and contain-
i.ºj}º:
&a. º - ..}
º
ing rather large cells, undergoing fatty
§§§ zººs ºvgº. 8-> ~, 85 85
gºś change, accompanied by many free
*ś.
º £ nuclei.
$4.45% $ºš Colloid, or gelatinous carcinoma.—
*s. §§ olloma is a soft, jelly-like tumor,
occurring most frequently in connec-
tion with the peritoneum, intestines,
Encephaloid carcinoma, showing and stomach. It is a colloid or mu-
large alveoli and small amount of coid degeneration of scirrhus, encepha-
stroma. X 200. (GREEN.) loid or epithelioma. Lipomas, chon-
dromas, myxomas, sarcomas, and other
growths undergoing change of a colloid or mucoid character may be mis-
taken clinically for colloid carcinoma.
The neoplasm has still less stroma than encephaloma, and the alveoli
are large and very distinct, because of their distention with a mucilaginous
or glue-like material. This colloid substance is transparent and colorless,
or sometimes yellowish, and for the most part structureless, though a few
epithelioid cells are seen. These cells are large and distended with the
gelatinous material similar to that surrounding them. At times they differ
little from ordinary carinoma cells. Sometimes they have a lamellar
surface. Q
Epithelioma, or skin carcinoma. Squamous epithelioma.-This is a more
distinct variety of carcinoma than the others, though it does, at times,
approach Scirrhus in its characteristics. It usually occurs at a muco-
cutaneous junction such as the lip, eyelid, ala of the nose, anus, and
prepuce; and appears first as a small nodule under the skin or as a scab
or an ulcerated abrasion or fissure. It not infrequently arises at the
situation of moles or warts. The tumor is quite firm and shows on sec-
*... . .
th #º
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C A R C IN O M A. S. 109
tion a whitish granular surface traversed by fibrous bands, from which a
thick, curdy material, like sebum, can be pressed. The epithelial nests,
to be described, can often be seen. Epithelioma is rare in young per-
sons; soon exhibits ulcerative action, though of somewhat slow progress;
commonly implicates the lymphatic glands but does not often infect the
viscera; and is traceable to traumatic irritation of the muco-cutaneous
tissues more frequently than the other carcinomas.
FIG. 35.
*.
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... 3 * - f … - * - * ºf ~
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S. S. - ſ: * , a . . . 2’ ...~" s' G. --→S v, tº ' &
N. : A * > / `s ~ __------- ~~ S-> ! { º f
S-sºº's M. f * - ~ . --T- - - - — `` SS #7 I af -
- I- ~ :- -- * ... • - - -: ..--º: * - SS 7,' ſ A
* - - - - - - ,” ~ * - - S. -
+ ^. - - * -- * * * wº
*~~~ 1. N. …” , , ...< * , , YSS. V." ' ',
W.ºr •. § *. w Y. - ^s \ , t
...” • * , , - J - ºr ‘N , , - * ;
{ . . . . Sº, is . . . . Ses . . . . .”
* / * *-> * * S-
~~~e ~~ Ü, Ö ; : '.…. <s N. v. -
- f • *w 3 \ - * * N - > ,
t .* > ** * *- 3 * : ['. S -
3 ** \ : ; ºr, N \ -
* f ii vº. - : ". . . . \ ./
; f, \* ... • i N
f [. ) J / & S Z | S `s
^ g f - * , , * --"
// \ - NSS
ſ z \ *- c. * - - ~ N------ 2^
,” - * *
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,2" SS--~ V t * >
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t
* *
Colloid tumor, showing large alveoli and colloid contents. X 300. (GREEN.)
A lobulated pavement-cell squamous epithelioma showing pearly bodies.
(Drawn by DR. CIIARLEs B. WILLIAMs.)
The cells of ordinary epithelioma resemble the squamous epithelium of
skin and mucous membrane, and contain one or more nuclei. They may
be flattened by pressure, but have not the varied shape of the other
9."ºomatous cells, nor do they so readily assume degenerative changes
of a fatty kind. They are grouped in the alveoli of the stroma, some-

110 T U M O R. S.
times as tubular prolongations or plugs, and tend to form nests or
“pearls’’ formed of concentric layers of flattened cells, which resemble
the structure of an onion. These epithelial globes or nests are very
characteristic of epithelioma, though not essential. They grow down
from the surface into the lymph spaces of the connective tissue like nails
or plugs. They merely signify that there is a rapid growth of squamous
epithelium and may occur in epidermic structures not carcinomatous.
The stroma is rarely so markedly alveolar as in the other members of
the carcinomatous group, and may be quite limited in amount. It is
represented by a fibrous-like tissue or by a tissue filled with small round
cells surrounding the epithelial nests.
Columnar epithelioma–When epithelioma occurs in the intestinal tract
the cells are of the colummar or cylindrical variety found in the mucous
glands of these parts, appear in more distinct alveoli, and usually do not
form concentric nests. The growth closely resembles adenoma.
obliquely, the others
transversely; the epithelium is irregular in shape and size and is sometimes arranged in
more than one layer. The stroma is fibrous, containing small round cells. (ERICHSEN.)
Epithelioma originates from the epithelium of the skin, mucous mem-
branes, and glands; and then the proliferation of epithelium which occurs
causes invasion of the adjacent structures, whether they be connective
tissue, muscle, or bone. It is the presence of epithelium in these unusual
localities that is the essence of the morbid growth. Rodent ulcer is a
form of epithelioma.
V. Tumors consisting of a sac with contents (cystomas, or cystic tumors).-
A cavity separated from neighboring tissues by a sac wall and having
fluid, semi-solid, or soft contents is called a cyst or cystic tumor.
Such tumors may result from the development of a sac-like cavity in
tissues where no sac or cyst previously existed. These are true tumors or
morbid growths, and are due to softening of structure, as occurs in fatty
and mucoid degeneration; to separation of connective tissue by a secretion
or deposition of fluid, as serous and blood cysts; and to the development
of a sac around foreign bodies and parasites. In all these cases condensa-
tion and irritative development of connective tissue lead to the formation
of a circumscribing capsule or sac wall.
Cysts are more frequently developed by slow accumulations within a

C Y S TIC TU M O R. S. 111
dilation of a prečxisting cavity or duct. These are not true tumors, but
are usually conveniently considered as such in connection with the form
just mentioned. The contents are the natural products or secretions of
the part, more or less altered by the changed conditions to which they
are subjected. Such cysts are developed when the duct of a secretory
gland becomes occluded, as is the case in sebaceous, mucous, salivary, and
other retention cysts; when a ductless cavity secretes more fluid than the
absorbents can remove, as in hydrocele, bunion, and bursal tumors; when
the blood is poured into a cavity, as in haematoceles. e
The wall of a cyst may be thick or thin, tough or friable, slightly or
firmly adherent to surrounding tissues, and is developed by condensation
and new growth of the circumscribing connective tissue. In the second
variety of cystic tumors the wall presents the features of the gland or
membrane from which it was developed, and has a similar epithelial lining.
Cysts may contain serum, saliva, milk, semen, sebum, blood, and other
materials, and often take their name from the contents.
The congenital cysts, which consist of a wall resembling skin contain-
ing epithelial structures, and those cysts, enclosing teeth and bones, found
in the abdomen and supposed to be imperfectly developed ova, are called
dermoid cysts.
The hydatid cyst is a peculiar tumor due to the presence in the tissues
of a parasite. This parasite is the undeveloped taenia echinococcus, which
infests animals of the canine family but never progresses to full maturity
in the human subject. The ovum having been introduced with food into
the human system, develops as far as its cystic stage. The irritation due
to the parasite in the tissues causes the formation of a sac or cyst wall
from the surrounding parts: within this lies the parasite, which is itself a
distended sac without any head, hence called an acephalo-cyst. It con-
tains a transparent, non-albuminous or almost non-albuminous liquid of
low specific gravity, in which are floating heads or the hooklets belonging
to the heads of this form of worm. These heads are called echinococci. The
echinococci may be adherent to the inner wall of the bladder like para-
sites. Hydatid tumors occur most frequently in the liver, lungs, muscles,
and subcutaneous tissue.
Various changes occur in cystic tumors. Thus, the contents may
become inspissated, fatty, or calcareous, and the wall may calcify, ossify,
or even undergo cystic or other degenerations. Sometimes inflammation
of the tumor supervenes, which leads to suppuration, discharge, or ab-
Sorption of the contents, and cure by granulation.
Occasionally, instead of cicatrization occurring, a foul chronic ulcer is
left.
A cystic tumor with one cavity is called simple or unilocular; one
With several cavities, compound or multilocular. It must be remembered
that many of the tumors previously described may undergo cystic de-
generation by mucoid or fatty change taking place in their interior.
The treatment of cystomas consists in their removal or their obliteration
by evacuation of contents and destruction of cyst walls. True cystomas
are benign, but may, as other malignant growths, cause death by their
Situation and size. If they are excised every portion of the cyst wall
must be removed, lest the part remaining become the starting-point for
a similar tumor. Cystic sarcomas and other tumors that have undergone
Cystic degeneration must be treated as growths of their own class.
9bliteration of cysts may be accomplished by tapping, internal scarifi-
cation, injection, and incision. If the contained fluid is not viscid it may
112 T U M O R. S.
be withdrawn with a trocar or aspirator; this causes collapse of the sac.
Usually the cyst refills, but occasionally the irritation resulting from the
puncture is sufficient to cause plastic inflammation of the interior of the
cyst and adhesion of the walls. Thus, obliteration of the cavity and cure
result. The cure may at times be accomplished by scarifying the internal
surface of the cyst wall with a tenotome or long needle thrust into it
at one or at several points without evacuating the fluid, which escapes
into the surrounding tissues and is absorbed, or undergoes absorption
during the progress of the resulting inflammation. This method is very
satisfactory in treating hydrocele in infants. Multiple puncture and
abrasion of the vaginal tunic with a needle seldom fail to cure such cases.
When tapping or scarification fails to induce obliteration of cysts with
liquid contents, it becomes necessary to inject into the cavity some irri-
tating fluid to set up inflammation of a plastic grade. The best agent is
carbolic acid liquefied by moderate heat or a few drops of water or
glycerine. Tincture of iodine, wine, and other irritating and astringent
solutions may be employed. The quantity should vary from twenty
minims to a fluidrachm, according to the size of the tumor, and should be
left within the cyst cavity.
Cysts with thick cheesy contents, if not excised, should be split open.
The surgeon must then scrape out the contents, and, if he does not re-
move the cyst wall, he must mop the interior of the sac with strong car-
bolic acid or some strong astringent or cauterizing application, and
leave the wound open to granulate. This destroys the secreting surface
of the wall and sets up inflammation, which, by means of the granulating
process, causes the wound to heal and the cyst to become obliterated.
O H A P T E R W III.
WOUNDS AND SHOCK.
DEFINITION.—A wound is a sudden and recent solution of continuity
of the soft parts caused by mechanical violence. A solution of continuity
of such tissue produced slowly by mechanical pressure or violence, or by
inflammation idiopathically, is an ulcer; a solution of continuity of bone
is called a fracture; hence, the term wound gives the idea of sudden vio-
lence to the soft tissues of the body. This mechanical violence is usually
directed from without, but it may arise from within, as is the case when
wounds are produced by muscular efforts or by the projection of frag-
ments of bone in fractures.
VARIETIES.—Wounds are either freely exposed to the external air
when they are called open wounds, or are protected from such exposure
by the more or less perfect integrity of the skin, when the term sub-
cutaneous is applied. A wound communicating with the air by a small
cutaneous opening may still be considered a subcutaneous wound, as are
also wounds beneath the mucous membranes, though the term, in this
instance, is a misnomer. 4.
For convenience of description I classify wounds under four heads:
1. Contused, or those in which the injury consists in a crushing or bruis-
ing of the parts, with or without rupture of the integument, 2. Incised,
or those in which the tissues are divided cleanly, or cut, as by a sharp
knife, and in which the length of the wound greatly exceeds its depth.
3. Punctured, or those in which a wound is made by a pointed instru-
ment, and in which the depth exceeds the length. 4. Lacerated, or those
in which the structures are torn apart, giving, therefore, irregular edges
to the wound. All wounds are referable to one of these groups, though
they may possess additional characteristics: thus, any wound infected
with a specific poison becomes a poisoned wound; if the vulnerating
body enters a cavity, as the chest or a joint, a penetrating wound results;
and missiles thrown by the explosive force of gunpowder produce con-
tused or lacerated injuries, called gunshot wounds.
SYMPTOMS.–Contused wounds are produced by blows or by sudden
forcible contact with surfaces that have no sharp edges. The typical
Contused wound is the ordinary bruise or contusion in which there is no
laceration of the skin; ordinarily, however, contused wounds are lace-
rated wounds in which the bruising is a more prominent feature than the
laceration. I consider a simple bruise or contusion a contused wound,
because there is a solution of continuity of the subcutaneous tissues in
*ll such cases. Contused wounds may involve the skin and superficial
fascia only, or may extend also to the muscles and deep structures. I
have seen the muscles of the arm so pulpefied that amputation was re-
Quired, though the skin appeared scarcely injured. In persons with a
8 ºut deal of subcutaneous fat a slight degree of pressure, as from a
pinch with the fingers, will cause a distinct bruise, because the vessels are
* readily ruptured. The characteristics of this class of wounds are dull
8 *
114 SH O C K.
pain or numbness, a black and blue color at the seat of injury due to
extravasation of blood from the ruptured capillary vessels, some swelling
from effused serum, little or no hemorrhage from any accompanying
laceration of the skin that may exist, and a tendency, if the contusion be
severe, to the production of abscess and gangrene. Abscess and gangrene
result because a place of least resistance is produced in the injured tissues
and because the cellular vitality is impaired, thus giving opportunity for
bacterial action. -
When structures are divided by a keen instrument and the length of
the wound is a more conspicuous feature than its depth the term incision
or incised wound is employed. Incised wounds are characterized by
acute pain and hemorrhage, a tendency to retraction or gaping of the
edges, and rapid cicatrization. These features vary, of course, with the
locality and extent of the injury. The bleeding washes away bacteria
and tends to keep the wound aseptic, hence the rapid healing often seen.
Punctured wounds are those inflicted by a pointed instrument piercing
the tissues, and hence they are remarkable for depth rather than for
linear extent. A wound one inch long and a half inch deep made by a
knife is an incised wound; one of similar extent, but three inches deep, is
a punctured wound. Punctured wounds vary according as they are
made with dull or sharp pointed instruments; in the former case they
resemble lacerations, in the latter incisions. As a rule, however, it may
be said that punctures are accompanied by great pain and slight hemor-
rhage. They are especially liable to be followed by severe inflammation,
because they are not likely to be kept as free from bacteria as are those
wounds which bleed profusely and which are readily cleansed.
Wounds produced by disruption or tearing asunder of the tissues are
termed lacerations or lacerated wounds, and are frequently accompanied
by contusion of the parts. In fact, a force which causes crushing of the
tissues without much tearing of the integument, gives rise to a contused
wound, while the same force, so applied as freely to rupture the skin as
well as underlying structures, is said to cause a laceration. Lacerations
are distinguished by irregular jagged edges, moderate pain, slight hemor-
rhage, little gaping, a tendency to suppuration and sloughing of the
edges and slow cicatrization. These features depend upon the method of
injury, for it is the tearing and twisting of the vessels and nerves that
prevent bleeding and acute pain, and the devitalization and irregularity
of the torn edges that occasion sloughing, favor microbic infection, and
prevent rapid healing.
SHOCK.
DEFINITION.—The constitutional symptoms that immediately follow the
receipt of a wound or injury, if it be sufficient to induce general dis-
turbance, are grouped under the head of shock or collapse. Subsequently
the general symptoms pertaining to inflammation arise, if the lesion is
grave enough to cause an active process of this kind. Delayed shock I
believe to be impossible. Cases so named are doubtless instances of fat
embolism, sapraemia, septicæmia, or other imperfectly understood con-
ditions."
SYMPTOMS.–Slight shock is shown by pallor of the skin, a sense of
giddiness and nausea, and a feeling of approaching unconsciousness. This
is but temporary, and reaction or return to the physiological condition
1 For a résumé of this subject see article on Collapse in Holmes's System of Surgery,
American edition, Phila., 1881.
T R. E. A. T M E N T. 115
quickly occurs. When severe shock is present there is great depression
exhibited by muscular relaxation, pallid and shrunken features, a lan-
guid and bewildered expression, clammy sweating, a frequent and per-
haps intermittent pulse which sometimes it is said may be slow, shallow
and gasping respiration, a lowered bodily temperature varying from one-
third of a degree to two or three degrees below normal, and nausea and
vomiting.
Usually the mind is clear or at most only slightly affected by aberra-
tions of the special senses. The tranquil mental condition of patients
suffering from profound shock due to grave railroad mutilations is often
very distressing to the observer. If these symptoms of shock continue
the patient dies, usually before inflammatory processes begin at the seat
of injury, from cardiac failure. -
In sudden death the heart may be spasmodically contracted, but oftener
perhaps, the right cavities and venous trunks are engorged with blood.
Recovery from shock, takes place by the depression stage being fol-
lowed by reaction, which is evidenced by increasing power and slowing
of the pulse, by a healthier hue of skin, a rise in temperature, and a dis-
position on the part of the patient to change his posture. Reaction may
be inordinate and pass across the health line to the domain of constitu-
tional over-action when symptoms akim to asthenic inflammatory fever
occur. It is usually preferable, however, to have an excess rather than
a deficiency of reaction, since it is easier to control force than to create
it; but the condition of excitability, coupled with prostration, must not
be mistaken for excessive reaction. The time at which reaction occurs
depends on the nature of the injury and the recuperative force of the
individual, and varies from minutes to hours.
The degree of shock varies with the severity of the injury and the
impressibility of the patient. The greater the extent of the injury and
the more important the structures involved, the more profound in a given
patient will be the shock. On the other hand, however, we find that an
impressible person will show great shock upon the receipt of a trivial
Wound, while a much more serious lesion in another man will be accom-
panied by little shock.
Shock is greater in injuries of the trunk than of the extremities, and
in wounds of the abdomen than in those of the chest. In estimating the
degree of shock and in diagnosticating the condition itself the surgeon
must remember that direct injury to nerve centres, hemorrhage, fat
embolism, rapid septicæmia, and abstraction of heat from internal viscera,
and fright are liable to simulate or increase the symptoms of shock. The
heart and kidneys should always be examined prior to operations, because
chronic disease of these organs increases the severity of the shock of
Operation.
The pathological condition causing the symptoms termed shock lies in
the sympathetic nervous system, and is probably a paralysis of the vaso-
motor centres. The perturbation of the vaso-motor nerves produces a
Spasmodic contraction of the minute bloodvessels, and then lowered tem-
Peature, pallor and the concomitant symptoms are exhibited.
. TREATMENT—The treatment of shock will be discussed here, because
in severe injuries the surgeon's attention is directed to this condition
before local measures for the cure of the wound are adopted. I shall
then recur to the subject of wounds and consider the modes of healing
and the treatment of the different classes of wounds,
If the Symptoms are slight a drink of water and fanning the face are
116 SH O C K .
sufficient treatment. In severe shock perfect quiet of mind and body in
the recumbent position and heat to keep up the bodily temperature are
the most important requisites. Cardiac stimulants and food are then
demanded in the majority of cases. Venesection, recommended by some
authors because of the occasional engorgement of the veins and right
heart, is probably never required. The distention of the hollow organs
occurs from the vaso-motor nervous disturbance causing paralysis and is a
result, not a cause of the shock. Heat and artificial respiration will be
well calculated to distribute the blood engorging the viscera. Heat is to
be maintained by warm rooms, blankets, bottles, or rubber bags filled with
hot water, hot water enemas, or by the hot bath in which the temperature
is raised from 98° to 110° F. A small amount (fā ss–f5 ij) of stimulant
in the form of brandy or whiskey, may be administered ; but it should be
remembered that many injured persons have been given alcoholic stimulus
by the bystanders before the surgeon's arrival, or have taken it as a bever-
age before the accident. Overdosing with such remedies produces de-
pression. Hence, the amount spoken of above should seldom be increased
but may sometimes be repeated at the expiration of several hours. Small
amounts of coffee, beef tea, or milk also should be given at intervals, but
here, as in the case of alcohol, large amounts lying unabsorbed in the
stomach do harm and may induce vonmiting.
The pulse is the indication to guide the attendant. If it increases in
force and diminishes in rapidity reaction has begun. Time is then re-
quired; reaction from severe shock may extend over six, twelve, or
twenty-four hours. The drugs employed in the management of shock are
morphia (gr. 3–3), tincture of digitalis (m, xx-f: j), carbonate of ammo-
nium (gr. v-xx), atropia (gr. Cº-º), all of which can be given hypoder-
matically; and quinia (gr. v-xx), best given by the mouth or rectum.
Ether in half-drachm doses may be given subcutaneously. I have
obtained in profound and almost hopeless shock very gratifying results,
which I believe due to the hypodermatic administration of digitalis, ammo-
nia, and alcohol.
As soon as reaction is fairly established cardiac stimulants must be
stopped lest the traumatic or inflammatory fever be enhanced.
When operations are necessary after injuries inducing severe shock, the
surgeon should wait, as a rule, until reaction has begun, since there is then
less danger of causing dangerous depression from the shock of operation.
Etherization has usually a stimulating effect and seems to combat the
symptoms of shock.
The shock after operations is often excessive because the surgeon has
been too slow in his operative work, has exposed the patient to cold air,
has reduced his temperature by wet dressings and irrigation, or has de-
pressed him by prolonged anaesthesia.
C H A P T E R IX.
MODE OF REPAIR AND TREATMENT OF WOUNDS.
REPAIR OF WOUNDS.—All wounds, large or small, open or cutaneous,
incised or punctured, contused or lacerated, heal by that reparative pro-
cess which I have, in the first chapter, called inflammation. In other words,
what was there styled inflammation is really nature's reparative effort to
reconstruct the injured tissues and limit the injurious influence of the origi-
nal irritant. The processes called inflammation are efforts, often more or
less futile, to restore physiological conditions. Inflammation is not a dis-
€3,862.
When the wound is of such a character that accurate adjustment of the
Several tissues can be and is accomplished, a reparative effort merely suffi-
cient to supply a small amount of fibrine or lymph supervenes. This
fibrine glues the parts together, then becomes changed into granulation
tissue, and finally into connective tissue, or scar, analogous to the original
structures. Thus is repaired the breach of continuity. This method of
union is union by first intention, or fibrinous repair, and occurs when no
foreign body, clotted blood or undue amount of transudation prevents
accurate approximation, and when the parts are kept quiet and the
patient's tissues are in a healthy condition and free from microbic infec-
tion or other irritation. By this mode are repaired subcutaneous and
other aseptic wounds.
When there is a loss of substance, or an irregularity of the edges of
the wound, the space or chasm due to the injury or to the destruction of
the ragged edges by sloughing is gradually covered and more or less filled
up with minute granular bodies of a pink color called granulations.
These are formed from lymph, capillary loops and indifferent cells in the
same way as the uniting band in cases of union by first intention. If
the wound is kept aseptic there will be no suppuration and epithelial
formation will occur when the granulation tissue has filled up or nearly
filled up the cavity. In the meantime there will be a serous exudate from
the surface of the granulations. It is difficult to keep pyogenic organisms
away from such wounds when large and superficial suppuration is not
unusual. Absolute asepsis should be attempted always.
. The granulations have absorbent power and are gradually converted
into a bluish-white connective tissue, called the cicatrix, which occupies
the situation of the wound and assumes characteristics similar, though not
identical, with the structures injured. This method is union by second
*tention or granulation. It is the only means by which healing of
Wounds can occur if union by first intention fails to take place. It is apt
to occur in contused and lacerated wounds unless they are subcutaneous
or have their devitalized edges trimmed off, are rendered aseptic and
accurately approximated. Other varieties of healing have been described,
but they are but modifications of the two here considered, which them-
selyºs are identical in pathological significance and process.
Healing by first intention is much to be preferred, because it requires
118 MODE OF REPAIR AND TREATMENT OF wou N'Ds.
much less time, say from two to seven days, and leaves very little cica-
trix. Union by granulation, or second intention, requires weeks or
months, according to the size of wound or ulcer, and leaves a large scar,
which often gives rise to deformity, on account of the contractile tendency
of cicatricial tissue.
TREATMENT OF WOUNDS.–In the management of all wounds, there are
four cardinal rules: 1. Arrest hemorrhage. 2. Render the wound asep-
tic by removal of all dirt and foreign bodies, as far as it is possible to do
So without incurring risk. 3. Bring the parts into apposition, if the
attempt does not, and will not, cause pressure and tension. 4, Assist the
matural reparative process by mechanical rest and the prevention of
putrefaction and suppuration.
These precepts apply to every wound, but their relative importance
varies with the character of the injury. Thus, in incised wounds there
is often much bleeding to be arrested, but no foreign body to be removed,
while in contused and lacerated injuries there is frequently no hemorrhage,
but numerous particles of foreign materials, such as shot, shreds of
clothing and dirt, to be extracted.
The arrest of bleeding will be spoken of under Diseases of the Blood-
vessels, and the methods of approximating and dressing wounds, and of
preventing germ infection under Minor Surgery and Surgical Dressings,
Hence, I shall at this point speak only of the constitutional treatment
required by patients suffering from wounds. To coöperate with the processes
of repair and to prevent the occurrence of retarding complications may or
may not require the surgeon's interference. In aseptic wounds, union
usually occurs steadily and expeditiously, and nothing is required but
patience on the part of the attendant, who has dressed the wound with germ-
free applications. At other times, because of the contaminated nature of
the wound or because of the conditions or surroundings of the patient,
sloughing, burrowing of pus, abscesses, erysipelas, or pyaemia, render the
surgeon's duties responsible in the highest degree. As all wounds heal by
the reparative efforts of nature, inaccurately called inflammation, the
treatment detailed on previous pages, for the management of the inflam-
matory process is to be pursued. Hence patients showing a sthenic
form of constitutional implication must be depleted and depressed by.
bloodletting, purging, arterial sedatives, and other measures of a kindred
nature. The asthenic type, on the other hand, demands supportive treat-
ment, which is effected by tonics, stimulants, and a generous nutritious diet.
Wounds must be treated locally according to their special characters,
after the general rules given above have been followed; but, in all cases,
the most rigid asepsis or antisepsis must be carried out. There is no
doubt that serious complications arising in connection with wounds,
whether the wounds be accidental or operative, can be mostly, if not
entirely, avoided by keeping the wound-surfaces free from microörganisms.
It is to these organisms, either introduced at the time of injury or allowed
to come in contact with the wound at a later period, that the constitutional
disturbances, slow healing, and suppuration so often found, are due. It
is the surgeon's duty to avoid such microbic infection in operation wounds,
and to limit it in accidental wounds when it has taken place before he
had control of the patient's destiny. Death is often, and has often been,
due to the surgeon’s ignorance or neglect of these precautions. This sub-
ject will be further discussed, under Surgical Dressings, in the next
section.
Treatment of the Different Classes of Wounds.-Contusions, being subcu-
T RE AT MIE NT OF W O U N DS. 119
taneous wounds, require little treatment. If there is a great deal of sub-
cutaneous extravasation, cold water and pressure with a bandage are
indicated to stop the hemorrhage. Absorption of the effused blood takes
place very slowly, but gradually the black and blue appearance changes
to a greenish and yellowish hue, and the discoloration then disappears.
Alcohol, chloride of ammonium solution (gr. X-xx to the fluidounce),
tincture of armica and hot water are often used as external lotions, but the
benefit derived from them is doubtful. They do no harm, however, and
serve to satisfy the patient. Moreover, the rubbing which they encourage
probably assists the vessels in taking up the effused blood. If the extra-
vasation is very great in regions where loose connective tissue is abund-
ant, as in the eyelids and scrotum, the swelling will be so great that the
surgeon may be tempted to make incisions for its escape. This is usually
bad practice, because large amounts of blood thus effused will be absorbed,
while contact with the air renders access of pyogenic or putrefactive
bacteria probable. When extravasation of blood and rapid inflammatory
effusion of serum cause such swelling and tension that the limb becomes
cold and there is danger of gangrene from interstitial pressure, long incis-
sions must be made through the tense skin. The skin then retracts and
relieves the pressure. These incisions must be made with antiseptic pre-
cautions, and the whole limb dressed with gauze. When absorption does
not occur, but there remains a tumor filled with fluid blood for a long
time, the term haematoma is employed. This usually requires aspiration
or incision. Abscesses and serous cysts occurring subsequent to contu-
sions demand evacuation.
The treatment of open contused wounds and of lacerations may be con-
sidered together, because the same principles govern their surgical manage-
ment. Such wounds are nearly always infected with germs, from con-
tact with the vulnerating body or from their surroundings at the time of
their infliction. Before the wounds are dressed, it is very necessary to
render them aseptic. This is done by the removal of all particles of dirt
with aseptic forceps or fingers, and by cleaning and disinfecting the
wounds by means of irrigation with antiseptic solutions. Corrosive subli-
mate solution (1 : 500 or 1 : 1000), poured upon and into the wound
from a pitcher or a syringe or squeezed from a sponge, is one of the most
effective of such agents. Betanaphthol and other substances may be
employed. All accidental wounds must be thoroughly sterilized in this
manner in order to avoid the occurrence of suppuration. In large
Wounds where such a procedure would give pain, it is not only justifiable,
but it is requisite, to give ether in order that this important procedure
may not be omitted. It is good surgery, after having etherized the
patient, to scrape and scrub such wounds thoroughly with a mail-brush
and soap-suds before using the antiseptic solution. This double proceed-
ing removes or destroys all germs that may exist in the wound. Injuries
received from machinery almost always need such treatment, because of
the dirt and grease ground into the tissues at the time of the accident, or
upon the patient's skin before the receipt of injury. After such wounds
have been made germ-free, they should be sutured as operative wounds,
and provision made by catgut strands or drainage-tubes for the escape
ºf serous and other fluids which may exude. The conversion of such acci-
dental Wounds into aseptic wounds by these measures is an essential first
step in treatment. Wounds subjected thoroughly to this treatment
usually unite by first intention. If this is not the case the granula-
tion process goes on so rapidly that the patient's convalescence is com-
120 MO DE OF REPAIR AND TREAT MENT OF WO UN DS.
paratively short. In former times it was considered impossible for such
wounds to heal without suppuration, which was accompanied in many
instances by more or less violent constitutional implication. We now
know that the wounds were, in those days, really complicated by infec-
tion from pyogenic and putrefactive germs.
After thorough cleansing with sublimate or betanaphthol solution,
and after all foreign bodies have been picked out with sterilized forceps,
the bruised and lacerated parts should be adjusted and kept in place by
sutures, if this can be done without causing tension or interfering with
the escape of the fluids to be subsequently secreted. Much damage is
often done by making nice approximation of such wounds and providing
no escape by drainage-tubes and counter openings for the serum and pus
which may arise in a few hours and cause tension and pain. If the fluids
thus secreted find no free avenue of escape, burrowing of pus and septic
conditions are liable to occur. Parts that cannot readily be brought
together should be allowed to gape.
Union by granulation is the method of healing in these wounds. Con-
tused and lacerated wounds are usually followed by sloughing of their
ragged borders; but it is improper to cut away anything more than the
edges at the first dressing, since it is not possible to determine what parts
are actually devitalized. The ordinary gauze dressing should be used.
Thorough drainage of deep and irregular wounds by tubes, strings of
rubber, or horsehair, is important. When the sloughing stage has given
place to the granulation stage the resulting ulcerated surface is treated as
an ulcer. If abscesses are liable to form, provision must be made for
draining the deep parts by drainage-tubes, incisions, and washing out
with syringes or by hydrostatic pressure.
When the injury has caused complete devitalization, amputation must
be done as soon as reaction from shock has occurred. If the soft parts
are completely stripped from the bones amputation may be demanded,
even when the Osseous tissues are intact, because of the danger of acute
traumatic gangrene. If attempts have been made to preserve crushed
limbs and rapidly spreading gangrene supervenes, amputation is usually
to be done promptly at a high point of the limb. *.
In incised wounds an attempt should always be made to secure union
by first intention, because thus time is saved, the scar is less disfiguring,
there is no drain from the system as when suppuration occurs, and there
is less chance for septic complications. If the effort fails union occurs by
granulation, as in lacerated wounds. In lacerated and contused wounds
union by first intention is, from the nature of the injury, almost impossi-
ble. After arrest of hemorrhage, removal of foreign matters, and the
production of an aseptic condition in incised wounds, accurate adjustment
is to be obtained by sutures of catgut, silk, or wire; or in small wounds
by a layer of gauze or absorbent cotton glued to the skin, by collodion.
About the face the latter dressing is sometimes preferable because a
scar is left by sutures. The transparent gauze allows the surgeon to see
that the wound is evenly apposed, and any unexpected serous or purulent
discharge soon leaks through the meshes of the tarletan and is not shut
in by the dressing. In other places than the face I prefer sutures, because
even deep wounds can be apposed along their entire surfaces by buried
catgut sutures applied to each successive layer of tissue. There is no ob-
jection to the minute points of scarring from sutures except on the face.
I always use sutures for the scalp. The application of interrupted and
twisted sutures and of the collodion gauze dressing will be described in
T R E A T M E N T OF W O U N ID S. 121
the chapter on Minor Surgery. I will merely repeat at this point the
caution to students that there is a tendency to apply sutures too tightly.
Mere approximation of the edges of the wound is what is desired. Any
marked puckering is a serious fault. Catgut sutures stretch a little after
tying and can be drawn tighter than wire ones.
Punctured wounds when made with a sharp instrument require treat-
ment like incised wounds; when made with dull instruments, such as car-
penter's nails, they are practically lacerations. If they are penetrating
wounds there will probably arise inflammation of the lining membrane or
viscera of the cavity opened. This will demand treatment directed to
the special lesion. The removal of the foreign body is often difficult in
the case of punctures. If withdrawal with forceps is impossible a free
incision will be required, especially if the vulnerating body is buried in
the tissues and invisible. This should usually be done at once, and par-
ticularly when the foreign body was probably covered with dirt and is
especially liable to cause septic infection. The incision adds little or noth-
ing to the gravity of the injury, may result in detection of the foreign
body, and even if unavailing gives free drainage and lessens the dangers
of erysipelas and other complications frequent in punctured wounds. A
simple or an electromagnet has been found serviceable at times in re-
moving chips of iron after lacerations or punctures of the eyeball. It is
almost impossible to render a punctured wound aseptic without enlarging
it; hence it is often good policy to increase it in order to sterilize it and
prevent the occurrence of cellulitis or gangrene.
Poisoned Wounds are usually punctures, since stings of insects, fangs
of reptiles, and points of knives are usually the vulnerating instruments.
Any form of abrasion or wound of the skin may be inoculated, however,
and at times simple maceration of the skin with poisonous fluids in loca-
tions where the integument is thin is sufficient.
The wounds made by insects are comparatively unimportant in this
country. It need only be said that if the sting remains in the wound it
should be extracted, and lead water, sublimate solution (1 : 1000), water
of ammonia, or spirit of camphor applied. Bites from insects with
poisonous saliva should be managed in the same way. Any subsequent
inflammation should be treated on general principles.
Venomous snake-bites are usually accompanied by rapid and multiple
interstitial hemorrhage, caused by an interference with the coagulability
of the blood and disintegration of the vessel walls, due to the poison;
paralysis of respiration and the spinal centres; and locally great swelling
and vesication. The profound prostration or collapse is accompanied,
however, with unimpaired intellection. Death occurs in an hour or so if
the amount of poison is large, but in other cases may be delayed several
days and occur through the depressing influences of gangrene and sup-
puration. Many constitutional remedies have been vaunted, but there is
no positive evidence in favor of any except alcohol, which should be
given freely, but not indiscriminately. The intravenous injection of am-
Imonia has been recommended, but its value is not yet established. The
local treatment is important, and consists in immediate free excision of the
Wound and surrounding tissues, the application of a tight ligature to the
limb. above the wound to prevent venous and lymphatic absorption,
sucking or cupping the wound left by the knife to extract the poison,
and cauterization with equal parts of carbolic acid and alcohol.
. Permanganate of potash freely injected into the wound and surround-
*g tissues is serviceable in destroying the poison and should always be
122 MO DE OF REPAIR AND TREATMENT OF WOUNDS.
used if obtainable. Nitrate of silver is valueless as a caustic, as, indeed,
it always is when a tissue-destroyer is desired. The so-called intermit-
tent ligature is a rational measure. It is merely a tightly constricting
band, applied at the cardiac side of the wound and relaxed momentarily
at intervals in order to allow the poison to enter the general circulation
slowly and in divided amounts. This gives the surgeon a better oppor-
tunity to counteract the effects of the poison and obtain its elimination
than when the venomous material is suddenly absorbed in full amount.
The poison is a chemical, not a microbic, one. It contains, according to
Mitchell and Reichert, two albuminous poisons, called by them venom
peptone and venom globulin. With the venom are introduced into the
wound many bacteria, which are the agents and causes of the putrefac-
tion which so rapidly occurs after snake-bites.
Inoculation with the fluids of diseased or of decomposing animal tissue
at times causes serious poisoned wounds. Malignant pustule, or charbon,
contracted from cattle suffering with murrain, and glanders, or equina
due to inoculation or infection from horses having this affection, are the
most important forms derived from the lower animals. These affections
are due to microörganisms and the ptomaines developed by their growth.
I omit the discussion of hydrophobia here, because all pathologists are not
agreed as to its being due to inoculation. It will be considered under
Diseases of the Nervous System.
Malignant pustule is especially found in tanners and butchers and is
characterized by a vesicle at the point of inoculation, which is soon fol-
lowed by violent inflammatory complications, such as angeioleucitis, cellu-
litis, and gangrene. The degree of asthenia accompanying this car-
buncular inflammation is profound and shown by its usual symptoms.
The affection is due to the presence of a vegetable organism, the anthrax
bacillus, contained in the blood and other fluids. The treatment consists
of excision, or free incision, followed by thorough cauterization with cor-
rosive sublimate or carbolic acid. Saturating the cellular tissues with
injections of iodine has been considered valuable. Stimulant, supportive,
and anodyne remedies internally administered are required. Free in-
cision through the swollen and infiltrated tissues involved are indicated,
even after the early stages.
Glanders is another infective or mycotic disease, and is characterized
by asthenia and by multiple indurations and ulcers of the surface, in-
flammation and suppuration of the salivary glands, and profuse nasal
discharge; though the last symptom is not always prominent in the dis-
ease in man. The treatment should be conducted on general principles,
as there is no special remedy for the condition.
The prognosis in malignant pustule and glanders is unfavorable in the
majority of cases.
The term dissection wound is applied to injuries received during opera-
tions on dead, and sometimes on living, bodies. They occur also in
butchers, fish-dealers, and others whose occupation causes them to handle
dead animals. Many wounds so received act merely as similar injuries
inflicted under other circumstances; sometimes there is an additional
amount of inflammation, as if the animal fluids irritated the part ; but
occasionally a most virulent form of local inflammation occurs, and is
accompanied by grave constitutional symptoms of blood infection.
Persons whose previous health is poor suffer more frequently from such
wounds than do other persons whose tissues have more resistence to in-
fectious influences. These disastrous symptoms appear to be due to a
T B E A T M E N T OF W O U N ID S. 123
specific poison generated in the cadaver a short time after death, or per-
haps before death, which seems to be destroyed by the advent of marked
decomposition. Cases of death from peritonitis, erysipelas, and pyaemia
are more likely than others to cause such dissection wounds. These
wounds owe their virulence to microörganisms or the chemical products
of such organisms. They are, in fact, Septic wounds.
There is a complete, or almost complete, protection afforded by pre-
serving cadavers with zinc chloride, as is done in our Philadelphia dis-
secting-rooms. It is important to recollect that the poison appears at
times to infect the pathologist, who is making an autopsy, through the
hair-follicles and unbroken skin of the hands, especially if they are im-
mersed in the fluids of pyaemic pleuritis or peritonitis.
The symptoms of a dissection wound, if of the ordinary variety, are
those of an acute inflammation about a wound—viz., pain, swelling,
inflamed lymphatic glands, fever, etc. Quite frequently suppuration
occurs. In the more serious form a vesicle appears, after the lapse of a
couple of days, at the point of puncture, and is followed by erysipelatous
inflammation, angeioleucitis, rapid involvement of the cellular tissue, Sup-
puration, sloughing, and septic symptoms, as shown by rigors, fever,
colliquative sweating, and rapid prostration of the vital powers. Those
cases seem to be worse in which inflammation of the lymphatic glands
occurs before active inflammation of the wound. .
The treatment consists in ligation above the wound to prevent absorp-
tion, excision and cupping to get rid of the virus, and cauterization, prob-
ably best effected by zinc chloride, corrosive sublimate, or carbolic acid.
If, however, septic symptoms occur in spite of these precautions, quinia,
alcoholic stimulus, anodynes, nutritious food, and supportive agents must
be given and the wound treated by incisions and antiseptic washes. It
S said that the spreading inflammation may at times be arrested by a
blister applied around the limb, above the wound, as soon as the red lines
indicating inflammation of the lymphatic vessels appear. Smearing the
surface freely with mercurial ointment is often beneficial in these and
other cases of angeioleucitis and phlebitis.
Gunshot Wounds.-Gunshot wounds are injuries produced by the
explosive force of gunpowder confined in firearms. They may, therefore,
be caused by the powder alone, by the projectiles discharged, by pieces
of clothing or splinters of wood given motion by such missiles, and by
portions of weapons shattered by explosion. Gunshot wounds partake of
the nature of contused and lacerated wounds, and hence are often fol-
lowed by sloughing. When fractures are produced they are almost in-
Variably open, or compound and comminuted. Cannon balls crush and
pulpefy the parts struck. The wind caused by a passing ball does not
and cannot produce a contusion, as was formerly supposed. In injuries
so attributed the elastic skin has escaped injury, though actually struck.
The wound made as the missile enters the tissues is called the wound of
entrance, that made as it leaves the part, after traversing it, is termed the
Wound of exit. The wounds of entrance and exit, especially if made by
a projectile travelling with a comparatively moderate velocity, differ in
*ppearance. The former is small and has depressed and regular edges,
stained, perhaps, with grease and powder. The wound of exit has everted,
Tagged margins, not stained, and is much larger than that of entrance,
because. the skin has no external support when it receives the impact
from within. Conical bullets discharged by rifled arms travel with
such velocity that these distinctions are not always present.
124 MODE OF REPAIR AND TREATMENT OF WO UN DS.
A bullet may traverse the tissues in a direct line, be deflected by bones
or fascias, or be split against a bone and make several openings of exit.
Instances are recorded where the bullet has taken a circular course and
been found imbedded near the wound of entrance. Portions of clothing
or wadding carried into the wound act as complications. Small shot fired
at short range, say a foot or two, will make a single wound of entrance
because there has been no scattering. Powder alone may, if discharged
near the skin, produce a serious injury. In any event, if unburnt powder
enters the skin there will be permanent discoloration like tattooing,
unless the grains are discharged by suppuration or removed by the
surgeon.
It is unnecessary to speak here of shock, hemorrhage, and the other
symptoms of gunshot wounds, since they correspond with injuries of
similar gravity produced by other vulnerating agents.
The treatment consists in removing the foreign body as soon as reaction
is established, provided it can be done without seriously increasing the
danger. The injury has been produced by the entrance of the projectile,
and its passive residence in the tissues does not do sufficient harm to per-
mit great risks to be taken for its removal. Bullets, especially if smooth,
often become encysted and may remain many years without causing
trouble. Still, the extraction of the ball, fragments of wadding or cloth-
ing, and splinters of bone hastens the cure by lessening the danger of
septic inflammation and suppuration, and at the same time gets rid of the
possibility of remote inconvenience from encysted bodies. Hence, the
bullet should be extracted, if it can be done either through the opening
of entrance, which seldom is possible, or by a counter-incision. Of course
if the wound of exit proves the escape of the entire bullet, and no foreign
material lies in the wound, these measures are unnecessary. The wound
should be made aseptic by cleansing, by irrigation with sublimate or
betanaphthol solution, by counter-openings and drainage, and should be
dressed with antiseptic gauze.
Gunshot wounds, in which nothing except the bullet has entered the
tissues, are often aseptic, probably because the missile has been sterilized
by the heat generated in its flight. Much harm is often done by infecting
such aseptic wounds by means of probes and fingers. Unless the examina-
tion is aseptically performed, it had better be omitted, and the wound
dressed with antiseptic gauze until a proper examination in skilled hands
is obtained.
To determine the course and position of the ball careful probing with
an aseptic finger or metal probe is proper. When the opening involves
the abdominal, cranial, or thoracic cavity, it is usually justifiable to make
a free incision under rigid asepsis and explore the contained organs.
This important topic will be discussed under injuries of the brain and
viscera. In abdominal wounds immediate exploratory operation is usu-
ally demanded. In cranial and thoracic wounds delay in or abstinence
from operation may be proper.
It is always well to examine the surface of the body on the opposite
side, for the projectile may have passed across and be lodged under the
skin, whence an incision will liberate it. For probing or examining the
wound the patient should be placed in the position occupied when shot,
to get the muscles and bones in the same mutual relation. The probe
should be slightly bent at the tip to enable it to follow tortuous passages
more readily as it is delicately inserted and turned about in the hand of
the surgeon. The probe of Nélaton, which has a roughened porcelain
T R. E.A.T MENT OF WO UN D S. 125
tip, may be serviceable, because it becomes marked by contact with the
leaden ball and thus shows that the hard mass touched is not bone. The
electrical apparatuses for determining the location of bullets are prac-
tically valueless. When the ball has been found, attempts at extraction
are to be made with the various forms of bullet-forceps and extractors.
The incision may be freely enlarged if necessary. Unburnt powder about
the face and hands is to be removed by patient picking with a small
knife, or by cutting out little disks of skin with an instrument like a
bunch.
| Another method is to prick the skin with a needle dipped in croton oil
or other irritant, which causes suppuration and leaves only minute white
scars instead of the blue powder marks.
When extraction has been accomplished or the attempt found fruitless,
the wound is to be managed on the general antiseptic principles previously
discussed. Thorough drainage by tubes or counter-incisions is resorted
to according to indications. Immobilization with gypsum bandages over
the antiseptic dressings will aid in protecting the injured bones from undue
motion, if gunshot fracture exists. Amputation may be required for gun-
shot injury if the bones are greatly shattered, large vessels or nerve-trunks
destroyed, joints freely exposed with comminution of bones, or if rapidly
spreading mortification is threatened. Primary amputations are usually
preferable in such cases to secondary operations.
Excision may at times be available in joint injuries or in gunshot
fractures of the shafts of long bones.
C H A P T E R X.
PRACTICAL SURGERY AND ANAESTHESIA.
INSTRUMENTS.—The instruments of the surgeon are innumerable, but
those ordinarily required are few in number and simple in construction.
Knives, forceps, scissors, hemostatic forceps, saws, needles, probes, and
grooved directors are indispensable for the performance of surgical opera-
tions, and undergo many modifications for special purposes. Certain
operations demand additional instruments of peculiar character, such as
the trocar, catheter, and syringe. A knife with a markedly convex or
bellied edge is technically called a scalpel, while one that has very little
belly and is nearly straight is termed a bistoury.
WL \ WºW Z_S,SKYNS
Scalpel with aseptic hollow metal handle.
Scalpels are usually too convex, and are satisfactory only when a large
flap of skin is to be dissected up. A knife nearly straight, partaking,
therefore, of the character of the bistoury, is the best form and answers
equally well for incisions, dissections, and opening abscesses by trans-
fixion.
Fº º-
Q,\ \\\\7 SSQNS
Bistoury with aseptic hollow metal handle.
The edge of a knife is tested by drawing it from heel to point across
the free border of a finger nail, for by this manoeuvre any notches will
be apparent. Its keenness is proved by the ease with which it will cut
when the edge is gently pressed upon the skin of the finger. The sharp-
ness of the point is tested by the thrusting it through a piece of kid or
gold-beaters’ skin stretched tightly over a ring. This little drum gives
out a distinct sound at the time of puncture if the point of the knife is
dull.
Hemostatic forceps have a lock and are used to compress wounded
vessels during the various steps of an operation, so that the surgeon need
not be delayed by ligating bleeding points. In truth this temporary
compression is often all that is needed; for small vessels soon become per-
manently sealed and when the forceps are removed require no ligature.
Large vessels should be tied before the hemostats are removed.
Straight needles with the point ground on three sides, such as are used
by glovers, are nearly always preferable to those curved near the point.





I N S T R U M E N T S, 127
They penetrate the tough skin more readily and enable the surgeon to
direct the point more certainly.
FIG. 40.
G.TIEMAN!!! 9, UO
(EE-ſºº -- - - --- - -
•ºr-zerº---------- E: -------
Glover's or bayonet-point needles, enlarged.
A needle fixed in a handle and having an eye in the point is often
useful.
The sharp hook employed for drawing out the ends of divided vessels
is called a tenaculum. It has been supplanted to a great extent by the
hemostatic forceps. Probes should always be firm, but sufficiently flexible
to allow the operator to bend the end slightly before beginning to explore
a sinus. The slightly curved extremity will follow more readily the
tortuosities of the channel, when the probe is rotated in the fingers.
FIG. 41.
º
|
|
#
# # | |
|: | | || {{ | ſti
º
| } º
# # § º
I # |; j; § Kºbe,
#|s: | ºf tº
|#; #|º j
º;|º] }
| | #|| § ; : º
fº tº
Sterilizing oven with thermo-regulator connected with gas tube to prevent temperature
rising too high.
All instruments should be kept scrupulously clean and protected from
dust, so as to be free from bacteria. Dried pus and blood are liable to
remain in crevices of instruments and infect wounds with which they
come in contact. ... The eyes of catheters and the teeth of forceps are
Very frequently allowed to contain foul material of this character. Or-
dinary dust usually contains germs, and if in these fissures, may infect























128 P R A CTIC A. L S U R G E H Y A N D A N AE S T H E S I A.
a wound. Moist or dry heat is the only perfect sterilizer of instruments.
They should always be washed perfectly clean after operation. Just
before use they should be heated to at least 212° F. and kept at that
temperature for ten or fifteen minutes. This may be done by boiling in
water, by steam, or by baking in an oven. The handles should be smooth
and of metal and not cemented, since cemented instruments are damaged
by heat. All unnecessary complications and crevices should be avoided.
Copper boxes with dust-tight lids are convenient receptacles in which to
keep, bake, and transport instruments.
FIG. 42.
* º º
| º:
§§
Šºº. º #.
* ſº :ań º : º º
SJ; § | º §
|
º
.
Copper boxes for sterilizing instruments by baking.
INCISIONS.—The knife should always be held delicately though firmly.
The most common position of the knife for making incisions is that
assumed when one uses a pen, though in dissecting up large flaps the
surgeon will often hold the knife as if it were a fiddle-bow. Occasion-
ally, as in amputations, the large handle is firmly grasped with the entire
hand. When an incision is to be made the fingers of the left hand should
support the skin at the point where the knife is to be entered, the surgeon
then thrusts the point into the tissues perpendicularly and, immediately
depressing the handle of the knife, cuts with the edge until the incision
is sufficiently long; he should then, in order that the tissues may all be
completely divided to the very end of the incision, elevate the handle
and bring the knife out perpendicularly.
Incisions should be sufficiently large to expose the parts and should be
made with decided strokes of the knife. Nothing discloses the inefficient
surgeon so much as small, button-hole like incisions, made by picking
with the point of the knife. When possible, incisions about the face
should follow the cutaneous creases that the scars may be as unnoticeable
as possible. Oblique division of the skin causes slight scarring, and curvi-
linear incisions are less noticeable than straight ones. In making incisions
over large vessels or important organs the grooved director is to be pushed
under the successive layers of tissue before the knife is used to divide
them. This does not apply to the skin incision.
ANAESTHESIA.
For trivial operations, such as opening abscesses and removing small
tumors, local anaesthesia is sufficient. It is induced in one or two minutes
by applying a lump of ice or a mixture of ice and salt to the skin; by
blowing ether, rhigolene, or other refrigerating vapor upon the surface
with an atomizer, or by employing cocaine hydrochlorate.








































A NAB, S T H E S I A. . 129
Local anaesthesia obtained by the use of aqueous solution of hydrochlo-
rate of cocaine is eminently satisfactory. A twenty grain solution of this
salt in water painted upon a mucous membrane with a camel's-hair pencil,
or dropped upon it from a medicine dropper, will produce local anaesthesia
in about three minutes and will permit the performance of any minor opera-
tion without giving the patient pain. If the application first made does not
produce insensibility to pain in the part to which it is applied, a repeated
application may be made in a similar manner. The anaesthesia thus
produced lasts a number of minutes. It is important that the part to
which the anaesthetic is applied should not be alkaline in reaction, since
alkalinity of the surface interferes with the anaesthetic power of
cocaine.
Local anaesthesia cannot be produced in the skin, as in mucous mem-
branes, by merely painting or brushing the surface with the solution,
except for operations made upon very thin skin, as that of the eyelids.
For cutaneous operations of a superficial character it is sufficient to inject
the cocaine into or under the skin by a hypodermic syringe. From five
to twenty minims should be introduced by one or two punctures. If more
perfect local anaesthesia is desired, as for the removal of small tumors, the
solution can often be incarcerated in the part, into which it has been
injected, by retarding the venous return from the cocainized area by means
of a ligature or a rubber ring. If an operation is to be made upon a
finger or upon the penis, for example, the anaesthetic will last longer and
prove more effective if it is incarcerated at the seat of operation by tying
a piece of tape or placing a rubber band around the base of the member
before the hypodermic injection. If an operation is to be made upon the
eyelids or upon very thin skin, but not at a very great depth, a sufficient
degree of painlessness can be obtained by simply painting the thin skin
with the solution in very much the same manner as is done in operations
on mucous membrane. In all such instances the surface should not be
alkaline, else the anaesthetic power of the drug will not be exerted.
It must be remembered that death has occurred from cocoaine poisoning.
It is best, therefore, to avoid the toxic affect by not using a solution
stronger than twenty grains to the ounce, and it is wise seldom to use more
than twenty minims at the most, unless the drug has been incarcerated.
Then after operating the surgeon can by intermittent relaxation allow it
to enter the system gradually. The passage of urethral bougies and instru-
ments of a similar character may be rendered quite painless by injecting
the urethra with cocaine. When used upon the eye in large quantity
and in too strong solution it occasions opacity, temporary however, of the
Cornea, and may, therefore, possibly do harm if it is not used with
proper caution.
For the production of general anaesthesia in surgery ether is preferable
to any other agent at present generally employed. Chloroform is much
more dangerous. This is a sufficient cause for the abolition of its use.
Its claimed advantages over ether are considerably overrated because of
the improper methods in which ether is often given.
Nitrous oxide is not a good anaesthetic for protracted operations, requires
bulky apparatus for its administration, and in short operations can readily
be substituted by local anaesthesia or the primary aniesthesia of ether.
Rapidly repeated deep inspirations continued for a minute or so will
Produce insensibility to pain (analgesia) for slight operations, though the
Sensibility to contact is not obliterated. This effect may be utilized in
9
130 P R A CTIC A. L S U R G E H Y A N D A N AE S T H E SIA .
surgery, but it and anaesthesia from nitrous oxide are used very little
outside of dentistry.
Before etherizing a patient the surgeon should examine the kidneys,
heart, and lungs. The presence of disease in one or all of these organs
should not deter one from the administration of ether when necessary for
a painful operation; but the knowledge of its existence renders one
exceedingly cautious, and protects him against the verdict of carelessness
in the event of dangerous symptoms or a fatal result.
Anaesthesia is always a dangerous condition, and requires the undivided
attention of an experienced assistant. Death has occurred not infre-
quently from etherization and often from chloroform anaesthesia.
The patient’s stomach should be empty, lest vomiting occur during or
after anaesthesia. Hence, he should fast for four or six hours prior to
etherization, and it is even better if no solid food has been taken since the
previous day. A hypodermic injection of morphia (gr. # to gr. 4) and
atropia (gr. Hºw to gr. ſº) should be administered about fifteen minutes
before inhalation is begun. This renders anaesthesia quieter, more rapid,
and more safe. It is not an absolute essential but is very judicious. All
clothing restricting deep inspiration must be removed or loosened. It is
important to insist upon women unfastening their corsets and the skirts
tied about the waist. Do not trust to the assertion that their clothes are
not tight. False teeth and pieces of tobacco must be removed from the
mouth, because of the danger of their falling backward into the fauces
and obstructing respiration. The patient is usually placed in the recum-
bent position, unless the operation is about the mouth or nose, when the
semi-recumbent posture is better, as it prevents the blood flowing back
into the pharynx. The semi-recumbent or sitting posture is not justifiable
during chloroform inhalation. In operations upon the nose and palate it
is often better to have the patient lying on his back with the head so bent
backward that the palate is lower than the floor of the mouth. Blood is
thus kept away from the site of operation and yet does not flow into the
larynx, causing choking and coughing. When these preliminaries have
been arranged the patient is shown how to inspire and expire deeply, and
is encouraged to do so for a few moments. I sometimes tranquillize my
patients and teach them to breathe properly by placing the dry towel
over the face for a few seconds before adding ether.
No inhaling apparatus is required. A cone of paper containing a
loosely folded towel is a very satisfactory contrivance; but a small napkin
or a handkerchief loosely folded and covered by a large towel so that the
ether vapor cannot escape is usually preferable. The outer towel should
cover the eyes of the patient, and no talking on the part of the bystanders
should be allowed until insensibility occurs. The senses of sight and
hearing should not be stimulated by any such disturbing influences. The
ether vapor must be given in a concentrated form, and from one to two
fluidounces should be poured on the napkin at first, that renewal may
not often be required. When inhalation has once fairly begun the ether
cloth should never be removed from the face, unless spasm of respiration
or actual vomiting necessitates its temporary withdrawal. It should be
held closely to the nose and mouth ; sufficient air will reach the lungs
through the meshes and folds of the towel. The patient becomes ex-
cited, the surgeon irritated, and the stage of etherization greatly pro-
longed by the etherizer allowing a large amount of air to mix with the
anaesthetic vapor. Frequently, indeed, I have seen the cloth taken
entirely away from the face while additional ether was being poured on
A N AEST H E SIA. 131
the napkin. This is mismanagement, for it allows the stage of excite-
ment to be prolonged, and condemns the patient to a protracted anaes-
thesia which increases the danger of subsequent bronchial irritation and
cardiac depression. If the room is kept quiet, the patient previously
taught how to breathe deeply, a full amount of ether poured on the towel,
the eyes of the patient covered, and no air admitted to the lungs except
that which passes through the towel, complete anaesthesia can be obtained
in from three to ten minutes in nearly every instance. It is not safe to
give chloroform in this manner.
During the entire period of etherization the administrator must care-
fully watch the respiration, color of skin, and pulse. The first two points
demand especial scrutiny, but the changes in cardiac force, which can be
most conveniently investigated at the temporal artery in front of the ear,
must not escape examination.
It occasionally happens that after a few inhalations have been taken a
spasm of respiration takes place, evinced by absence of inspiratory effort
and cyanosis of the face. This calls for the withdrawal of the ether for
a moment, when a deep inspiration occurs, and no further symptoms of
asphyxia are shown. If in the stage of excitation the patient struggles
and cries out, the ether cloth must be kept closely applied, because access
of air increases the excitement. The crying and shouting are desirable
at times, because by the deep inspirations necessitated inhalation is more
quickly accomplished. Retching as if vomiting was about to occur is an
indication to keep up the ether. During complete anaesthesia vomiting
does not take place. If, however, the stomach contents are regurgitated
upward into the pharynx and mouth, the ether must be stopped until the
fauces are cleared of materials that might pass into the larynx. The
suspension of inhalation should be as momentary as possible. Sometimes
the ether vapor causes an abundant secretion of bronchial mucus, which
collects in the larynx and fauces and causes impeded respiration. This
complication is met by clearing the throat with a finger introduced into
the mouth, or by turning the patient on his face for a moment with his
head hanging down over the edge of the operating-table.
When the conjunctiva is insensible to touch with the finger, the muscular
relaxation complete, and a tendency to stertorous breathing noticeable, the
time for operating has arrived. The ether may then be withdrawn or
only administered in sufficient quantities to keep up the anaesthetic state
without inducing a continuance of loud palatal and laryngeal stertor.
Stertorous respiration usually means that anaesthesia should not be pushed,
since the patient is then insensible to pain.
There is a primary anaesthesia lasting about a minute which is asso-
ciated with muscular relaxation and occurs soon after inhalation has
begun. This stage of etherization may be utilized for the performance
of such operations as opening abscesses and extracting teeth. The re-
covery from this anaesthetic condition is very prompt and unattended with
the nausea and other after-effects of prolonged etherization. This primary
anæsthesia or first insensibility of ether is not sufficient for other than
minor surgical operations. It resembles to my mind the analgesic effects
of rapid respiration, previously mentioned, more than true anaesthesia.
. In all administrations of ether it must be remembered that its vapor is
inflammable and so dense that it falls toward the floor; therefore all
candles or other lights should be placed at a distance from the patient
and at a higher level than the operating table.
hen patients regain consciousness after etherization they occasionally
132 PRACTICAL SURGERY AND AN AST H ESIA.
become very noisy and hysterical. The shouting can be stopped by pour-
ing a little water into the mouth every time the patient opens it to cry
out. This compels him to close his mouth to swallow. If the nostrils
are closed by one hand of the attendant while the other hand administers
frequent doses of water, the patient soon becomes too much occupied with
Swallowing and mouth breathing to think of making further outcry. If
dangerous symptoms, such as asphyxia, or cardiac failure, occur during
the administration of an anaesthetic the inhalation must at once be sus-
pended. If mucus or vomited matters produce interference with respira-
tion they must be promptly removed. Tracheotomy might be demanded
when ankylosis of the jaws or other causes interfered with proper clear-
ance of the larynx. Imperfect respiration may be due to an effect of the
ether on the nerve-centres. Pulling the tip of the tongue forward and
far out of the mouth often aids the respiratory function, but artificial
respiration and electrical stimulus may occasionally be required. In many
cases dashing cold water in the face, slapping the cheeks with a towel
dipped in water, or pouring a little ether upon the epigastrium is sufficient.
Pushing the lower jaw upward and forward has been recommended as a
valuable procedure.
Heart failure producing anaemia of the brain is combated by inversion
of the body, perfect muscular quiescence, and inhalations of nitrite of
amyl. In addition atropia, digitalis, and perhaps ammonia should be
given hypodermically in full doses to combat the toxic effects of ether.
Experimental investigation in physiological laboratories seems to prove
that alcohol is injudicious in the treatment of ether poisoning. It should,
therefore, not be given in such cases. If this experimental evidence is
accepted it is improper to administer alcohol before etherization to avert
shock. Quinine, atropia, digitalis, and morphia are preferable.
Persons addicted to alcoholic stimulation require more ether to induce
profound anaesthesia than temperate ones, because they have become
habituated to the effects of similar intoxicating agents. The administra-
tion of the anaesthetic must be cautious, because the viscera of drunkards
are frequently diseased.
It is unwise to etherize a patient without assistance, because dangerous
symptoms might arise from the anaesthetic or the operation, and the sur-
geon would be unable to give efficient aid alone. A woman should never
be etherized by a man unless a third person is present, since a charge of
criminal assault might be made because of erotic dreams during the
anaesthetic state.
C H A P T E R XI.
OPERATIVE SURGERY.
PREPARATION OF THE PATIENT AND THE SURGEON AND MODE OF
CONIDUCTING OPERATIONS.
THE preparatory treatment of persons about to undergo operations that
do not require immediate execution is important. Debilitated patients
should be built up by food and tonic regimen; those of an opposite con-
stitution may require more moderate diet than usual, purgation, and
some restriction as to stimulants.
Peculiarities of disposition and constitution should be studied by the
surgeon, since the existence of the hemorrhagic diathesis, a tendency to
delirium or any other marked habit of body might influence the choice
of methods of operating. Encouraging words are of great value in sus-
taining the spirits of timid patients. All patients, if placed in a hospital
or removed from their homes, should ordinarily be allowed a day's delay
in order to become accustomed to strange surroundings, nurses, beds, etc.
If restraint of a limb in one position is essential to the success of an
operation, it is well to keep the limb in that abnormal posture for a day
or two that the weariness so caused may pass away. Menstruation if
normal does not seem much of a contra-indication to operation, though
the time between the periods should ordinarily be selected. Pregnancy
is usually a proper cause of delay in operations of expediency. The
seat of operation must always be rendered aseptic by shaving, so as to
remove the fine hairs which may retain dust and germs, and by subsequent
thorough scrubbing of the skin with soap and water. A second washing
with a sublimate solution (1 : 1000) is then proper. Before serious ope-
rations the patient should, if possible, be given in addition a full bath
the evening previous. This is to avoid septic contamination from bac-
teria on the skin. The umbilicus and the folds of the skin about the
groins, axillae, and toes are especially apt to be overlooked in these
cleansing processes. The secretions, epidermis, and dirt retained there
are full of bacteria, as are the spaces underneath the nails of the patient
as well as of the surgeon.
A good light and a bright, cheerful day are important factors in se-
Quring the best conditions for operative surgery. A patient should never
be kept waiting by the surgeon after the appointed hour. Anxiety and
suspense induce nervousness. I always endeavor to arrive before the
time agreed upon so as to anticipate the worrying period.
It becomes mecessary at this point to enter with more detail into the
matter of asepsis and antisepsis. -
By asepsis is meant absence of all vegetable parasites or microörganisms.
The word, therefore, is employed to signify that the surgeon has used
*Very effort to prevent the presence of any such organisms in the wound;
and implies, therefore, the absence of such parasites from the surgeon's
134 O P E R A TIVE SU R G E R Y.
hands, from the instruments used, from the dressings applied and from
the surroundings. Asepsis then, or aseptic surgery, means that the pro-
cedure is germ free.
By antisepsis is meant that the manipulations are directed toward the
destruction of all microörganisms which may be present. In the one
case the endeavor is to obtain perfect freedom from pathogenic organisms;
in the other case it is to destroy any pathogenic organisms which may be
present in the wound, upon the hands of the surgeon, or upon the dress-
ings. If absolute asepsis could always be assured, antisepsis would be
unnecessary. It is because there are so many sources by which bacteria
may get into a wound, even when done under the supervision of the most
careful surgeon, that many of us prefer to use antiseptic precautions in
addition to cleansing the skin of the patient, scrubbing the surgeon's
hands, and sterilizing the instruments and sponges.
In some cases the use of chemical agents may be deleterious because
they act upon the patient's tissues in such a way as to produce irritation ;
at least, such is the case when they are applied in sufficient strength to
render their antiseptic properties valuable. For example, an ordinary
solution of carbolic acid or corrosive sublimate can never be put into the
peritoneal cavity without danger. It is also possible that frequent wash-
ing of recent wounds with such solutions irritates the tissues and leads to
greater exudation of serum after the lips of the wound have been ap-
proximated than would be the case if the wound was not subjected to
such irritation.
As has been said in an earlier chapter, heat is the most perfect destroyer
of vegetable fungi; therefore, instruments, sponges and dressings, which
have been sufficiently heated are free from germs. If the instruments
and sponges are kept in the water in which they have been boiled they
can be used with impunity, provided that dust is prevented from falling
into the receptacle. Such sterilized, or aseptic, water is far less irritating
than water containing chemical antiseptics.
The antiseptic solution most often used for washing the skin of the
patient and for scrubbing the surgeon's hands is water containing corrosive
sublimate in the proportion of 1:1000 or 1: 2000. This solution, how-
ever, is too strong to be used for irrigating cavities, because if any portion
of the fluid should remain, as it often will do, there is great danger of
producing corrosive sublimate poisoning. This is evidenced by the
occurrence of vomiting and bloody stools. Betanaphthol (1:2500) is
preferable for washing out such cavities because it is a non-poisonous
agent. Betanaphthol, however, is not as powerful a parasiticide as cor-
rosive sublimate. Boiled water, or steam which has been condensed in
clean receptacles, should be used for abdominal operations.
Sublimate solution should never be used to sterilize instruments, because
it tarnishes the steel and dulls the edges of cutting instruments. For
such purposes a betanaphthol solution or a solution of carbolic acid
(1: 40) should be employed. If the surgeon prefers he may boil his in-
struments and let them stand in the water until it has sufficiently cooled
to allow him to put his hands in it or until he is ready for their use. The
vessels should be protected from atmospheric dust by covers. I, myself,
prefer betanaphthol solution, as a rule, for instruments, because it does
not irritate the skin of the surgeon's hands as do corrosive sublimate and
carbolic acid, and because it is safer than boiled water as it is antiseptic
instead of merely aseptic. The sterilization of instruments by baking in
copper boxes has already been described.
PR E P A R A TI O N OF T H E P A TI E N T . 135
When an operation is to be performed the instruments required should
previously be put in trays containing sterilized water or antiseptic solu-
tion, and these trays should be set upon a table without being seen by the
family or patient. All sponges, sutures and dressings must be sterile.
The patient's skin must be made aseptic by thorough cleansing, the
surgeon's finger-nails cleaned and his hands and arms scrubbed with soap
and made free from possible pathogenic germs, his clothing covered with
a clean operating apron, and his sleeves rolled up to the elbow; just before
operating his hands should be dipped in a sublimate solution (1:1000)
for a couple of minutes and the patient's skin washed with a similar
solution. Every assistant should know his duty and attend to it alone.
And no loud talking or unseemly jesting should be permitted. The
assistants whose hands are to touch sponges, instruments, and the wound
must be as aseptic as the surgeon. No one else should be allowed to
handle anything. Nothing, unless it is germ free, is permitted to come
into contact with the incised tissues. An instrument which has dropped
upon the floor or touched the bed clothes must be rejected until again
sterilized. The surgeon must touch nothing that is not sterile, unless he
sterilizes his hands again with an antiseptic solution or washes them in
sterilized water before approaching the wound. He dare not put his
hands into his pocket or scratch his head or face without endangering
the patient's life by the possible conveyance of a single bacterium into the
wound. It is, therefore, well to surround the seat of operation with steril-
ized towels laid over the clothing or bed coverings. These may be baked
towels or towels soaked in sublimate solution and dried. A table or firm
bed is preferable to a reclining chair because more steady, and not so
easily disarranged by struggles during etherization. The patient's body
and limbs should be covered and not exposed to the chilling influence of
the air.
A skilful surgeon usually has the whole plan of the operation clear in
his mind before starting, and proceeds to its completion by successive
steps with confidence and without hurry. Where uncertainty of diagnosis
exists, the plan of procedure may require modification as the condition is
revealed ; but this is very different from the vacillating course of the man
who undertakes an operation without knowing exactly what he expects to
do and constantly appeals to the surgical spectators for suggestions.
The occurrence of hemorrhage should be precluded by the use of the
Esmarch elastic bandage, or by acupressure or digital pressure to the
main arterial trunk. Much of the depression formerly attributed to
shock was really due to hemorrhage occurring after injury or during
operation. The surgeon should not, however, stop in operations to ligate
the numerous little branches that bleed; for many of them will cease
Spontaneously, and others can be controlled by hemostatic forceps, applied
by the assistants, until the operation is completed. Then ligatures can
be used. In operations about the face it is especially noticeable that
Small vessels spurt very vigorously for a moment or so, but soon stop with-
out ligation.
In major operations, as for the removal of tumors for example, the
most difficult points should be attacked first. Let the operator get under
the mass, if it be a tumor, as soon as he has made his cutaneous incision.
Then he knows what he has to meet, and having controlled the sources of
hemorrhage and mastered the grave complications, he can dextrously and
With facility complete the work of removal.
136 O P E R A TI W E S U R G E R Y .
The principles or fundamental laws of operative surgery are:
1. Obtain the services of an etherizer who will not require you to super-
intend the anaesthetic.
2. Take precautions to prevent hemorrhage, if the locality renders this
possible.
3. After proper thought and consultation have the plan of operation
clearly outlined in your own mind.
4. Have the patient, the instruments, yourself and your assistants abso-
lutely aseptic.
5. Proceed systematically with the steps of the operation decided upon,
and do not be led into a mixed operation by bystanders, unless unexpected
developments in diagnosis occur.
6. Attack the greatest difficulties and dangers of the operation first.
7. Do not stop to tie any except large vessels, but let assistants apply
hemostatic forceps, or make pressure with their fingers until incisions are
completed.
8. When the operation is finished, stop hemorrhage and apply dressings.
9. Finally, remember that suppuration in an operation wound is
usually, probably always, due to careless asepsis on the part of the sur-
geon or his assistants, except in those instances where the operation is
done on tissues already suppurating.
CONTROL OF HEMORRHAGE.
The prevention and management of hemorrhage during operations will
be considered in the chapter on Diseases and Injuries of Bloodvessels.
SUTURES.
When a wound has a tendency to gape, and there is a probability that
union by first intention can be secured by correct apposition of the edges,
sutures are employed. They should not be used in contused and lacer-
ated wounds, if tension is induced by adjusting the parts, or if the wound
is not perfectly aseptic, and there is danger of preventing thereby the
free escape of serum and pus.
The suturing materials most commonly used at the present time are
catgut and silk. Occasionally wire or wormgut sutures are employed. It
goes without saying that these sutures must be rendered aseptic, in order
that they may not induce suppuration or other pathological conditions
in the tissues into which they are inserted. Wire and silk sutures are
rendered aseptic by baking, or by soaking in a strong antiseptic solution.
Catgut is prepared and then kept in an antiseptic Solution until it is used.
I, myself, prefer catgut kept in alcohol, because the oily menstrua in
which it is sometimes preserved make it disagreeable to handle. Anti-
septic catgut and silk sutures and wire for suturing can be obtained from
the instrument-makers. Surgeons often prepare the catgut sutures and
ligatures themselves, by purchasing violin strings and rendering them
antiseptic by some such formula as the following: Soak the catgut violin
strings in oil of juniper wood for forty-eight hours, in order to remove the
fat; then wash in alcohol, and store in fresh alcohol until required for
use. It is best to thread the needles, which should be aseptic, before they
and the gut are put in the antiseptic trays used at the operation; because
the catgut, when taken from the alcohol, is somewhat stiff and shrunken,
but when put in water becomes swollen and cannot, therefore, be threaded
SU TU H. E. S. 137
through needles with ordinary eyes. Such catgut sutures will become
absorbed by the tissues in which they are placed in from five to ten days,
varying according to the thickness of the thread. If it is desired to pre-
vent the absorption of the sutures at such an early period—as happens, for
example, when tendons or bones have been sutured—it is proper to use
chromicized gut. This is catgut rendered less absorbable than ordinary
antiseptic gut by the addition of chromic acid to the Solution in which it
is prepared. To chromicize catgut the following formula is a good one :
After having soaked the gut in oil of juniper wood for forty-eight hours,
wash it in alcohol and let it soak for forty-eight hours in a solution pre-
pared according to the following formula: Carbolic acid, 1 part ;
chromic acid, gºt part; water, 20 parts; catgut, 1 part. After standing
in this solution forty-eight hours the sutures should be washed in alcohol,
and then preserved in fresh alcohol. Sutures, or ligatures, prepared in
this way will be absorbed in from ten to thirty days, according to the
thickness of the thread. The thicker the thread the longer the time
required for absorption.
Since they are not absorbed in the tissues for many days, chromicized
catgut sutures can often be used with advantage where wire sutures were
formerly and are often still used. The advantage of catgut sutures,
whether chromicized or not, is that the surgeon does not have to withdraw
them after union has taken place, as is the case when wire sutures are
used. Silk sutures are often cut and withdrawn by the surgeon, although
they need not be when buried in the tissues, for they become encysted or
absorbed. Sutures of silk upon the surface are, however, always with-
drawn.
The forms of sutures usually employed are the interrupted, the con-
tinuous, and the twisted or pin suture. The quill suture is deservedly
nearly obsolete. The interrupted suture is made by carrying with a
needle a catgut, silk, wire, or wormgut thread across the wound, cutting
it off and fastening the two ends by tying, twisting or clamping with per-
forated shot. This is repeated at intervals along the wound. The twisted,
or pin suture, is made by thrusting a steel pin through the lips of the
Wound, which are then held in apposition by a silk or catgut thread
wrapped around the ends of the pin and across the surface of the wound.
The pin is left in position until union has occurred. The thread may be
twisted about the pin in an elliptical or figure 8 manner, or a rubber band
may be employed in its stead.
FIG. 43. FIG. 44.
º
;Ss
Granny knot, which is never used in Flat or reef knot. (J. D. BRYANT.)
Surgery. (J. D. BRYANT.)
Interrupted sutures are best made with catgut, silk or flexible iron-wire
and a straight needle. Occasionally a curved needle may be preferable.






138 O P E R A TI W E S U R G E R Y.
In linear wounds the first suture should be inserted across the middle ; in
irregular wounds the projecting points had better be approximated first.
The needle should puncture the skin not nearer than about one-eighth to
half of an inch from the margin of the wound, and be carried deeply
enough to bring the entire depth of the wound-surfaces together.
First tie of surgeon’s or friction knot. The second tie is like that of the
flat knot. (J. D. BRYANT.)
The ends of the suture should be fastened at one side of the wound by
a flat or reef knot if silk is used, by a surgical knot if gut is employed, by
twisting the ends or clamping them with shot if wire is employed.
Sutures should be placed at intervals of one-fourth or one-half inch, and
should never be applied tightly, since mere apposition of the edges is all
that is required and swelling will probably increase
FIG. 46. the tension. Sutures would be unnecessary if there
º was in wounds no gaping, or tendency to motion
from muscular movements. A sufficient number of
sutures should be inserted to avoid gaping between
them. This is better than placing them far apart
and using adhesive plaster in the intervals, since
adhesive can scarcely ever be sterile. It is a useless
and dangerous agent in the treatment of wounds.
Three to six days is long enough, as a rule, for
sutures to remain, though in deep wounds and in
positions where strain is liable to occur, the sutures,
if of wire, may remain almost indefinitely. When
Interrupted suture of Stitches are to be removed the wire should be cut
silk, showing the lower close to the knot or twist, the long end bent over to
stitch too tightly tied, the other puncture and the wire drawn through the
(STEPHEN SMITH.) tissues in a curved direction by means of a forceps
grasping the knot. If this is not done, a little hook
of wire is left when the suture is cut, and pain is caused by drawing this
through the tissues. Catgut sutures need not be removed, because the
portion of the loop buried in the tissues is absorbed and the external
portion finally falls away from the skin. Chromicized catgut requires
from ten to thirty days to be absorbed; ordinary antiseptic catgut is
absorbed in from five to ten days. The time in each instance depends
largely on the thickness of the thread of gut. Silk sutures may be cut
and withdrawn, or, if entirely buried, may be allowed to remain in the
tissues; when they are either absorbed as are buried gut sutures or they
become encysted. These processes only occur perfectly when the sutures
and wound are free from germs.
The twisted, pin, or hare-lip suture is especially serviceable when the
wound is situated in movable tissues, as about the face, and additional
support is desirable, and also where considerable hemorrhage is taking


SUT U R E S. 139
place from the wound. The pins must be inserted rather deeply, carried
transversely across the wound and brought out through the opposite edge
of skin. The thread must not be applied too tightly. The sharp point
of the pin is then cut off or guarded by a piece of cork. After three or
four days, when union has occurred, the head of the pin is seized with
forceps, the pin rotated and gently withdrawn. The thread is often left
in place to afford support until it falls off under desiccating influences
about the wound. A combination of the interrupted and twisted suture
is sometimes judicious in wounds requiring support and accurate adjust-
ment.
FIG. 47.
2.2322222° 22′2.2×zz * * **, *, *, ºr
2. % gº * ar º, a *.*.*
** 3% ź º 2%, 3. ****
% %
3%, ’2 22.2%
2 A.
...????
22*2%’.
2 ºz. ..." ... . “. .2:
* - º,” • . . . 4 *
- *. • . . . . 2, . & 4 , , , , -"
* ... . “. ..…..'.2.2%'.2.2.2%.2%.
Twisted or pin suture. (WYETH.)
Continuous differ from interrupted sutures in that the first stitch is taken
near the end of the wound and the thread carried through the tissues
FIG. 48. FIG. 49.
Continuous suture. (ESMARCH.)
from side to side without being
cut off and tied every time it
crosses the wound. This form
of suturing is used a good deal
more now than in the days
When suppuration of wounds
almost constantly occurred. At
that time and under those cir-
cumstances the interrupted su-
ture was convenient because
One stitch could be removed
for the evacuation of any pus
which formed at the bottom }
of the wound cavity. Now that Showing beginning and final knot of continued
We have little fear of suppu- suture.
ration occurring the continuous
suture is preferable in many instances, because it is much more rapidly
*pplied than the interrupted and because it brings the edges of the wound








140 O P E R A TIW E S U R G E R Y.
into neater apposition. When the continuous suture is begun the end of
the thread of gut is tied to the main portion of the thread after the needle
has drawn it through the second puncture. The needle then carries the
thread across the wound and through the tissues in the way shown by the
illustration. The suture is ended, at the other extremity of the wound,
by tying the end of the thread and the loop made by leaving the thread
long in the stitch next to the last. This method is shown in the diagram.
Buried sutures are stitches which are used to bring together tissues at
the bottom of a wound, and which are subsequently entirely covered up
by more superficial layers of muscle or fascia, or by skin. In closing
large and deep wounds extending through different planes of muscle the
surgeon should suture each layer of muscle and each layer of fascia step
by step from the bottom to the surface. This hastens union, prevents the
formation of pockets or cavities in which blood or wound secretions might
collect, and restores most effectually the normal integrity of the parts.
Divided nerve-trunks should be united by these buried sutures, severed
tendons accurately approximated and muscular masses and fascial sheaths
carefully reconstructed. Perfect asepticism is essential for success; cat-
gut or silk sutures are to be employed for these purposes. In suturing
tendons chromicized gut should be used, because ordinary gut is apt to
be absorbed before the tendons unite, and because the strain upon the
suture is often considerable. In all these instances the sutures are cut off
close to the knots and are allowed to become absorbed or encysted. The
peculiar method of passing the suture shown in the illustration is the best
for tendons; other structures may be united by the interrupted or con-
tinuous suture as seems best to the operator. t
Diagram of suture of tendon. (ESMARCH.)
The peculiar devices used for Suturing intestinal wounds will be de-
scribed under Surgery of the Abdomen.
DRESSINGs.
The dressing which practically is used for all wounds, whether opera-
tive or accidental, is gauze. This gauze is what is technically called
in trade circles cheese-cloth or butter-cloth. It is a loose cotton mate-
rial with open meshes and readily absorbs fluids. It can be bought
from dealers in surgical supplies, either plain or impregnated with cor-
rosive sublimate or betanaphthol in varying proportions, and is, in the
latter case, properly called antiseptic gauze. Plain gauze is supposed
to be perfectly free from germs, which, of course, it never is, unless
previously subjected to high heat and kept in cans tightly sealed. Cheese-
cloth can also be readily bought at dry goods stores, and after it has
been washed in hot water containing a little soda and dried, it becomes
a very cheap and effective dressing. This the surgeon must make aseptic
for himself, by baking it in an oven and keeping it free from the slightest

D R E S SIN G. S. 141
possible contamination with dust, or antiseptic by saturating it with a
ermicide Solution.
When the wounds are open and the gauze dressing comes in actual
contact with the wound surface the secretions on drying glue it to the
wound. A great deal of pain is therefore given to the patient upon the
removal of such a dressing, unless it has been carefully soaked for some
time with water, which must be sterilized to prevent infection. It is
well, therefore, to cover open wounds with a piece of thin rubber tissue or
oiled silk “protective” before applying the gauze dressing. If rubber
tissue is used it should be cut full of slits or small holes with a pair of
scissors, in order that the secretions from the wound may escape into the
gauze and not macerate the tissues lying under the rubber, film. Evap-
oration and percolation are more free through the oiled silk, which goes
by the name of “protective,” than through rubber tissue, hence the
former does not, as a rule, need to be perforated. If a wound has unfor-
tunately become the seat of profuse suppuration the gauze will not adhere
even when placed in direct contact with it. In wounds the edges of
which are brought into actual contact by sutures there is no occasion for
using “protective” under the gauze; the gauze may then be laid directly
upon the wound itself. It must be understood, of course, that this
rubber film or oiled silk must be thoroughly cleansed and rendered aseptic
or antiseptic before being applied to the wound. It is perhaps unneces-
sary to say that all drainage-tubes, whether of rubber or of glass, must
in a similar manner be rendered aseptic or antiseptic before use.
When a wound is dressed a large mass of gauze consisting of from four
to twenty layers, varying with the degree of serous effusion which the sur-
geon presumes will escape from the wound, must be firmly and evenly
bandaged over the injured surface. It is absolutely necessary that the
margin of the dressing should extend a considerable distance beyond the
limits of the wound, in order that the wound secretions may not, by trav-
elling between the skin and dressing, get beyond the edge of the latter
and become infected with bacteria from the air, clothing or bandages
before the surgeon repeats his visit. In such an event the organisms will
develop in the bandages or portion of clothing soiled with the discharge
and cause putrefaction and suppuration; the infection will continue
along the path of serum made under or in the gauze, and finally enter
the wound. It is important, therefore, that no such entrance shall be
made through or under the dressing by such a track of albuminous
fluid extending to infected objects outside. The bloody serous trans-
udate, which takes place from the wound, usually occurs within the first
few hours. It is, therefore, wise to change the dressing of large wounds
and of wounds where there has been a great deal of secretion, within the
first twenty-four hours, because of the possibility of such fluids reaching
the surface at some part of the dressing not easily examined by the sur-
geon. This second dressing will cause no annoyance or harm if it is done
With the same attention to antiseptic precautions as is given to the first
dressing. The hands of the surgeon and all instruments and dressings
must be as carefully free from germs as at the time of the operation.
After the second dressing no change is required until the fluid soaks
through the gauze in the course of several days, or until pain in the
Wound or a marked rise in the temperature of the patient shows that
Some complication has arisen, and that the wound is not doing well. The
drainage-tubes may often be removed at the time of the second dressing,
unless suppuration has occurred, which condition, however, we do not
142 O P E R A TI W E S U R G E R Y .
look for in aseptic wounds. If suppuration from any cause does exist
in a wound tubes will be required, to give free vent to the pus.
In small wounds where there is but little effusion a single dressing is
often sufficient, and by the second or third day the wound will frequently
be found cicatrized. This sometimes occurs at the second dressing of
quite large wounds when that dressing is not made for two or three
weeks.
In my opinion the gauze should always be applied dry, because bacteria
are much less liable to multiply in dry situations than in wet ones; hence
a wet dressing seems to me to increase the possibility of microbic infec-
tion, even when these dressings have been moistened with antiseptic solu-
tions. I prefer gauze which has been made aseptic by baking, applied
dry, or gauze which has been impregnated with sublimate solution and
subsequently dried. Gauze which has been sterilized by baking is not
very absorbent. A small amount of glycerine sprinkled upon it before
it is baked makes it absorb fluids much more efficiently.
When there is no wound and a poultice is desired to relieve pain it
should be made of aseptic or antiseptic gauze, covered with oiled silk or
rubber cloth to prevent evaporation. Poultices of flaxseed and similar
material, are seldom used or desirable.
In some small incised wounds a dressing of collodion and iodoform, or
collodion and boric acid may be used instead of a gauze dressing; for
example, after the removal of a small tumor of the face a little collodion
mixed with iodoform may be painted over the edges of the wound in such
a way as to make an impervious varnish, which keeps the wound free
from germs. Sometimes this collodion dressing can be made a little
stronger by laying a small portion of aseptic absorbent cotton upon the
wound and saturating it with collodion and iodoform or with collodion
alone. Boric acid or corrosive sublimate would probably answer as well
as iodoform to mix with the collodion and would be less obnoxious in odor.
The mixture is painted upon the part after the catgut sutures have been
used. If corrosive sublimate is selected, not more than an eighth or a
quarter of a grain should be mixed with a fluidounce of collodion.
BANDAGES.
Roller bandages are used by the surgeon for the purpose of retaining
dressings in position, making pressure, and restraining motion. A bandage
is a strip of muslin, linen, or flannel, varying in width from one-half inch
to two or three inches and in length from three to ten yards. It is ap-
plied smoothly to the surface by circular, spiral, and reverse turns, and
should always make equable pressure and be firmly enough applied to
its place during the ordinary movements allowed the patient.
When a considerable amount of elastic pressure is required for pro-
moting absorption, as in treating diseased joints and chronic ulcers, a
bandage made of pure rubber is invaluable, though a flannel bandage
will in some degree effect the purpose.
The Esmarch apparatus, which consists of a rubber bandage for expel-
ling blood from a limb and a rubber tourniquet for preventing its return
during the time of operation, will be discussed under Diseases and In-
juries of Blood vessels, where hemorrhage is considered.
A B S T R A CT I O N OF B L O O D. 143
COUNTER-IRRITATION.
When a mild form of counter-irritation is wanted, mustard plasters,
tincture of iodine, water of ammonia, and similar agents, or dry cups, are
applied to the skin; if vesication or blistering is desirable, cantharidal
collodion, cantharidal citrate, or an iron disk heated by immersion in hot
water is employed. More powerful revulsive agents are setons, caustic
potassa, and the red-hot iron. The best form of actual cautery is the
thermo-Cautery of Paquelin, which consists of a double metal tube with
a hollow platinum end through which a current of benzole vapor is blown
by compressing a rubber bulb. If the platinum portion is first moder-
ately heated in a lamp, it can be raised to and maintained at a red or
white heat by keeping a constant current of benzole vapor circulating
within it.
Paquelin’s thermo-cautery.
This is an exceedingly convenient and manageable instrument. Ordi-
nary cautery or soldering irons, heated in a furnace, answer the same
purpose. The electro-cautery is usually inconvenient for the surgeon's
use. The pain felt from the cauterization after the patient recovers from
anaesthesia can be averted by painting the burned surfaces with undiluted
carbolic acid before sensibility is regained.
Counter-irritation is sometimes obtained by thrusting needles into the
tissues—a method termed acupuncture. The needles may be arranged in
* bundle and propelled by a spring, or may be introduced singly by the
fingers of the surgeon. Additional irritation is induced, when necessary,
by dipping the points in croton oil. $:
ABSTRACTION OF BLOOD.
Local abstraction of blood by leeches has been superseded, to a great
$ºtent, by multiple punctures and scarifications with a sharp knife and
by wet cupping. In both cases the flow of blood is encouraged by affu-

144 O P E R A T L V E S U R G E R Y .
sions of hot water. General bloodletting is accomplished by opening a
vein, usually at the bend of the elbow, or, when a sudden and powerful
impression is required, by incising the temporal or radial artery.
When venesection from the arm is to be performed, a bandage is tied
around the arm above the elbow, sufficiently tight to prevent the
venous return but not firm enough to prevent the downward arterial
flow. The veins then become distended. The arm must next be made
aseptic, after which the operator, selecting the median cephalic vein be-
cause it is not in close relation with the brachial artery, steadies it with
the thumb and forefinger of his left hand, and makes an oblique incision
into it by transfixing it with the point of a bistoury. The incision must
be a free one to allow the blood to escape in a jet. If the median cephalic
vein is not large enough to give a good flow, the median basilic or any
one that is prominent may be selected. It must be remembered that the
brachial artery lies under the median basilic vein; but if the vein is
transfixed laterally with the point of a knife and the incision made from
within outward, there is no danger of wounding the artery. The old-
fashioned spring lancet is much more dangerous, and is inferior to an
ordinary bistoury for such an operation. The vein can be nicely steadied
for the incision by passing a small acupressure or harelip pin through the
skin and underneath the vessel. This is better than attempting to pre-
vent its slipping away from the bistoury by means of the fingers.
Phlebotomy should be done when the patient is in the semi-recumbent
position. Removal of the bandage around the arm will stop the flow of
blood, after which an antiseptic pad is placed over the wound and the
limb kept comparatively quiet for a day or two. *
Arteriotomy is performed by merely cutting down upon the pulsating
vessel and making an oblique or transverse incision into its wall. When
the amount of bleeding is satisfactory, the vessel should be completely
divided and pressure applied; or ligatures may be put upon the ends of
the artery.
ASPIRATION AND TAPPING.
Aspiration is the evacuation of fluids by means of a vacuum connected
with a hollow needle or a canula, and is advantageous because it prevents
the admission of air to the cavity from which the fluid is taken. Hence
septic changes are avoided. The aspirator, as perfected by Potain, con-
sists essentially of a reservoir which is connected with an exhausting
pump and from which a tube passes to be connected with a hollow needle
or a canula and trocar. Stop-cocks are provided to prevent the admis-
sion of air to the tubes and reservoir or to the cavity to be tapped.
When an abscess or serous collection is to be aspirated, a vacuum is
created in the reservoir with the air-pump, and the needle introduced
into the tissues. The vacuum chamber is then connected with the needle
by turning a stop cock, and as soon as the point of the needle enters the
cavity atmospheric pressure forces the fluid into the chamber.
When an aspirator is not at hand, or when it is desirable to have less
pressure than that induced by a vacuum, the principle of the siphon may
be utilized by attaching a long tube to a trocar or hollow needle and
carrying the end below the level of the patient.
The hypodermatic syringe answers admirably for aspirating small cysts
and abscesses, and is also of great value in determining the character of
obscure swellings. The grooved exploring needle, so frequently used, is
<º
A SPI R A TI O N A N ID TA PPI N G . 145
far inferior to the hollow needle and syringe, and is never used by me for
diagnostic purposes. Motion of the end of the hypodermic needle will
often disclose a cavity, even if the contents are too viscid to escape through
the orifice into the glass barrel of the hypodermic syringe.
FIG. 52.
gººse 2 ºº
& Y. º N
M3
M3
§
§
&N
§
§
W
w Öğ
º §
#! 3
º W3
fl §
- §
§ &
&
Aspirator.
When the entrance of air into the cavity to be evacuated is considered
unimportant a trocar and canula are employed. In using a trocar the
surgeon should make the parts tense by pressure with the fingers of the
left hand, select a point free from veins or arteries and plunge the trocar
and its surrounding canula through the skin with a sudden rotary
thrust. As long as fluid flows freely enough to fill the entire calibre of
the canula no air will enter. Such a free flow can be kept up until the
. is nearly empty if pressure is made upon its walls by the surgeon's
ngers.
In many instances open aseptic incision is preferable to either aspira-
tion or tapping, which are too often the resources of a timid and dilatory
Surgery. They have, however, a legitimate field.
10


C H A P T E R X II.
PLASTIC OR REPARATIVE SURGERY.
UNDER the term plastic surgery are grouped those operations which
have for their object the construction of absent parts, usually from the
patient's own tissues, and the reposition or curtailment of parts displaced
or deformed by accident or disease. -
The word plasty is often used with a prefix to indicate the organ
formed; thus, rhinoplasty means the reconstruction of a nose, cheilo-
plasty the formation of a lip.
Plastic surgery is called into play to overcome both congenital and
acquired defects and deformities. Its objects, therefore, may be stated to
be : To correct deformity due to imperfect foetal development, as harelip
and cleft palate; to replace parts lost or deformed by injury or ulcera-
tion, as in closing fistules or clefts, and reconstructing destroyed noses or
lips; to relieve or prevent distortion from cicatricial contraction, as after
burns and cervical abscesses and the removal of tumors requiring abla-
tion of a large amount of integument; and to curtail organs rendered
unseemly by abnormal growth, as in greatly hypertrophied nose or
tongue, and in large and protruding ears.
The structures used in constructive operations are especially skin and
subcutaneous cellular tissue, though mucous membrane, which becomes
somewhat like skin when removed to the external surface, muscle, peri-
osteum, and even bone, are at times successfully utilized.
The steps of a plastic operation are to be followed in regular succession
and the plan of procedure should be clearly fixed in the operator's mind
before he makes the first incision.
The patient must be in good health, so as to be less likely to have
erysipelas or ulcerative action attack the wounds made. When parts
destroyed by syphilis are about to be reconstructed, it must be ascer-
tained that no syphilitic manifestations have occurred for several months,
since a recurrence of specific ulceration would destroy the success of the
plastic operation and perhaps render future measures impossible. The
operation should be rigidly aseptic.
The successive steps are: Freshening the edges of the vacuity to be filled
and obtaining one or more flaps if such are required; arresting all
bleeding, since clots between the raw surfaces may prevent union by first
intention; adjusting the parts in proper relation without tension and
retaining them in apposition by sutures; closing the gap left by removal
of the flaps, if such have been employed; dressing all the wounds anti-
septically or aseptically, and preventing motion and frequent handling of
the parts.
In complicated reparative procedures it is often necessary to accom-
plish the desired end by a series of operations, each one of which effects
a result which affords a basis for subsequent measures. The time between
any two operations may be weeks or months, for the secondary operation
should not be undertaken until cicatrization and shrinkage have fully
determined the condition gained by the primary one.
M ET H O D S U S E D IN PLA STI C S U R G E R Y . 147
Sutures of catgut, plain or chromicized, of silk, and of wire are used
according to the length of time their sustaining power is needed. In
applying the sutures, doubling in of the edges of the flaps can be pre-
vented by introducing the needle obliquely, so that the punctures on the
inner surface are further from the margin than the external punctures.
This causes the apposed sides to pout out a little at first, but the protru-
sion disappears with cicatrization ; if not, it can be pared away subse-
quently. A few deeply placed sustaining sutures may be advantageous
in maintaining approximation when the plastic operation requires the
union of large surfaces extending inward to a considerable depth, or
buried sutures may be employed. The strain is thus taken from the
superficial sutures, and rapid union of all portions of the wound is
encouraged. Sometimes the support given by the pin suture makes it
preferable to the interrupted or continuous sutures. Silk or gut sutures
are sometimes employed between metallic ones to make very accurate
apposition of thin edges. Their early removal or absorption, before it is
safe to take out the deeper metallic sutures is not disadvantageous.
The tongue-and-groove sutures of Dr. Joseph Pancoast is often a very
excellent method of maintaining apposition in rhinoplasty and operations
for exstrophy of the bladder. It consists in
slipping the flap margin, which has been FIG. 53.
bevelled, into a groove made by dissecting up
the edge of skin surrounding the raw surface
to be covered.
Four raw surfaces are thus apposed. Wire
or silk sutures are then applied, as shown in
the diagram, and fastened over a perforated **
disk or a pad. It is easy to adjust the sutures Diagram of tongue and groove
by having both ends armed with needles. suture.
The gap left by the removal of the flap in
plastic operations should be closed, if possible, by drawing the integument
together, or by inserting a flap taken from the neighboring skin if it can
be obtained from a site which will put the cicatricial tension in a less
objectionable locality. If neither means is applicable provision should
be made for healing by granulation. Often the tissue dissected away
to make a raw surface for adhesion of the flap can be utilized for closing
the hiatus left by the elevation of that flap.
The various plastic procedures are included in the three methods of
Operating which I shall term respectively the methods by displacement,
by interpolation, and by retrenchment. Under the displacement method
are included operations done by simple approximation and by sliding;
under the method of interpolation are classed procedures accomplished
by transference and by transplantation.
The relations and characteristics of these modes of operating will be
Seen by the schedule.
Methods used in Plastic Surgery.
Disrºacúſūnt—stretching or sliding of tissues.
1. Sºmple approvination after freshening the edges, as in harelip, vesico-vaginal fistule,
Y and notches caused by tearing out ear-rings.
II. Sliding into position after transferring tension to adjoining localitics, as in V-shaped
incision for ectropium and cicatricial contraction of joints after burns, and in
linear incisions to allow stretching of skin to cover large wounds and to relax
contracted parts.

148 P L A. STIC O R. R. E. P. A. R. A.T. I W E S U R G E R Y .
INTERPOLATION.—borrowing material from adjacent regions, from a limb, or from another
person.
I. Transferring ſlap with a pedicle."
A. Putting in place at once.
1. By rotating flap on the pedicle in its own plane through one-ſourth or
one-half a circle, as in making upper eyelid or nose from ſorehead.
2. By twisting flap on its pedicle, as in making side of nose from lip.
3. By everting flap entirely so that raw surface is uppermost, as in covering
exstrophy of bladder by a scrotal flap.
4. Superimposing one flap on another which has been everted. This is done
where a thick wall is desirable, as in closing the front of an exstrophy
of the bladder.
5. By jumping, or carrying flap across a bridge of skim, and fixing only its
end to the part to be repaired. When the flap has become attached the
pedicle is severed. This manoeuvre is rarely employed.
B. Putting in place gradually by successive migrations, by same manoeuvres as
when the flap is placed at once in its permanent position.
This method is not very commonly needed, but may be valuable whem
there is nothing but cicatricial material in the immediate vicinity of the
part to be repaired.
II, Transplanting without a pedicle.
a. By carefully suturing or fixing in the gap areas of tissue recently dissected
from distant regions, or taken from the lower animals; such as re-
placing the bone button after trephining, inserting portions of merve-
trunks in wounded nerves, etc.
b. By skin-grafting with small pieces or large shavings of skin. This is
the manoeuvre of this class that has been followed by the greatest
success. As it lessens cicatricial contraction it may be advantageously
used at times in plastic operations that necessarily leave surfaces to heal
by granulation. Skin from the frog's abdomen may answer well.
c. By readjusting finger-tips, ears, and noses recently completely severed by
injuries.
RETRENCHMENT—removing superfluous material and causing cicatricial contraction.
I. By cutting out elliptical or semi-elliptical pieces of tissue, as in ptosis, cystocele,
and prolapse of the rectum.
II. By cutting out triangular or wedge-shaped portions of tissue, as in closing the
vaginal aperture, decreasing the size of a lip, ear, or nose, and separating
webbed fingers.
Retrenchment is often valuable because it decreases the relative size of
features; thus, if a nose has been partially lost the upper lip appears too
large, and its diminution will render the deficient nose less noticeable.
When material is taken from the prominent feature, and especially if
added to the other the normal proportion is nearly reëstablished and de-
formity greatly concealed.
To secure success in plastic devices certain precautions should be
observed. In the first place, the patient should be in good general health
and free from irritation or inflammation about the seat of the proposed
operation. In transferring or transplanting it is essential to select normal
integument for the flap, because cicatricial tissue is almost sure to slough
if dissected from the Subjacent structures. Approximation and sliding
operations, however, may be successfully performed with cicatricial tissue,
because these methods interfere very little with the vascular supply from
beneath.
All flaps should be made large, thick, and with a good vascular supply
through a wide pedicle. As soon as the flap is dissected loose, it shrinks
and becomes paler and cooler. Hence, it should consist of skin and
plenty of subcutaneous tissue, because thick flaps contract less and are
more vascular. It should be made about one-third larger in area than
* When a flap is borrowed ſrom the arm or hand there is less necessity for rotating and
twisting than when it is taken from the neighborhood of the organ to be constructed.
The latter is generally the preferred method, however, because less irksome to the patient
than the former with its constrained posture.
M ET HO D S USE I) IN PLA STI C S U R G E R Y. 149
the space to be filled and should be allowed to cool as little as possible by
being placed in position as quickly as practicable. For the last two
reasons I consider it preferable to freshen the edges of the part to be
repaired before making the flap. This is especially true in transplanting
flaps.
}. is sometimes well to cut a diagram of the flap out of paper or cloth,
and mark a similar outline upon the skin with ink before beginning the
dissection of the flap. It must be remembered that when the flap is
formed it contracts very much. At the same time the gap from which it
was taken appears larger than is really the fact because of retraction of
the margins of the wound. Nevertheless, it is well to make the flap at
least one-third larger and much thicker than the space into which it is to
be interpolated would seem to require, since the flap shrinks at once and
undergoes contraction and absorption from cicatricial changes for many
weeks after union has occurred. Any redundancy can be readily re-
moved when lapse of time proves it actually to exist.
To guard against imperfect nutrition and consequent sloughing of the
flap, it is well to make it with its long axis corresponding with the direc-
tion of arterial supply, and its base presenting toward the cardiac portion
of the arteries. Where there is very free anastomosis, as upon the face,
this rule may be disregarded to a considerable extent. The calibre of
the supplying vessels must not be interfered with by too much twisting or
tension of the pedicle, which must always be wide and thick. Injurious
tension on the pedicle can frequently be prevented by cutting a pedicle with
curved margins, which will allow increased stretching without occluding
the vessels. Skin free from hairs should be selected when possible, unless
it is desired to make eyebrows.
A gap to be filled by interpolation and parts to be united by approx-
imation should have their surfaces prepared by such free incisions as will
give abundant areas of contact for union by first intention. It is an error
to pare away so little tissue that only a thin raw edge is obtained. It is
necessary to have broad surfaces of contact to make successful plastic
operations, and these must be obtained even at the sacrifice of consider-
able material. The additional material removed will not be so great but
that it can be supplied during the subsequent steps of the operation.
Operations for harelip and torn perineum are often imperfect because
of neglect of this rule. -
When all hemorrhage from the flaps and freshened edges has been con-
trolled, accurate approximation is to be made by numerous sutures, which
should hold the parts merely in contact, allowing them to lie loosely and
Without tension. It is important in constructing new noses and other
features to be satisfied at first with obtaining a bulky semblance of the
organ, and not to endeavor to trim down the structures to an accurate
conformation, because it is impossible to estimate the amount and char-
actºr of cicatricial shrinkage which will inevitably occur. -
Exudation and organization of lymph sufficient to hold the parts to-
gether with moderate firmness occurs in from two to three days; then
Some or all of the sutures may usually be removed. Metallic sutures
°ºuse so little local irritation that they may be allowed to remain as long
*there is any danger of disruption of the adhering parts. The silk
*ures, which are often useful in securing accurate adjustment at the
Very edges of the wounds, are generally removed early. Gut sutures
*y be allowed to remain until they fall off from absorption of the por-
* lying in the tissues. Absolute antisepsis adds greatly to the success
150 P L A ST IC O R R EP A R AT IV E S U R G E R Y.
of plastic operations, and causes healing with the minimum degree of
scarring.
In transplanting without a pedicle, it is of the utmost importance that
the tissues be kept absolutely aseptic and warm. Disks of bone, pieces
of nerve, skin shavings, and such tissues, when to be thus used, should be
kept warm in sterilized water of about 105° F. If antiseptic solutions
are employed, they should be weak and unirritating.
The success following well devised and carefully performed plastic
operations is very gratifying. It is especially so in cosmetic operations,
since the improved appearance, though not equal to the normal condition,
is of great solace to the disfigured patient. It is always a long time be-
fore the cicatrices become white and soft ; therefore the full result is not
apparent until many months have elapsed. The scars always remain
visible, however; hence the illustrations of many published cases] are
deceptive in the apparent absence of scarring.
The disabilities due to fistules, ruptured perineum, and many other
conditions, can often be entirely removed by plastic surgery. If gangrene
of the flap does not occur before the end of the fourth day it is not likely
to take place, and the integrity of the operation is pretty well assured.
If, however, during the first three or four days the flap becomes grayish
and pulpy, and shows a loosened cuticle, or, on the other hand, if it
assumes a dry and withered appearance, it is evident that destruction by
sloughing of more or less tissue is supervening. The surgeon should,
nevertheless, leave the parts in position, keep them warm, and disturb the
dressings as little as possible, because the gangrene may involve only the
edges or the superficial layers of the flaps. A small amount of living
tissue remaining after the limitation of the sloughing process will often be
very serviceable in making the operation entirely, or at least partially,
successful.
FIG. 54.
IFIG. 55.
Plastic operation by V-shaped flap to Plastic operation by V-shaped flap.
correct eversion of lower eyelid. Sutures applied. (STELLWAG.)
To illustrate the manner of doing plastic operations, I shall describe a
few of the plans that will be found useful. As every case has peculiari.
ties of its own, the illustrations are given merely as types which will
prove suggestive.

M ET HO D S US E D . I N P L ASTIC S U R G E R Y . 151
Harelip, as will be shown in another part of this treatise, is usually
remedied by paring the edges of the cleft and approximating the fresh-
ened surfaces with the pin suture. Ectropium, or eversion of the lower
eyelid from cicatricial contraction, is greatly improved by making a
V-shaped incision downward, with its base embracing the everted section
of the lid, and dissecting the tense structures from the adjacent muscles
so that the V-shaped area of the skin can be slid upward until the lid
assumes its natural position. This re-
lieves the downward tension without FIG. 56.
materially disturbing the blood-supply
of the somewhat poorly nourished
cicatricial tissue. The gaping wound
left below and laterally can usually
be closed by stretching the skin or
by interpolating flaps.
This principle of relieving tension
can be utilized in many regions after
deformity from burns. The point of
the V must always be in the line of
greatest tension.
Depressed and irregular cicatrices,
such as occur in the neck after chronic
suppuration of lymphatic glands, can
be rendered more sightly by carrying
an elliptical incision around them,
freeing the integument laterally, and
drawing the under-cut skin over the
depression, which has previously been
made raw by abrasion.
This method gets rid of the depres-
sion and leaves a linear cicatrix. It
has been proposed by Mr. Adams to
cut, loose the deep attachments of
such scars with a tenotome, and then Operation for depressed scar, a shows
to keep the scar tissue raised for a lines of incision around depressed scar,
few days by pins inserted beneath. and knife Separating skin from under-
Elevated scars can be excised as lying tissues. b. Edges sutured after being
tumors, though the redundancy Some- drawn to middle line over depressed tis-
times returns. - sues which have been made raw by scrap-
Plastic operations for reconstruct- ing.
ing the nose may be made by trans-
ferring flaps from the forehead, or from the arm as suggested by
Taliacotius. The septum, or at least the columna, can be weiſ made out
of a piece cut from the entire thickness of the upper lip. Portions of the
nose may be restored by flaps from the cheeks or upper lip. It is well to
remember that taking portions of the lip away gives a flattened nose a
imºre, marked prominence; hence, two indications are fulfilled by using
labial flaps for rhinoplastic procedures. The parts may be kept in place
by transfixing the organ and the septum with pins, or tubes or plugs may
be placed in the nostrils for a few days. When the bridge is very much
shrunken, flaps from the forehead and cheeks may be Superposed to give
thickness. The lower lip can be repaired by flaps from the chin or
cheeks, from the upper lip if the loss of substance is near the angle of
the mouth. The plastic operations by which crooked noses and other

152 PLA STIC O R. R. EP A R AT IV E SU R. G. E. B.Y.
deformed features are improved vary with the character of the dis-
tortion."
FIG. 57. FIG. 58.
º
/
Nº.
Outline of flap taken from forehead for Outline of flap taken from upper lip for
reconstruction of nose. (BRYANT). * reconstruction of ala of nose.
%
(º, b
Shows outline of flaps for making the Shows the frontal flap turned down
nasal bridge higher, (STIMSON.) under the lateral flaps. The raw surface
Plastic operation for reconstructing lower lip. (ERICHs EN.)
FIG. 59.
on forehead is left to granulate. (STIMson.)
FIG. 60.
1 See author's monograph on the Cure of Crooked and Otherwise Deformed Noses.








P A R T II.
SPECIAL SURGICAL PATHOLOGY, OR PRACTICE OF
SURGERY.
C H A P T E R XIII.
SURGERY OF SPECIAL STRUCTURES.
DISEASES AND INJURIES OF THE SEIN AND ITS APPEND AGES AND OF
THE SUBCUTANEOUS TISSUE.
THE cutaneous eruptions do not belong to the domain of surgery, and
therefore will not be discussed in this treatise. Ulcers, wounds of the
Soft parts, and tumors have had sufficient attention given them in the
preceding chapters, hence no further reference to them is required in this
connection.
WART OR VIERRUCA.
DEFINITION.—A wart is a circumscribed hypertrophy of the cutaneous
papillae.
PATHOLOGY..—It is in fact a papilloma, and may have a smooth or rough
surface according to the arrangement of epithelium covering the enlarged
papillae. The histology of papilloma is discussed in the chapter on
tumors. Warts may be quite hard and horny, as in the common form
found on the hands, moderately soft, as seen upon the backs of old
persons, or very soft and friable, as the moist verrucous vegetations
situated upon the anal and genital muco-cutaneous surfaces. The last
are not syphilitic, but depend upon an irritation due to muco-purulent
discharges of any kind. The discharge may be venereal, but this has
nothing to do with its causing the warts. The growths are very vascular
and may be the source of hemorrhages. The fetid odor is due to decom-
position of the secretions. The other forms are not very vascular and
are usually darker than the adjacent skin. Warts on mucous membranes
often bleed freely and in the bladder and urethra may cause obstruction
to urination. A warty growth occurs on the hands of those engaged in
making post-mortem examinations, as a result of irritation from the
cadaveric fluids.
. The horny wart at times disappears spontaneously, hence the reputa-
tion of many household applications.
TREATMENT-Excision with scissors or curette or repeated cauteriza-
tion with chromic acid, glacial acetic acid, or ethylate of sodium is the
best treatment. A mixture of salicylic acid (gr. xxx), extract of canna-
154 SU R G E R Y O F SPECIAL S T R U C T U R ES.
bis indica (gr. x), and collodion (3.j) is recommended to be applied
daily. After a few days the devitalized tissue should be scraped off.
Ligation may be employed if the wart is pedunculated.
The soft warts, often improperly called venereal vegetations, may be
treated in the same way, though, when large, provision against hemor-
rhage must be made by the surgeon being ready to apply pressure or
astringents. Powdered tannic acid I have found a good styptic appli-
cation. The écraseur or the actual cautery may be used for removing
very large masses of these vegetations.
CORN OR CLAVUs.
DEFINITION.—A corn is a small, circumscribed, cone-shaped callosity,
due to hypertrophy of the epidermis, usually situated upon the feet or
hands, and having its apex pressing upon the papillary layer of the
skin.
PATHOLOGY..—A corn is originally a papilloma or wart, but as the
epidermis thickens it is pressed into the underlying tissues like a nail
driven into a board and the papillae finally atrophy.
The cause of corns is pressure, of misfitting shoes or from some instru-
ment used in manual labor, which induces chronic inflammatory hyper-
lasia.
p The pain is due to pressure on the delicate papillary layer of the true
skin, between which and the callosity a small bursa is sometimes developed.
If active inflammation and suppuration occur beneath the corn, the pain
is intense, because the pus cannot escape through the thickened epidermis.
When moisture is constantly present, as between the toes, the corn is
macerated and is called a soft corn. Pathologically hard and soft corns
are the same. A hard corn is occasionally found under the toenail.
TREATMENT.—The treatment consists in removing pressure by wearing
broad-soled shoes, straight along the inner border, with low heels. The
hardened epidermis may be scraped or cut away. This is best done per-
haps after softening the epidermis by soaking in hot water, by poultices,
or by applications of alkaline solutions, such as sodium carbonate (gr. X.
to fºj). In using strong alkalies care should be exercised not to touch
surrounding parts. The corn may be surrounded with a ring of wax.
As the removal of the horny exterior relieves the pressure on the true
skin, pain will be mitigated by these measures. A thick pad or plaster
with a central perforation to admit the callosity will palliate pain in the
same way. The salicylic acid application given for the treatment of warts
is often beneficial in cases of corns. Strong applications of nitrate of
silver will often relieve the pain of either hard or soft corns. Inflamed
corns require elevation of the foot and moist antiseptic dressings. Gauze
moistened with an antiseptic solution and covered with rubber tissue,
oiled silk or waxed paper is an antiseptic poultice and is valuable. Soft
corns are benefited by dusting tannic acid or oxide of zinc upon them.
These modes of treatment are only palliative. Excisions of the horny cone-
shaped mass by careful dissection or by cutting out an elliptical portion
of tissue down to the superficial fascia is the radical treatment. If abscess
occurs under the corn prompt incision will relieve pain and probably
effect a permanent cure.
It must be remembered that the peripheral circulation in the feet of
old and infirm persons is not vigorous; hence, slight operative interference
may be followed by gangrene in such patients.
B O II, O R F U R U N C L E . 15:
5
BOIL OR FURUNCLE.
DEFINITION.—A boil is a circumscribed, painful, and reddish elevation,
due to a localized inflammation of the skin and cellular tissue usually
terminating in central suppuration and sloughing.
PATHOLOGY..—Furuncles occur singly or scattered over the surface in
crops, showing a predilection for the back, axillae, perineum, buttocks,
legs, and face.
They are at times associated with diabetes and other diathetic condi-
tions.
There seem to be two classes of boils: Those primarily superficial, due
to local irritation about a hair follicle or sebaceous gland, as when the
hands are exposed to irritating fluids in dissecting; and those which begin
deeply on account of a localized depressed state of resistance in the cellu-
lar elements of the skin and subcutaneous tissue. Boils occur among
those of depraved physical condition and in those of robust and vigorous
health. Sea air has a tendency to induce their appearance in many
people. The cause of furuncle is a mycotic one. The cocci in many in-
stances enter the sebaceous duct or hair follicle from the surface of the
skin. In other cases, probably, they are in the blood and become local-
ized at a point where the tissues have least resisting power. This explains
the location of boils and their occurrence in the healthy.
SYMPTOMS.—The sharp stinging pain felt upon accidental pressure may
first call attention to a small, red pimple, which gradually enlarges, be-
comes hard and purplish, and is surrounded by a red areola. The pain
becomes throbbing and constant, about the fifth day a yellowish spot at
the apex of the elevation proclaims the occurrence of suppuration and in
a day or two longer a cylindrical greenish-yellow core or slough of cellular
tissue is discharged by the suppurative process, leaving a deep, punched-
out looking cavity. This is gradually filled by granulations, the adjacent
exudation of lymph is absorbed so that the tissues around regain their
normal softness, and cicatrization is finally accomplished.
The course of a moderate size boil, that is, one which with its areola
is say 13 inches in diameter, is run in eight or ten days. Pain subsides
as soon as the slough or core is discharged. Smaller boils or pimples fre-
quently appear about the same locality some days after the disappearance
of the primary boil. Lymphatic glandular involvement is common
during the height of the inflammation. Occasionally the inflammation
terminates by resolution, and as no discharge takes place such furuncles
are termed blind boils. Severe boils usually cause some fever.
The diagnosis between furuncle and its congener, carbuncle, is made
by the single point of suppuration, the circular and conical shape, the
smaller size, the tenderness on pressure, which does not exist in carbuncle,
and the usual association with other boils.
TREATMENT-It is sometimes possible to abort furuncle by early appli-
Cations of tincture of iodine, nitrate of silver, blisters, or undiluted carbolic
acid, or by puncture with a red-hot needle; but such procedures seem at
times to cause the subsequent irruption of a more than usually virulent
furuncle, which cannot be kept in check by such measures. Carbolic
acid has been injected into the forming boil with alleged advantage.
Pain is quieted and suppuration probably hastened by wet antiseptic
dressings covered with rubber tissue or oiled silk so as to constitute poul-
tices, and by anodyne plasters, of which belladonna plaster is one of the
156 SU R G E R Y O F SPECIAL ST R U C T U R ES.
best ; but these are far inferior to early and free incision, which relieves
tension and pain, depletes the engorged tissues and allows rapid extrusion
of the slough. It is the effort of the dead cellular tissue to escape that,
in the majority of instances, causes much of the pain. My usual course
is to wait only until the boil becomes quite painful, when I at once make
a deep incision without waiting for pus.
Scraping the diseased tissue out with the curette while the patient is
etherized may hasten cure. This, especially if followed by moist anti-
septic dressings and removal of the slough with forceps, speedily relieves
pain and shortens the duration of the disease several days. Dry anti-
septic dressings should be used after the slough has been removed or dis-
charged.
The treatment of the condition giving rise to a succession of boils
(furunculosis) is difficult, because a determination of the underlying
causes is often impossible. Impoverished blood demands iron, quinine,
mineral acids, cod-liver oil, malt and alcoholic beverages, and pure
air. Arsenic (gr. ºn to Hº), hyposulphite of sodium (3ss to 3.j), sulphide
of calcium (gr. j to gr. iv), and solution of potassa (mixv to mixxx) have
Some reputation as antagonists to the furunculous diathesis, and one or
other may be administered three or four times daily. Eliminative
measures, such as the Turkish bath, should be employed; and any gastric,
intestinal, or genital derangement corrected. Thorough cleansing of the
skin with soap, aided, perhaps, by turpentine, ether, and non-poisonous
antiseptics, seems most philosophical. The occasional association of fur-
unculous inflammations with syphilis, septicæmia, nephritis, and diabetes
must not be forgotten. When healing does not progress after separation
of the slough, the superficial ulcer left requires such management as has
been previously detailed in the discussion of ulcers.
CARBUNCLE.
DEFINITION.—Carbuncle is a more or less localized, deeply seated Sup-
purative inflammation of the skin and cellular tissue, attended by a hard,
very painful, flattened swelling and asthenic symptoms.
PATHOLOGY..—This section does not discuss the disease called malignant
pustule, or anthrax, which is spoken of in an earlier chapter. Unfortu-
nately the term anthrax is applied to both diseases. They may be related.
Malignant pustule is certainly due to the anthrax bacillus. Carbuncle is
probably due to a pyogenic Organism. There is a great clinical similarity
between furuncle and the more severe disease, carbuncle; while there is
apparently a pathological or etiological relationship between carbuncle
and malignant pustule and erysipelas.
SYMPTOMS.–Carbuncle is usually single and is most frequent in elderly
people and in those of impaired health; it is often associated with dia-
betes and chronic renal disease. A chill may be the premonition of the
carbuncle, which appears as a painful red spot, perhaps surmounted
by a vesicle. The posterior part of the trunk and neck is its favorite
locality. A firm, flattened, dusky red swelling, evidently involving a
considerable depth of tissue and exceedingly painful, though the pain is
not much increased by pressure, soon shows that a mere furuncle is not to
be expected. The brawny inflammation is localized, though it evinces
some tendency to spread, which is quite unlike the sharply defined fur-
unculous affection. This suggests a possibility that carbuncle may be due
C A R B U N C L E . 157
to the streptococcus pyogenes and furuncle to one of the other pus-causing
fungi. The feeling of tension and the throbbing pain are very marked,
the muscles in the vicinity become stiff from pain, and glandular swelling
is quite prominent. After the lapse of ten days or two weeks the skin
softens, first perhaps becoming vesicular, and is riddled by gangrenous
openings through which sloughing cellular tissue and ichorous pus is dis-
charged. Tough fibrous cores or sloughs are extruded and the continuous
destruction of skin goes on until there is left a deep excavated ulcer with
irregular indurated margins. The diameter of a carbuncle varies from
one to six inches and it may extend down to the underlying muscular
tissue, but rarely goes beyond. The duration of the disease is a month or
six weeks, though this period may be greatly lengthened by indolent
cicatrization of the ulceration. The prognosis is exceedingly unfavorable
when the carbuncle is large and situated upon the head or neck, especially
if the patient is old or infirm.
The constitutional symptoms are asthenic, and are of course more
grave if the sloughing causes profuse hemorrhage.
TREATMENT.-The internal treatment, therefore, comprises supportive
and anodyne measures, for even preliminary depletion would be inadvis-
able. Quinia (gr. x-xx daily), dried sulphate of iron (gr. iij-vj daily),
and milk punch (whiskey, f 3 j-v daily) represent the character of
agents to be employed in severe cases.
Ice has been recommended as a local application in the early stage to
cause the disease to abort. Blisters are sometimes employed with a sim-
ilar object, and are also sometimes applied around the carbuncle to pre-
vent extension of the inflammation by causing abundant effusion of
serum. Circular compression made by plasters with a central hole over
the focus of inflammation or by a cupping glass has advocates, who think
that the progress of the carbuncle is limited or its severity lessened by
this device. When it is evident that arrest cannot be accomplished, moist
antiseptic dressings, covered with rubber cloth to prevent evaporation,
are the proper applications to hasten suppuration and the discharge of
the gangrenous tissue. Thorough cleansing with sublimate solutions
(1:1000) of the cavities under the perforated and sieve-like integument
is judicious. Cicatrization of the resulting ulcer is accomplished as in
ordinary cases of ulceration after gangrene. Stimulating ointments or
lotions and skin-grafting may be required. The cicatricial contraction is
usually less than would seem probable from the extent of the ulceration.
This is due to the fact that the thickened and indurated edges give the
ulcer a factitious depth.
I have purposely omitted the discussion of the propriety of incising
Carbuncles until now, because high authorities differ as to the therapeutic
Value of incision. Some surgeons seldom incise them and believe that
the operation as a rule neither hastens cure nor lessens suffering. Others
think that incision is beneficial because it relieves the tension and conse-
quent interstitial strangulation, diminishes pain, and allows early escape
of pus and sloughs. If the parts are relaxed and soft no incision is re-
quired; but tension is so nearly universal that I am impressed with the
Value of free early incision, at least in the majority of cases. The creak-
ing as the knife divides the tissues shows the great induration. My
opinion does not differ from that expressed under the treatment of boils.
Subcutaneous incision is inferior to a direct incision which may or may
not be crucial. Capillary hemorrhage may be pretty free, but will relieve
engorgement, and is not likely to do harm, even in the asthenic condition
158 SUT R G E R Y O F S P E CIA L ST R U C T U R ES.
present, unless a vessel of considerable size is wounded. Pressure with
compresses and bandages will control such capillary oozing if it is suffi-
cient to require treatment. Applications of very hot water have a styptic
influence. Early curetting of the diseased region so as to remove sloughs,
pus, and disintegrated tissues seems to me rational. It must be done
under anaesthesia, and the cavity made antiseptic. The diseased struc-
tures may be destroyed without hemorrhage by the application of caustic
potassa, which cauterizes and causes chemical destruction of the skin and
subcutaneous tissue.
Thorough cauterization with a red-hot iron thrust through the skin and
carried under the skin in all directions may, if used at an early period,
destroy the pyogenic organism and prevent spread of the phlegmonous
inflammation. It seems to me a valuable suggestion.
LUPUs.
DEFINITION.—Lupus, or lupus vulgaris, is a chronic cellular infiltra-
tion of the skin, exhibiting itself as irregular, nodular, reddish-brown
patches of granulation tissue, which may or may not proceed to destruc-
tive ulceration but which usually leave disfiguring cicatrices. Lupus,
as previously stated, is probably a form of cutaneous tuberculosis, due to
the tubercle bacillus.
PATHOLOGY..—The disease has an important surgical bearing, because
there is a liability of its being confounded with syphilitic and epithelio-
matous ulceration.
The superficial form of lupus, erythematous lupus as it is called, is a
very different affection from ulcerating lupus. It is a skin disease located
especially in the sebaceous glands and does not interest the surgeon.
SYMPTOMS.—Lupus begins as a group of small, hardened, reddish
brown points in the skin which increase until they become papules or
tubercles. The patch may enlarge or several small patches may coalesce.
There is no pain. Cure may occur at this stage by absorption of the
nodules, leaving an atrophic kind of scar; or destructive ulceration of
the affected skin may take place. Such ulceration is exceedingly chronic
and is characterized by accumulation of crusts, slight discharge, slow in-
volvement and destruction of underlying cartilaginous structures, and
contracting cicatrices which cause marked deformity. Ulcerating lupus
usually attacks the face in the neighborhood of the mouth, nose, and
ears, but may appear upon other parts of the body, especially the fingers.
There may be slight pain in the later stages of the disease.
The causation of lupus has been obscure, but is now believed by many
to be due to the tubercle bacillus. The general health may be good. It
occurs in children chiefly, and is rare in this country, except among the
foreign element of our population. -
Lupus must be carefully differentiated from syphilitic ulcers and from
epithelioma, which shows a predilection to attack similar regions of the
face. &
Lupous Ulceration. Syphilitic Ulceration.
Comparatively superficial. Quite deep, often excavated.
Area rather small. Area may be quite large.
Ulceration usually limited to one region. Ulcers often disseminated over surface of
body.
Increases by coalescing of adjacent patches. Ulcers remain separate.
Border illy defined, Border sharply defined.
LU P U. S. 159
Lupous Ulceration.
Discharge slight and not felid.
Scabs thin and reddish-brown.
Progress slow, takes months to develop.
Scars hard, yellowish, and have great
tendency to contract.
No other lesions.
Not improved by medicinal treatment.
Lupous Ulceration.
Usually upon face, may attack other parts.
Induration not very marked and is diffuse.
No pain.
Ulceration begins at several points of the
patch.
Destruction of tissue usually not very
reat.
No hard and everted border ever present.
Ulcer usually rather superficial, with base
of small, red granulations.
Slow in its progress.
Occurs especially in children.
Syphilitic Ulceration.
Discharge abundant and foul.
Scabs thick, often greenish.
Progress more rapid, a large ulcer will de-
velop in a few weeks.
Scars soft, whitish, have little contractile
tendency.
Lesions of bones, glands, etc.
Cured by mercury and potassium iodide
in full doses.
Epitheliomatous Ulceration.
Situated usually at muco-cutaneous junc-
tions.
Induration well marked and circum-
scribed.
Pain may be quite severe.
Ulceration begins at one point and spreads.
Destruction and loss of substance great.
Indurated and everted border a charac-
teristic.
Ulcer deep, with uneven base and foul
discharge.
More rapid in its progress.
Occurs especially in adults and aged.
It will be seen that the clinical history of the ulcerative stages of these
affections—lupus, syphilis, and epithelioma—are very different. I am
convinced that many cases described as lupus have really been epithe-
lioma, for the great destruction of tissue and abundant discharge and
pain attributed to lupus are antagonistic to its ordinary clinical features.
Rodent ulcer, which is a form of epithelioma, lupus and syphilis, have
been confounded by many writers, who have thereby confused the pro-
fession.
TREATMENT.—This intractable affection requires active and prolonged
treatment. Good, nutritious food, general hygienic measures, and consti-
tutional and local remedies are demanded.
Cod-liver oil (fºij to fºss), iodide of potassium (gr. v-x), and syrup
of iodide of iron (fºss to faj) are probably the most valuable internal
remedies, and should be tested before severe local applications are
adopted. Arsenic is a constitutional remedy worthy of trial. Caustics
are necessary as topical remedies, unless absorption of the infiltration
occurs in the early stages of the disease. Absorption may possibly be
assisted at this time by painting with tincture of iodine, undiluted or
mixed with glycerin, or by applying tar or some murcurial ointment, or
using iodoform powder. Later it becomes necessary to use caustics to
destroy the diseased tissue. Nitrate of silver is highly recommended by
Hebra, but it is not as powerful as other agents, which, however, in some
instances destroy the healthy as well as the unhealthy skin. Potassa and
lime are painful applications, and have a very destructive tendency;
hence, the surrounding parts must be protected by pieces of plaster or
cloth, and some weak acid should be at hand to neutralize the alkali if
*Cessary. Arsenious acid (gr. xx-xxx to 3 of ointment) is painful,
but acts. only on affected structures. Pyrogallic acid ointment (3 to
āj) is painless, and acts very slightly on the normal tissue. Chromic acid,
to which a few drops of water have been added, applied with a brush, is
ºny favorite for such purposes. Solution of ethylate of sodium may be
160 S U R (; E R Y O F S P E CIA I, S T R U C T U R. E. S.
used and is efficacious as a destroyer of abnormal structures. Scraping
away the diseased skin with a sharp-edged scoop, or curette, and applying
caustics subsequently, such as zinc chloride or one of those mentioned
above, is a proper and often an efficient method of treatment. The
thermo-cautery, or galvanic cautery, is an available method of obtaining
a similar object. Excision of the ulcer may sometimes be justifiable
when the gap can be closed by a plastic procedure. Multiple incisions
are said to be beneficial by arousing traumatic inflammation.
ARABIAN ELEPHANTIASIS.
DEFINITION.—Arabian elephantiasis, or Barbadoes leg, is a local dis-
ease, characterized by chronic hypertrophy of the skin and underlying
cellular tissue, giving rise to discoloration, thickening, induration, warty
growths and deformity. *
It is essentially different from Grecian elephantiasis, or lepra, the
Biblical leprosy, which is probably due to a vegetable parasite, the bacil-
lus of leprosy. Leprosy does not belong to the domain of surgery.
FIG. 62,
Arabian elephantiasis.
SYMPTOMS.–The first step in the disease is a local inflammation of an
erysipelatous kind, accompanied by involvement of the lymphatic vessels
and glands. This attack subsides, leaving the part, usually a leg or the
genitals, somewhat enlarged and Oedematous. Recurrence of such inflam-
matory conditions takes place at intervals, leaving in each instance more
thickening and deformity. In the course of a year or two the hypertrophied
skin and subcutaneous tissue cause the part to assume enormous propor-
tions. The thickened, hardened skin hangs in irregular folds, and the
surface often becomes eczematous. From the accompanying fissures and
ulcers bloody serum exudes and causes scabs to form. The surface may
be smooth and eczematous, or very rough, from the development of papil-
lary enlargements or warts. The enlarged region is usually darker than
natural and greatly mis-shapen. The decomposing secretions, if abund-
ant, give rise to fetor. The great weight is a source of inconvenience,
and pain or itching may at times add to the patient's discomfort. During

Blj H. N S. 1618
the active inflammatory periods fever is present, and the local symptoms
are more SéVere.
Arabian elephantiasis is not common in the United States, but is fre-
quently seen in the West Indies, South America, and other tropical coun-
tries. A condition resembling, if not identical with it, is not infrequently
seen associated with chronic leg ulcer. The cause is obscure, but is prob-
ably connected with the lymphatic system. The disease is attributed by
some investigators to occlusion of the lymphatic vessels by an animal
parasite, the filaria. It is found among the poor, especially in adults, and
is neither hereditary nor contagious. It is always chronic in its progress,
and does not tend to a fatal issue. One of the legs, the scrotum, penis, or
vulva is the usual situation of the disease.
Pathologically it consists of an hypertrophy of the skin and areolar
tissue, with enlarged blood vessels and dilated lymphatics. In very pro-
tracted cases muscular atrophy and degeneration, and thickening of the
bones take place.
TREATMENT.-It should be treated in the acute inflammatory stages by
rest in the horizontal posture, and by cold water and anodyne applica-
tions. When these symptoms have abated inunction with mercurial oint-
ment, painting with tincture of iodine, and the application of the elastic
bandage are the best methods of inducing absorption and diminution of
bulk. Continuous elevation of the limb should always form an impor-
tant factor of the treatment. The rapid decrease in size under elevation
and frequent readjustment of the elastic bandage is often a matter of
astonishment, but the hypertrophy is liable to return when the patient
regains the erect position. The eczematous complication is often bene-
fited by a paste of salicylic acid (3ij), carbolic acid (3ij), zinc oxide (3ss),
mucilage (3xx), and glycerin (3xx).
Ligation of the main arterial trunk has been followed by amelioration,
and Dr. T. G. Morton, of Philadelphia, has reported very favorable results
in a case where he excised an inch and a quarter of the sciatic nerve five
years after ligation of the femoral artery had been performed with partial
success. Amputation may, at times, be justifiable.
BURNs.
DEFINITION.—Burns are injuries produced by the application to the
surface of heat sufficient to cause inflammation or destroy the vitality of
the tissues. Scalds are burns due to contact with hot fluids.
PATHOLOGY..—Sunburn is a dermatitis or inflammation of the skin
resembling that caused by heat, but due to exposure to the sun's rays.
Such inflammation is prevented by protecting the skin with dark veils or
clothing, and, when caused, is to be treated as an ordinary burn by cool-
ing and anodyne applications. Injuries due to the chemical action of
strong acids and alkalies are improperly called burns, though the effects
are similar to those caused by heat.
. Injuries from chemicals should be treated locally at first by weak alka-
line or acid solutions to neutralize respectively the acid or alkali doing
the mischief. The subsequent treatment is identical with that of burns.
Lightning and contact with electric light wires sometimes cause burns,
in addition to the nervous phenomena due to the electric current. Thé
burns are to be treated as other burns.
The local effects of contact with heat necessarily depend upon the tem-
; 11
162 S U R G E R Y O F S P E CIA L S T R U C T U R E S.
perature and the time of exposure. There are practically only three
classes of burns: 1. Erythematous burns, or those so superficial in their
influence that nothing further than hyperaemia and slight serous effusion
into the skin occur. 2. Vesicating burns, which do a greater degree of
damage, and are followed by vesicles resulting from an effusion of serum
between the derma and epidermis. 3. Necrotic burns, which are followed
by eschars, because the upper portion of the derma, or, perhaps, the whole
thickness of the skin or the muscles, fasciae, and bones, are devitalized.
SYMPTOMS.–In erythematous burns the skin is red, painful, and
swollen; but these inflammatory symptoms subside in a few hours or
days, and no cicatrix is left, even when desquamation takes place.
Vesicating burns promptly show vesicles or blebs filled with clear or
blood-stained serum, and are the seat of active inflammation causing severe
pain. The serum escapes by rupture of the vesicle, or is absorbed, and a
new epidermis is formed in the course of a week. If the old cuticle is
early cast off or removed by friction, so that the cutis is exposed to irri-
tation and to pus infection from pyogenic germs, in the air or on the
clothing, great pain and superficial suppuration result.
No cicatrix follows vesicating burns, though a discolored stain, similar
to that often seen after blistering with cantharides, may remain for a con-
siderable period.
Necrotic burns destroy the vitality of the tissues; therefore the eschars,
when separated, leave ulcerated surfaces to heal by granulation. The
pain of such burns is intense, if shock does not prevent its being felt. The
dirty brown color of such burns is characteristic, but it is impossible to
tell how deep the destruction has been until the sloughs separate. If the
parts are kept aseptic there will be no suppuration under the eschars,
which will drop off when the parts beneath are healed. Cicatricial con-
traction and deformity are usually great. The cicatrices may assume a very
rough and irregular appearance from abnormal development of fibrous
tissue. Keloid and malignant degenerations at times attack such scars.
The constitutional effects of burns vary with the amount of surface in-
volved and the degree of burning. An erythematous burn of a large
surface will cause more dangerous symptoms than a deeper burn of
limited area. When burns are severe enough to cause constitutional
manifestations, these symptoms are exhibited in three stages: 1, that of
shock; 2, that of inflammatory fever; 3, that of exhaustion.
The stage of shock is accompanied by feeble, frequent pulse, great de-
pression of the nervous system, lowered temperature, chills, nausea, rest-
lessness, and perhaps delirium. Pain is not very prominent if shock is
great. Greater shock attends burns of the trunk than of the limbs.
Congestion of the brain, of the thoracic and abdominal organs occurs,
and the patient often dies in twelve or twenty-four hours without showing
any reaction from the collapsed state. The degree of shock shown by
children and the aged is greater than in the middle period of life.
The stage of inflammatory fever, which lasts from the second to about
the fourteenth day, is characterized by increased bodily temperature, dis;
ordered secretions, great thirst, and often by inflammation of the internal
organs, such as cerebral meningitis, bronchitis, pleuro-pneumonia, and
enteritis. It is due largely, if not entirely, to infection by putrefactive
and pyogenic germs of the burned surfaces. Ulceration of the duodenum,
sometimes proceeding to perforation, is a remarkable lesion occurring at
times during this stage. It is to be suspected if hypogastric pain, vomit:
ing of blood, abdominal tenderness, and bloody stools are observed. Its
BU R. N. S. 163
occurrence has been attributed to the unusual vicarious action thrown
upon the duodenal glands, and also to a possible embolic plugging of the
vessels of the intestine. Neither of these theories has been proved.
Duodenal ulcer, if it occurs, is developed, as a rule, about the seventh
or tenth day of the inflammatory stage. In this stage albuminuria vary-
ing with the temperature, and a small vascular eruption thickly scattered
over the trunk, have been noticed. Erysipelas may occur.
The stage of exhaustion is due to the depression caused by the inflam-
matory irritation, and by the profuse suppuration often accompanying the
detachment of the eschars and the cicatrization of the resulting ulcers.
The suppuration is due to pyogenic infection, which is difficult to pre-
vent when large areas are injured. Infection usually occurs before
the surgeon reaches the burned individual. There is great debility but
no pain unless the ulcers are subjected to pressure or rudely handled in
reapplying dressings. Amyloid visceral changes may possibly result from
prolonged suppuration.
Few cases of severe burn, and superficial burns must be considered
severe if one-third of the surface is injured, survive until the suppurative
stage begins. The majority die of shock within the first thirty-six hours.
Many others die during the inflammatory stage from lesions of the in-
ternal organs, tetanus, etc. Inflammatory oedema of the glottis from
inhalation of steam may be a cause of death ; but flame itself is not in-
haled, as is supposed by the laity. In most instances where incinerated
bodies are found in burned buildings asphyxia has occurred from the
gaseous products of combustion before the tissues have been subjected to
the action of fire. Spontaneous combustion of the human body is im-
possible.
TREATMENT.-The constitutional treatment of burns should be di-
rected to the relief of shock and pain, the prevention of secondary
visceral inflammations, and the support of the general powers of the
system ; while topical remedies should be employed to relieve pain,
moderate local inflammation, prevent infection with pus and other germs,
hasten cicatrization, and prevent contractile deformity.
Reaction from shock should be sought for by the application of heat
and the administration of stimulants and concentrated food in small
quantities. The hot bath may be available to raise temperature and re-
lieve pain. In fact, all the measures spoken of in the chapter where
Shock after Wounds is discussed are to be employed. Pain is to be
relieved in severe cases by an immediate hypodermic injection of a quarter
or half grain of morphia, or by the inhalation of an anaesthetic. In the
later stages of burns laxatives, diuretics, revulsives, and other anti-
phlogistic measures may be demanded to prevent internal inflammation
and to substitute the derivative action of the skin. The stage of exhaus-
tion prečminently requires tonics; and on this account actively depressing
remedies are to be avoided in the inflammatory stage.
The local treatment varies with the degree of burn. Erythematous
burns, if limited in extent, are relieved of pain by solution of sodium
bicarbonate, cold water, lead water and laudanum, and in fact by almost
any dressing that excludes air and constringes the dilated capillaries.
Menthol or Japanese peppermint might, I think, from its great refrigerant
action, be exceedingly soothing. The application of cold to large
erythematous burns is ill-advised because of the tendency to depress the
surface temperature and congest the internal organs. A household
remedy for small burns of this degree is to hold the part near a hot fire
164 S U R G E R Y O F SPECIAL ST R U CTU. RES,
and thus apply dry heat. Zinc ointment spread on cloth, and wheat flour
dusted over the burned surface are recommended highly. s
The proper treatment for vesicating burns is to puncture the blebs care-
fully and allow the serum to escape, so as to prevent the epidermis from
being rudely rubbed off. This epidermis makes the best possible protec-
tion from irritation and septic infection. Antiseptic gauze, or cotton, or
some form of dry sterilized dressing should then be applied. Salicylic
acid cotton does well. Sublimate cotton would be apt to poison the
patient if used for extensive burns. The dressing should not be changed
oftener than once in two or three days, because detachment of loosened
cuticle and exposure to air increase pain and the liability to germ infec-
tion, Antiseptic powders form with the exuded fluids a coating which
serves as a good protection from atmospheric influences, and should not
be removed until detached spontaneously. Iodoform powder is liable to
give rise to toxic symptoms when used in large quantity. Boric and
salicylic acids are harmless, or practically so. Much harm is often done
by tearing off the epidermis when removing underclothing. It is better,
perhaps, in such cases, to leave the soiled shirt or drawers upon the body
and saturate it with carbolized castor-oil (1:15) applied upon the outside.
Three days later, if the patient live so long, less harm will be occasioned
by cutting and removing the garments. In this method suppuration is to
be expected since infection from the skin and clothing is almost certain.
Necrotic burns require the same line of treatment as vesicating burns,
with which indeed they are usually associated. After separation of the
sloughs the ulcers are to be treated as previously described under Ulcera-
tion. Metallic astringents are often exceedingly valuable to keep down
redundant granulations and hasten repair of the breach of continuity.
Skin-grafting, in its numerous forms, is often required, and lessens con-
traction of the cicatrix. Deep burns of extremities may be so destructive
to tissue or so threaten life by reason of spreading gangrene, hemorrhage,
or violent inflammation that amputation gives the best prospect of re-
COVer W.
wºn possible burned surfaces should at once be rendered aseptic by
thorough cleansing and disinfection with antiseptic solutions. To do this
etherization and scrubbing the burned surface with soap and a brush may
be justifiable if the patient's condition does not contra-indicate. Deaths
occurring after the period of reaction are largely due to sepsis.
The greatest ingenuity has to be called into play in the endeavor to
prevent cicatricial contraction, which is especially marked when a deep
burn has injured the surface of a joint. The irresistible power of the scar
contractility everts the margins of mucous orifices, as in ectropium,
narrows the outlets of normal canals, flexes or extends joints and renders
them immovable, drags features out of position, causing horrid deformity,
and binds neighboring members together into one mass. During cicatri-
zation this contraction should be prevented as much as possible by keep-
ing joints extended by splints or by weights applied with adhesive plaster
or by elastic bands. Adjacent surfaces should be kept separated by
similar measures or by interposed dressings or metallic plates. It must
be remembered that two apposed granulating surfaces will readily become
connected by union by second intention. In this way several fingers may
be united throughout their entire length, if not enveloped in separate
dressings. Much can be accomplished by careful and judicious treatment
to prevent marked cicatricial deformity; but some disfigurement will
often occur despite the best-directed efforts.
F R O ST BITE A N D C H I L BLA IN . 165
Recent cicatrices may be stretched to a certain extent, but old ones
usually require operative treatment.
Correction of deformity may at times be accomplished by multiple in-
cision of the scar tissue, or by subcutaneous incisions and unfolding of
inodular ridges. Plastic operations are often requisite and gain the
desired end by transferring the tension to some neighboring region where
the cutaneous structures are sufficiently distensible to allow traction with-
out causing distortion. The various means of transferring tissue by
sliding, twisting, and transplanting with and without pedicles will be
found under Plastic Surgery.
FROSTBITE AND CHILBLAIN.
DEFINITION.—Frostbite is the injury produced by the application to
the surface of cold sufficient to cause inflammation or to destroy the
vitality of the tissues.
Chilblain, or pernio, consists in a local paralysis and dilatation of the
capillaries of the skin caused by previous frostbite, giving rise to a bluish-
red swelling accompanied by great itching and tenderness, and which
may terminate in vesication and ulceration.
SYMPTOMs.--When a man is exposed to extreme cold the circulation
and respiration become feeble, the limbs stiff and numb, the senses are
overcome by drowsiness, and he sinks into a comatose state. If he is
not rescued from this condition of apparent death, the fatal issue occurs
from congestion of the brain and other organs induced by the contraction
of the vessels of the surface. The proper method of restoration is the
very gradual application of warmth by means of friction with snow or
cold water, followed by removal to a very slightly warmed apartment,
and the careful use of stimulants internally and warm embrocations ex-
ternally. Friction with clothes should also be made in the direction of
the venous current. Artificial respiration and other measures should be
persisted in for many hours.
It is, however, the local and not the general effects of cold that we are
now studying. Frostbites resemble burns, except that their course is
slow, and like burns are of three degrees of severity: 1, erythematous;
2, vesicular; 3, necrotic.
Erythematous frostbite follows exposure to a moderate degree of cold
and is due to the capillary congestion and slight inflammatory serous
effusion that succeed the primary contraction of the vessels. The skin
during the application of the low temperature becomes white from defi-
cient circulation, wrinkled and numb; but as soon as return to warmth
occurs a bluish-rédness, swelling, and tingling pain or itching arise. The
equilibrium of circulation is restored gradually and no further patholog-
ical changes occur. *
When the cold is greater or more prolonged the parts become white,
entirely insensible and shrunken, and reaction is accompanied by inflam-
mation, leading to vesication. The vesicles in vesicating frostbite are
filled usually with blood-stained serum, and there is danger of gangrene
occurring from the violence of the inflammatory process.
Extreme cold devitalizes the tissues at once and they have a mottled
appearance from coagulation of blood in the superficial vessels. It is
said that the part may be brittle and easily broken, like glass. The
necrosed structures are finally separated in the same manner as sloughs
166 S U R G E R Y O F S P E CIA L S T R U C T U R. E. S.
produced by heat or chemical agents. In these cases of necrotic frost-
bite, as well as in vesicating frostbite leading to gangrene because of
active inflammation, it is impossible to tell how much of the tissues is
capable of having physiological function restored. Amputation, there-
fore, must not be attempted in the primary condition of the injury.
The extremities and the peripheral points, such as the ears, nose, and
chin, are most frequently frozen, because normal circulation is less active
in these localities. For a similar reason persons with weak hearts, and
those enfeebled by disease, dissipation, or old age are most liable to suffer
from exposure to low temperatures.
Parts of the body subjected to constriction from tight clothing, as
gloves, or shoes, or kept in contact with metal are especially apt to be
frozen. Cold combined with moisture or wind is more dangerous than
cold and dry weather without wind.
Chilblains are local dilatations of the cutaneous capillaries, due to
slight frostbites, usually to freezing that has been repeated. The con-
gestion which occurs in these paralytic vessels is accompanied by Oedema,
bluish-red swelling, severe itching and burning, and occasionally by the
formation of vesicles and intractable ulcers. They are most frequent in
women and young persons, and those of feeble cutaneous circulation, and
give more trouble when the weather changes from cold to warm than
when it is continuously cold. When the limbs become warm after going
to bed, or when the patient has been indulging in stimulating food or
beverages, the itching becomes almost intolerable.
TREATMENT.—The treatment of all degrees of frostbite should begin
by preventing sudden return to normal temperature, because sudden
access of blood to the injured capillaries will cause pain and a high degree
of inflammation. Hence the parts should never be subjected to heat or
put in warm water. The circulation and sensibility are to be restored
gradually by friction with articles only a little warmer than the frozen
parts. Snow, ice water, and wet cloths are usually employed for this
purpose. Afterward slightly stimulating applications, such as alcohol,
may be used to complete the reaction. Elevation of the limb and friction
toward the trunk may be valuable accessories, because the venous return
is thus assisted and congestion in the semi-paralyzed capillaries rendered
less intense.
The erythematous, vesicular, and necrotic inflammations that occur
after reaction has been established are to be treated very much as burns
of similar degrees. Anodyne and cooling lotions or ointments, evacua-
tion of the serum in the vesicles, protection of the skin from atmospheric
contact, so as to avoid infection, and moist antiseptic dressings, perhaps,
to separate the sloughs, are all indicated in the various degrees of injury.
The resulting ulcers are managed as such, without regard to their causa-
tion. Amputation is frequently required after severe frostbite, but should
not be done until the line of demarcation has been definitely formed.
Parts that are insensitive when a needle is thrust into them at the time of
freezing, will often have the circulation restored, much to the surprise of
the surgeon.
The treatment of chilblains is very unsatisfactory. Tincture of iodine :
carbolic acid (1:10); carbolized ointment of petroleum; nitrate of silver
(1:40); menthol; tincture of cantharides; tincture of aconite root; mus-
tard foot-baths; nitric acid (1:30); ammonia; turpentine or camphor
liniment; chloroform ; metallic astringents and chloral, as lotions or un-
guents, and similar applications, are to be tried. Tincture of iodine
I N G R O WIN G TO E - N A I L. 167
(mxx), ether (fāj), collodion (fāj), may be applied with a brush.
Perhaps hypodermic injections of fluid extract of ergot (mx) or of ergo-
tine (gr. iij) near the seat of pain would be beneficial. All pressure from
shoes or gloves aggravates the pain, and should, therefore, be avoided.
The ulcers that occur demand treatment calculated to cause healing and
to alleviate the itching pain, but care must be observed not to employ
remedies that will induce serious inflammation.
ONYCHIA OR ONYCHITIS.
DEFINITION.—Onychia, or onychitis, is an inflammation and ulcera-
tion of the matrix of a nail of the fingers or toes, by which the nail is
discolored and usually loosened, and finally cast off. Onychia must be
distinguished from paronchia, or felon, which is an entirely different
affection.
SYMPTOMS.–The condition may or may not arise from injury, and is
most frequently observed in children as a simple inflammation and suppu-
ration about the root of the nail. The new nail that supplies the place
of the diseased one is commonly irregularly developed. At times onychitis
assumes a much more serious and intractable form. The ulceration ex-
hibits no tendency to heal, the foul discharge and fungous granulations
show the finger or toe to be in an unhealthy in-
flammatory condition, the end of the member be- FIG. 63.
comes bulbous from morbid deposits, and caries or
necrosis of the phalanx occurs. This form of
Onychia, which is chronic in its course, has been
called malignant, and frequently is syphilitic in its
Origin.
TREATMENT.—The treatment in simple cases con-
sists of antiseptic lotions and dressings, and anodyne
solutions or ointments. The cases depending upon
constitutional states require internal remedies, such
as iodide of potassium, mercury, and tonics. Lo-
cally, cauterization with solid nitrate of silver or
nitrate of lead, or the application of iodoform, of
nitrate of mercury ointment, or arsenious acid oint-
ment (gr. j. to 3.j) is proper. Scraping away the -
fungous granulations and irregularly developed Onychitis.
nail tissue often assists in effecting cure. Entire
ablation of the nail, and even amputation of the finger may become
necessary.
INGROWING TOE-NAIL.
DEFINITION.—Ingrowing toe-nail is a vicious position of the lateral
border of the nail in relation to soft parts of the toe, by which the former
is buried in, or overlapped by, the latter. w
SYMPTOMs.-The malposition of the nail may be due to abnormal cur-
Vature of the same, to tight shoes pressing the soft tissues over its border,
or to a collection of hardened cuticle under the nail, causing it to assume
an unnatural relation to the adjacent structures. The affection is usually
*en at the outer edge of the great toe, and becomes in time very painful,
because the constant pressure gives rise to inflammation and ulceration

168 SU R G E R Y O F SPECIAL ST R U C T U R E S.
with foul discharge. The corner of the nail may even perforate the
substance of the toe.
TREATMENT-Palliative treatment consists in allowing the nail to grow
forward, and, after scraping away the thickened cuticle beneath, to keep
the square corner elevated by a small piece of cotton carefully pushed
under it. By a similar piece of cotton or lint the border of the toe
should be kept pressed away from the dorsal aspect of the mail margin.
The shoes worn must be wide in the sole, be long, and have toes high
enough to make no pressure on the top of the nail. The ulceration, if
it exists, should be treated with nitrate of silver or nitrate of lead
before the cotton is inserted. Salicylic acid (3.jss), extract of cannabis
indica (gr. x), collodion (3.j) make a good
FIG. 64. application. In inveterate cases the soft
parts may be pared away obliquely by an
incision beginning as far back as the root
of the nail. This fully exposes the ulcer,
and by bevelling off the side of the toe
prevents the nail irritating the tissues;
hence cicatrization and cure usually follow.
At times, however, it is better to remove
the offending portion of nail. This is done
by carrying an incision through the length
Operation for ingrowing toe- of the nail, about a quarter of an inch from
mail. Tape around root of toe to the edge, beginning far enough up the toe
prevent bleeding, and incarcerate to extend beyond the root of nail. A
cocaine solution injected hypo- transverse cut is then made from the upper
dermically. end of this incision, and a second longi-
tudinal one carried through the inflamed
skin in such a manner as to liberate the buried border of the nail. The
lateral portion of the nail is then pulled away. The unhealthy and
swollen soft parts near the mail are generally also trimmed off.
The raw surface left by the avulsion is soon healed by granulation
under the ordinary dressings for exposed and non-approximated wounds.
This is a better operation than removing the entire mail; for, even if both
margins have to be cut out, the centre of the toe still retains its covering
of nail tissue.
In many cases the surgeon can make his second longitudinal incision
run under the skin obliquely and thus free the incurvated margin of nail
without leaving so large a surface for granulation. This is a sort of a
subcutaneous excision of the nail border.
The operation is practically bloodless if a piece of tape is tightly tied
around the root of the toe before the incisions are made. Cocaine solu-
tion may be injected into the tissues so as to produce local anaesthesia.
Its incarceration by the tape ligature increases the degree of anaesthesia.
§

C H A P T E R XIV.
DISEASES AND INJURIES OF MUSCLES, TENDONS AND
BURSAE.
WOUNDS AND RUPTURES OF MIUSCLES AND TENDONS.
INCISED and lacerated wounds of muscles and tendons, if they involve
the entire thickness of the structure, are followed by retraction of the cut
ends and loss of motion. The treatment consists in relaxing the muscular
belly by flexion or extension of the joints, and applying sutures to hold
the divided muscular or tendinous structures together.
In suturing tendons it is well to pull down the upper end strongly in
order to stretch and paralyze the muscles and then to overlap the ends
and stitch them together in that position by longitudinal sutures. If the
tendon is wide the suture illustrated in Fig. 50 is a good one. After
suturing the limb should be kept for several weeks in the position which
relaxes the muscles. This can be done by bandages or the plaster-of-
Paris dressing. If the torn belly of the muscle protrudes through a
small cutaneous wound it must be pushed back, even if the opening in
the skin requires to be enlarged to accomplish this object. Excision of
the muscular protrusion is usually improper. If the upper portion of
the tendon is so retracted in its sheath that it cannot be pulled down by
narrow-blade forceps, an incision upward must be made so that it can be
found. A tendon should be attached to a neighboring tendon or muscle
when it is impossible to find the two ends of the severed cord. This will
prevent entire paralysis of the finger or limb to which the tendon is in-
serted. Tenosuture and myosuture are often neglected in wounds accom-
panied by division of the tendons and muscles. In such improperly
treated cases the loss of motion may be so detrimental that it is judicious
to cut through the cicatrized parts, even after several years have elapsed,
and pare the ends of the separated tendon or muscles and suture them
properly. As a rule, tendons divided subcutaneously, as in tenotomy, re-
unite quickly and satisfactorily as to function; but when their surround-
ings have been freely divided, as in open wounds, good union does not
follow unless sutures have been applied to the cut tendons. This is due
to the great retraction of the muscular end which occurs in such wounds.
Subcutaneous rupture of a few muscular fibres is not uncommon in
Severe strains thrown suddenly upon the muscles, and usually is accom-
panied by sudden, sharp, localized pain and, perhaps, ecchymosis. Rest,
the elastic bandage, and massage, supplemented, perhaps, by friction with
Some sorbefacient liniment is the treatment requisite. The cure is usually
Somewhat slow.
Complete rupture of the belly of a muscle or of its tendon, either from
the bony insertion or at the musculo-tendinous junction, is rather unusual
though not rare. Violence, or a sudden powerful muscular contraction,
* in tetanus or in the effort to recover equilibrium when about to fall, is
the cause of such lesions. When muscles have undergone fatty or other
degenerative changes, rupture is possible from very slight strain; but
170 MUSCLES, TEND ONS AND BU RSAE.
these tears are unattended by pain, as a rule, and do not concern us
surgically. The tendon of the long head of the biceps, that of the calf
muscles, and that of the four-headed extensor of the leg are the tendons
most frequently torn.
The symptoms of rupture of a muscle or tendon are the occurrence
during action of sharp pain, accompanied possibly by an audible snap
and associated with almost complete loss of motion, a groove or depres-
sion in the surface and, in muscular rupture, ecchymosis. The degree of
separation of the ends depends upon the amount of laceration of the sur-
rounding tissues and may be as much as an inch. If the tendon is wide
Some power of motion may remain because the margin is intact; as in a
case seen by me a few years ago, where there was slight extension possible
after rupture of the tendon inserted into the patella. Some fibres from
the external vastus muscle had evidently escaped rupture.
Rupture of muscles and tendons should be treated by laying open the
overlying tissues and suturing the torn structures with chromicized cat-
gut. The limb should then be placed in the posture which tends to keep
the extremities of the torn organ near together, and should be so retained
by bandages, splints, plaster-of-Paris dressings or by an apparatus of
straps adapted to this requirement.
Local weakness remains a long time after union of ruptured muscles
and tendons; and the repair that occurs is usually of analogous tissue,
which, in the case of tendons, however, finally assumes the characteristics
of the original tissue.
DISLOCATION OF MUSCLES AND TENDONs.
Dislocation of a tendon occasionally occurs when a sudden strain or
twist is brought to bear upon it at a point when its direction is changed
by passing around a bony prominence. The long head of the biceps of
the arm, the long and short peroneal and the posterior tibial tendons are
more frequently displaced than any others. Dislocation of the patella is
usually practically a dislocated tendon containing a sesamoid bone.
Reduction is easily accomplished by relaxation of the muscle and pres-
sure upon the displaced tendon, but as the sheath is torn in such luxa-
tions, it is difficult to keep the tendon in place after reduction."
Pressure with pads and the elastic bandage will often be effectual, but
sudden strain is apt to reproduce the luxation and pain.
Tenotomy may be resorted to in cases of repeated luxation, as has been
done by Mr. Bryant. It is possible that some cases might be benefited
by open incision, followed by suturing neighboring structures, so as to
prevent subsequent displacement.
It is probable that muscles themselves sometimes become displaced
from the grooves in which they lie. Such cases would probably be bene-
fited by manipulation, followed by bandaging.
INFLAMMATION OF TENDONs.
SYMPTOMS.—Tenosynovitis, or inflammation of the tendons and their
fibrous and synovial coverings, may be acute or chronic. Thecitis, the
1 Comparatively little has been written on these injuries, but the reader may find inter-
esting facts in New York Med. Journal, May, 1878, and British Med. Journal, July 13,
1878.
IN FL. A M M ATION OF T E N ID O N S. 171
term often used, properly refers to inflammation of the theca or sheath
alone, but as both structures are involved in the majority of instances,
the word tenosynovitis is a preferable designation of the condition.
Acute tenosynovitis is produced by punctured and other wounds, or
may arise without any traumatism, and is usually found affecting the
flexor tendons of the fingers or toes. The pain and other inflammatory
symptoms, both local and constitutional are very severe, and may ter-
minate in diffuse suppuration, sloughing, necrosis of the phalanges, and
septicæmia. The rapid spread of the inflammation to the hand and arm
by burrowing of pus along the tendinous sheaths and by gangrenous cel-
lulitis, suggests in many of these cases a resemblance to erysipelas. The
severe forms of paronychia, often called whitlow or felon, are usually
instances of inflammation of tendons, beginning at the end of the finger.
Sometimes the term whitlow is used to signify a mere suppurative inflam-
mation of the cellular tissue of the pulp of the finger-tip, a simple abscess
in fact; but the destructive paronychia, which is followed by gangrene
and necrosis, involves the tendinous structures and periosteum.
TREATMENT.-Acute inflammation of tendons demands purgatives,
sedatives, and morphia internally, and hot applications and elevation
locally, which must, however, be followed very early by free incision to
prevent burrowing of pus along the sheaths. A free, longitudinal in-
cision should be practised in the middle line of the tendon, going through
the structures down to the bone. This should be done as soon as it is
seen that resolution of the inflammation will not occur, and without wait-
ing for the formation of pus. The limb should be kept elevated after-
Ward and enclosed in a moist antiseptic dressing. In whitlow supposed
to involve only the structures about the tendon, it has been recommended
to incise on both sides of the middle line rather than in the centre of the
finger, in order to avoid opening the sheath and thereby allow the sup-
purative and sloughing action to involve the tendon. My own opinion is
that it is not probable that the incision into the sheath adds materially to
the risk of the involvement of the tendinous structures, if the incision is
sufficiently free to allow all discharges external exit.
Necrosis, subsequent to acute tenosynovitis, may necessitate resection of
a joint or amputation of a portion of the finger or limb. -
Stiffness or deformity of joints is a frequent sequel of well-treated cases
of acute tenosynovitis.
Constitutional diseases, such as rheumatism, gout, and syphilis, are
liable to cause inflammation of the fibrous tissue of tendons and aponeuro-
ses, but this is not of the phlegmonous kind, and demands therapeutic
management, depending on the cause. Alkalies, salicylic acid, colchicum,
iodide of potassium, and mercury are to be administered as indicated.
There is a peculiar form of chronic inflammation of the sheath of ten-
dons accompanied by a characteristic creaking or crackling felt, and some-
times heard, on motion that must be mentioned. This crepitating thecitis
usually occurs in the forearm, and seems to be due to roughening of the
sheaths by lymph, which causes scraping when the tendons slip in the
*Vesting coverings. The inflammation apparently results from long-
99ntinued and violent muscular action, or from gout or rheumatism, and
* associated with a moderate amount of pain and occasionally with tender-
º and swelling. The term “thecitis” is properly applied to this con-
OD.
. The crepitation felt when the wrist is firmly grasped by the other hand
is characteristic. Its Superficial character and occurrence during volun-
172 MMSCLES, TEN DO N S A N D B U R SAE.
tary motion make it very different from the crepitus of fracture. It
should be treated by rest, the elastic bandage, blisters, and friction with
stimulating liniments.
DEFORMITIES FROM MUSCULAR PARALYSIs, CoNTRACTION, AND
RIGIDITY.-MYOTOMY AND TENOTOMY.
PATHOLOGY..—Any disturbance of the normal equilibrium of the mus-
cular forces gives rise to deformity, hence it is evident that such deformity
may be due to increased action of one set of muscles or to impaired power
of the opposing group. There are four methods by which muscular dis-
tortions occur: 1. Inflammation of muscular tissue (myositis), which is
often due to gout, rheumatism, and syphilis, may lead to rigidity and con-
traction of muscles. 2. Long-continued abnormal position or disuse of
muscles, such as result from an unreduced dislocation of a bone, and from
inflammation or anchylosis of a joint, may be, and usually is, followed by
Spastic contraction. 3. Lesions in the nerve centres may give rise to par-
tial or complete paralysis of a group of muscles, and thus allow the antago-
mistic muscles to exert unrestrained force; or, on the other hand, the
central nervous disease may cause such a tonic contraction of certain
muscles that their opponents are unable to resist the displacing tendency.
In either event deformity ensues. 4. Irritation of the peripheral nerves
may, by a reflex influence, cause contraction or paresis of neighboring or
distant muscles. Such instances are seen in connection with diseased
teeth and gums, and with intestinal and uterine irritation.
TREATMENT.-The management of deformities arising from abnormal
muscular action should differ with the cause of the disturbance of muscular
equilibrium. If it is impaired function that causes the distortion the
weakened muscles should be strengthened by systematic exercise, elec-
tricity, massage, and hypodermic injections of Strychnia, and by remedies
directed to the promotion of the nervous supply. Brain or spinal cord
disease should be sought for and, if possible, removed.
After efforts to strengthen the paretic muscles have proved unavailing,
their action may be supplemented by elastic tension or some form of
mechanical support. Mechanical appliances tend to do harm if they
entirely substitute the action of the weak muscles, because they remove
the stimulus to exertion. Hence, the early treatment should be such as
will encourage the development of power. If this is found impracticable,
mechanical agencies to aid, but not to substitute, are a proper resort.
Muscular contraction from syphilis, gout, and rheumatism can often be
relieved by iodide of potassium, mercury, colchicum, morphia or atropia
hypodermically, alkalies, massage, Turkish baths, and similar measures.
Spastic contraction from cerebral or spinal disease is to be treated by the
proper remedies for the lesion there existing; and that due to abnormal
position or disuse, by restoring the function to the Osseous or other struc-
tures primarily involved. Passive motion will often be all that is re-
quired to give suppleness to the stiffened muscles around an impaired
ioint.
J Repeated stretching by manipulation, or continuous stretching by
weights, elastic extension, or mechanical apparatus adjusted with screws
will often overcome muscular rigidity and deformity. The removal of the
source of peripheral irritation has often been promptly followed by relief
of the muscular contraction or paresis. Tonic spasm of the masseter
MUSCULAR P A R A LY SIS, CONTRACTION, ETC. 173
muscle has been quickly cured by extracting a wisdom tooth occupying
an abnormal position in the alveolus. When the nervous irritation is
central and cannot be removed, stretching or excision of a portion of the
nerve-trunk supplying the contracted muscle may be useful in curing
deformity and relieving the pain which often accompanies the condition
of muscular spasm. It is not impossible that cases may occur in which
it would be good surgery to trephine the skull and remove the cortical
brain centre.
When ordinary measures have been unsuccessful in curing deformity
due to muscular contraction the patient should be subjected to division of
the displacing muscle. This operation is done subcutaneously and con-
sists in cutting through the belly or tendon of the muscle with a narrow,
short-blade knife called a tenotome.
Division of the muscular fibres is myotomy, division of the tendon,
tenotomy; but the latter term is sometimes used to include division of
muscles and fascias as well as of tendons. It is usually better to cut the
tendon than the muscle, if a choice is possible, since the muscular gap is
repaired by fibrous tisssue and not by muscle, while the two ends of the
divided tendon are united by tissue almost, if not quite, identical with
tendinous structure. The operation practically inserts a piece of new
tendon in the gap and thus lengthens the muscle. If the tendon is so
short as to be inaccessible, the muscular belly may be divided.
Tenotomy should not usually be performed if the deformity depends
upon palsy of the opposing muscles, nor if the deformity can be over-
. by moderate mechanical power applied by apparatus or by manual
OI’Cé.
In ophthalmic surgery tenotomy is sometimes performed when double
vision is due to a strong muscle overbalancing a paretic one.
Tenotome with round end and aseptic metal handle.
The tenotome should have a short cutting edge and a rounded end
Somewhat keen in order to divide the skin, but it should not be pointed.
There is then no need of a preparatory incision of the skin with another
instrument and no danger of the point injuring vessels. The shank of
the knife should be strong, but slender to permit turning in the small
Wound, and the handle so marked that the position of the cutting edge
imbedded in the tissues can be determined. It is usually preferable to
divide the tendon by inserting the tenotome under it and cutting toward
the surface. This, however, is not a matter of much moment. -
The operation is seldom followed by any untoward results. After the
ºdge of the tendon or muscle has been determined by the thumb-nail of
the left hand and while the parts are kept stretched and tense by an
*Sistant, the operator slips the tenotome flatwise through the skin and

174 MUSCLES, TEN DO N S AN D B URSA.
under the tendon. The edge of the knife is then turned against the rigid
cord, which is completely divided by a sawing motion and separates,
perhaps, with a snap, so as to leave a distinct gap under the skin. If this
springing apart of the ends is not very evident some of the fibres of the
tendon have escaped division, or other tendons, or some bands of con-
tracted fascia require section. These must be searched for and cut. Then
the knife is turned flatwise and withdrawn. As it is removed the surgeon
presses the blood out after it in order that no air may enter the puncture.
A gauze dressing is finally placed over the wound, which unites by first
intention. The skin and instrument must be aseptic in this as in all
Surgery.
After tenotomy it is usual to bring the deformed member into good
position at once by manipulation and retain it so by appropriate appa-
ratus. Some authorities think it well to wait a few days before attempt-
ing restitution of position, but this does not seem to me judicious. The
operation is not done to stretch the parts, but to put the foot or limb in
proper position and substitute a long tendon for a short one, and the
forcible manipulation, if done at once, is painless, because the patient has
not recovered from the anaesthetic.
Tenotomy may at times be demanded for the relief of other conditions
than spastic contractions, club foot, and similar deformities.
In oblique fractures with great displacement tenotomy may be required
to allow proper adjustment of the fragments. The tendon of Achilles is
the one that is most likely to be cut for this reason. Recurring painful
spasm of muscles about inflamed joints may sometimes justify such a pro-
cedure.
In performing tenotomy the vicinity of arteries and nerves must be
recollected. The posterior tibial vessels and nerves near the inner border
of the tendon of Achilles and the peroneal nerve just inside of the outer
hamstring tendon are to be carefully avoided. It is fortunate that when
tendons need to be cut they generally stand out in relief because of their
tenseness and rigidity.
This prominence can be made more marked by an assistant extending
or flexing the joints. Hence, the risk of dividing other structures which
are not tense, is reduced to a minimum. Small veins and arteries may be
divided with impunity, because the wound is subcutaneous and pressure
is readily applied.
Care must always be taken not to puncture inadvertently with the point
of the tenotome the skin on the opposite side of the limb. The finger of
the Surgeon should be kept upon that surface to avert such an accident.
CONTRACTION OF THE PALMAR FASCIA AND ITS DIGITAL
§
PROLONGATIONs.
DEFINITION.—This seems to be the proper place to consider the peculiar
flexion of the fingers which has been called Dupuytren's contraction. It
is a contraction of the palmar fascia and its digital prolongations, not in-
volving the flexor tendons, which is found especially in male patients
beyond the middle period of life, and which seems to be associated with
and caused by the gouty diathesis.
SYMPTOMs.-The little, the ring, and the middle fingers are most fre-
quently involved, though the other fingers and even the thumb may be
similarly affected. The patient notices that during several years a finger
CO N T R A CTION OF PA. L. M. A. R. F. A. S CIA. 175
becomes more and more flexed upon the palm, until even forcible exten-
sion is impossible and the first and second phalanges are so bent that the
last phalanx and nail are, perhaps, pressed against the surface of the palm.
This gradually increasing deformity
and disability is painless. The neigh- FIG. 66.
boring fingers and even one or two ~.
fingers of the other hand may subse- fººd.
quently present the same distortion. wº sº º
Examination of the palm shows one º i ſº º
or more tense cords or ridges under the w f º
Fººt;
º
§§
# º 13
% ºft
t t
!" | '. hº
*. -- º
#'ll # AA \; |
wºn "
ſ-ºriº º \ \
* *\,\!
skin extending to the sides or middle
of the affected fingers. The disease
shows a markedly hereditary tendency,
and according to recent investigations
is evidently of a gouty etiology. Trau-
matism has been thought to be a cause,
but the history of the cases, the heredi-
tary character of the affection, its ocur-
rence in both hands with almost equal
frequency, and its comparative infre-
quency in females, who are known to
be more free from gout than males,
make injury a rather improbable etio-
logical factor.
The diagnosis of this affection from
stiffness of the fingers due to arthritis
or to inflammation about the tendons
is readily made. Chronic changes in
the skin and joints, preventing perfect Dissection of finger contraction, affect-
extension of all the fingers, is seen in ing middle and ring fingers. Con-
the hardened hand of the sailor and tracted band of palmar fascia stretches
laborer. These conditions are very dif across like string of a bow. Flexor ten-
ferent in appearance from Dupuytren's dons, b lying deeply along the con-
contraction of the palmar fascia. The cavity of the curve, close to the bones,
rigid cord or cords extending from the are bound down along the first pha-
middle of the palm forward upon the langes of the fingers by the dense,
sides or middle of the fingers and pro- tubular sheath through which they
ducing flexion of the first and second pass. Digital prolongations extend to
phalanges especially, the elevation of articulation between first and second
the skin over these bands, and the in- phalanges in each finger. (ADAMs.)
volvement in the great majority of
cases of one or more of the fingers of the ulnar side of the hand, point
unmistakably to contraction being in the palmar fascia.
A similar contraction of the plantar fascia may occur, but it is very
much more unusual than the disease in the hand.
TREATMENT—In the early stages of the deformity friction, passive
motion, and retention on a straight splint for a long time may prevent the
increasing distortion, and, perhaps, restore the function of the finger. As
the Cases usually present themselves operation and prolonged treatment
by Šplints and passive motion are necessary. The contracted fascia and
its digital prolongation should be freely divided by a small tenotome in-
troduced between the skin and fascia at various points. The finger should
be at once fully extended and kept in that position by a splint, which
should be worn constantly for several weeks. Even after the splint is
(. º lſ, ſilt
tº
§§i)}
§ i.
h
º
§§
\º
§ \{ *
W \ | *






176 MUSCLES, TEN DO NS AND BU R.S.A.
dispensed with during the day it should be applied and worn at night. It
has been recommended to dissect up a triangular flap of skin in order to
cut away the tense fascia piecemeal, but the subcutaneous method of
Adams described is usually efficient. *.
FIG, 67. FIG. 68.
. º
S. * , sy >
§ '', § jºr §§ - .
sº ‘.. %. ſº * -- sº
\º S, \, . #º sº:
§ -ºs. ? § §º
Šsº gº sº; §ºft"fiºs
§§§ &#º: § { º #ffº. "ºs
§ § : % - Sº § - Mºiſ § w" * 3: §:º
§§§ s ł Ś # -
§N & § R. * * ‘s
§§ § * -
§ § • ?: L, .3 º |
§ * l i
§ § x sº &
§S.'s § V.S. .
§: § sº
*ś: § Š
S.
§
e ºf
§- º
š'
Contraction of palmar fascia before Contraction of palmar fascia after mul-
operation, (Case from Polyclinic Hos- tiple subcutaneous incision.
pital.)
If the open method is adopted the apex of the flap should be in the
palm over the prominent band of contracted fascia, while the base should
be made far enough forward on the finger to give access to the median
and lateral digital bands, which may extend as far as the second phalanx.
After these fibrous ridges have all been clipped away the cutaneous flap
is sutured in its former position.
THECAL CYST OR GANGLION.
DEFINITION.—The term ganglion is frequently, though ill-advisedly,
applied to cystic tumors connected with the sheaths of tendons. This
name should be discarded, because it has, in another sense, become so
intimately associated with the anatomy of the nervous system.
SYMPTOMS.—This form of cystoma, or cystic tumor, is seldom found
except in connection with the tendons about the wrist and ankle. In
symptoms and treatment the disease much resembles chronic inflammation
of the normally existing bursae, which will be described hereafter. The
cause of these cysts is unknown, though they may be due to strain or
some other form of traumatism.
The simple cyst, which is most frequently seen on the radial side of the
back of the wrist, occurs as a globular swelling situated over the carpus,
smooth, elastic, quite tense, somewhat movable and unaccompanied by







T H E C A L C Y ST. O. R. G. A N G L I O N . 177
discoloration of the surface. An elongated cyst extending along the
sheath of an extensor tendon, such as is shown in Fig. 69, is rare.
, , ,',
2%, ºv,
zº, *
2-2.3% Ż &2,.... ." & *
* =
zºº
• *f
#'A'. - %. . . . . .
}% º.º. ... ', t
jº Zºº, ,” "
º jº, g
% % * z
% w
zzº
:*:
* * *
*** &# º
\\ S& j; #
.NW.jº
'Nºſt
%
-
W
\
)
º
* ſº
ãº: § \
Cystic tumor of tendon sheath.
There is no pain unless nerve pressure exists, but the tumor causes a
feeling of weakness at the wrist. Authorities differ as to whether such
cysts are developed upon the sheath of the tendon, or are localized dilata-
tions of the sheath cavity containing the synovial fluid of the sheath more
or less altered in character. If formed in the latter way, the orifice of
communication probably becomes occluded during the progress of the
tumor, for, as a rule, the cyst does not seem to connect with the interior
of the sheath.
The compound ganglion, as the other variety is called, is more fre-
quently found connected with the flexor tendons, and is a general dilata-
tion of the sheath cavity, which may involve several tendons. This tumor,
though a cystoma, and though called a compound ganglion, has not, as a
rule, the multilocular character of compound cysts. The term compound
is applied to it rather because of its being a more complicated and more
troublesome affection than the simple ganglion just described. It is an
irregular, fluctuating tumor, often giving on manipulation a creaking
Sound and a peculiar crepitant sensation to the finger of the examiner.
It contains synovial fluid, which may be dark or bloody, and in which are
frequently found floating many small bodies, resembling rice-grains. It
is these seed-like bodies which give rise to the crepitation. They are little
masses of lymph, probably derived from the cyst wall, which may present
à roughened internal surface. The tumor is not painful, but when located
in the palm of the hand, its most common situation, causes flexion and
impaired motion of the finger. The tumor is not tensely filled, and it is
easy to press the fluid from the palmar portion of the tumor upward,
under the annular ligament, until the distention is exhibited at the wrist.
Both forms of cystic tumor of the tendons may be found in the foot and
other localities. In this connection must be mentioned the fact that in
the knee, hand, elbow, and other joints there are occasionally met hernia-
like protrusions of the synovial membrane of the joint cavity through the
ligaments. These become distended with fluid, and cause some stiffness,
though there need be no effusion into the joint proper. Surgical inter-
ference with such tumors is very apt to be followed by general synovitis,
unless asepsis is rigidly observed.
TREATMENT:-The localized thecal cyst is treated by sudden pressure
°ºusing, subcutaneous rupture, or by subcutaneous puncture and discis-
*With a tenotome. The fluid thus distributed through the cellular tis-
Sue becomes absorbed. Firm pressure made by the surgeon’s thumbs will









12 &
178 MUSCLES, TEN DO NS AND BUR SAE.
rupture the sac unless the wall is quite thick. If this manoeuvre does not
succeed, it is proper to introduce a tenotome obliquely through the skin at
a short distance from the tumor, and then puncture the sac and cut the
wall in various directions by means of the single cutaneous opening. The
fluid is thus liberated into the cellular tissue, or pressed out through the
cutaneous opening, and, as the sac is freely divided, there is little liability
of its reforming. The old-fashioned method of striking the tumor with a
heavy book is crude, and withal unsurgical, because severe contusions may
be caused. The limb should be kept at rest after the operation, and firm
pressure made by an elastic bandage, or by an ordinary bandage and
compress for several days. The external application of blisters and iodine
to such tumors is generally of no service. st
If rupture or subcutaneous incision does not cure these simple thecal
cysts, and they are the cause of sufficient disability to justify a more
extended operation, it is proper to inject tincture of iodine, carbolic acid
or other irritating fluid, to lay them open freely, and paint the interior
with undiluted carbolic acid, or to excise them.
These procedures are more serious in the order in which they are
named, because there is a possibility, though scarcely a probability, of
causing violent inflammation of the tendon and secondary impairment of
function. If there is no communication between the cavity of the cyst
and the sheath of the tendon, this danger is reduced to a minimum, but it
is often impossible to distinguish the fact of such absence.
Compound thecal cysts cause considerable interference with the use of
fingers or toes, and, therefore, constitute a greater disability than the
simple cysts. They are also more serious to treat, because of their free
communication with the general synovial cavity of the sheath. Free
incision, occasionally in more than one place, with complete evacuation
of the seed-like bodies and absolute rest of the part, is probably the best
treatment. Some operators prefer to use a trocar to withdraw the con-
tents, and then, after washing out the cavity with antiseptics, inject iodine
or some other irritant. As the danger of operation lies in putrefaction
and burrowing of pus along the tendons, I am inclined to favor a free
incision with aseptic or antiseptic dressings to small punctures or the use
of Setons.
INFLAMMATION OF A BURSA OR BURSITIS, AND BURSAL TUMoRS.
PATHOLOGY..—In connection with affections of the tendons, diseases of
the vesicular synovial membranes, or sacs called bursae, must be consid-
ered. Bursae normally exist, as a rule, where a tendon or the integument
slides over a bony prominence; but they may become advantageously
developed wherever constant pressure and friction call for protection of
the underlying structures. The normal bursae number, it is said, about
one hundred and fifty, and are found principally in the extremities. The
most important, surgically, are those found over the patella, olecranon,
great trochanter, tuberosity of the ischium, and heads of the first and fifth
metatarsal bones. The bursal sacs in the popliteal space, under the liga-
ment of the patella, under the psoas and iliac tendons as they cross the
pelvic brim, over the acromion, between the angle of the scapula and
broad dorsal muscle, beneath the deltoid, and under the four-headed €X-
tensor muscle of the leg, should be remembered. Inflammatory affections
of these bursae, though somewhat unusual, are liable to occur, and may
IN FLA M M A TI O N OF A B U R S.A.. 179
prove confusing to the surgeon. Occasionally a transmitted arterial
impulse causes bursal tumors in some of these localities to bear a slight
resemblance to aneurism.
Adventitious bursae are often developed at the points of pressure in
club-foot and other distortions, and, indeed, wherever the occupation of
the man or woman causes more or less constant pressure.
Bursitis, or inflammation of the bursal sac, may arise from injury or
from constitutional conditions, such as gout, rheumatism, and syphilis.
The inflammation may be acute or chronic, and may be followed by Sup-
puration or by distention with dropsical effusions.
SYMPTOMs.-Acute is not as common as chronic bursitis. The symp-
toms are those of acute inflammation limited to the known situation of a
bursal sac, with some distention of the Sac by increased effusion of fluid.
A slight crepitation may at times be felt with the first symptoms of pain
before swelling occurs. The immediately adjacent structures are oedema-
tous, and there is often considerable constitutional disturbance.
The sac, when distended with inflammatory fluids, forms a fluctuating
tumor. Suppuration may be supposed to have occurred when high con-
stitutional disturbance has persisted for some time, or there have been
rigors. The pus may make its exit from the bursa, or suppurative in-
flammation in the neighboring cellular tissue may occur without actual
rupture of the sac until the skin and deep fascia covering the knee, for
example, are completely undermined by the burrowing matter. In time
neglected cases will point externally, leaving, perhaps, fistulous tracts or
ulcerated openings. Sloughing of the tissues overlying a bursa may happen.
Chronic bursitis is more usual, and is characterized by much less pain,
perhaps a mere feeling of stiffness or weakness of a limb, and by marked
distention and thickening of the sac until a smooth, fluctuating, more or
less globular tumor is developed. -
The serous fluid contained in the cystic tumor, for such it practically
is, may be quite dark from disorganized blood-cells, and frequently ex-
hibits rice-like or melon-seed bodies identical with those described in the
Section on thecal cysts. The amount of fluid may exceed a half-dozen
fluidounces.
Sometimes the walls of a bursa undergo a chronic inflammatory change
which, by thickening and deposit of lymph, converts the sac into a hard,
fibrous-like tumor, with perhaps a small central cavity.
The most frequent location of bursitis is the bursa lying over the pa-
tella, which is frequently subjected to traumatic influences, especially in
housemaids and others whose calling requires the kneeling posture. This
bursa extends downward over the upper part of the ligament of the
Paiella and thus receives many impacts that the patella itself escapes, for
it is Well known that in kneeling much of the weight comes in the situa-
tion ºf ligament of the patella and the head of the tibia and not on the
patella itself.
Bursitis is to be distinguished from arthritis of the adjacent joint by
the localized nature of the swelling and fluctuation, the less interference
With motion, the absence of the characteristic semi-flexed position due to
*Vial effusion in joints, and the comparative ease with which the
normal articular prominences can be seen. Synovitis of the knee-joint
º the patella to float upon the effused fluid so that it is raised from
i. º of the condyles of the femur. If the surgeon strikes with
thr ºgers upon the skin over the patella he can feel the patella descend
”gh the fluid and come in contact with the femur. This test shows
180 MUSCLES, TEN DO NS AND BUR SAE.
in cases of inflammation at the knee whether the swelling present is due
to fluid below the patella and in the joint or to serous effusion above the
bone in the bursa.
Slight inflammation of the joint occasionally takes place as an accom-
paniment of bursitis because of the proximity of tissues. If the bursa
ruptures and allows pus to enter the joint, acute arthritis may readily
result.
TREATMENT.—The treatment of acute bursitis should be rest of the
limb, accomplished by elevation and splints, and the application of ano-
dyne or refrigerant lotions. Leeches may be of service. In subacute
cases or in the earliest stage of acute inflammation a blister may be ap-
plied. If suppuration is suspected an early and free incision followed by
curetting is proper, because the danger of burrowing of pus and pro-
tracted convalescence is great. It is probably preferable in patellar bur-
sitis to make the incision a little to one side of the median line, in order
that the cicatrix may not be so subject to pressure after cure has been
obtained. Sloughing of soft parts and caries of the patella must be
treated on general principles.
If spontaneous evacuation of pus and burrowing have taken place
before the case comes to the attendant, the sinuses must be laid open and
all pouches must be washed out with betanaphthol or sublimate solution
or carbolized water, and emptied by counter-openings or drainage.
Chronic inflammation or dropsy of a bursa is to be treated by counter-
irritation and elastic pressure. If this fails, as it usually will, tapping
with a trocar or aspirator, followed by the injection of strong carbolic
acid solutions or iodine tincture, or by pressure, should be adopted. Lay-
ing open the sac and keeping it stuffed with antiseptic gauze, thus causing
granulation and obliteration to occur, is an available method. After
laying open the sac the interior may be mopped with some strong caustic,
as carbolic or nitric acid. Solid bursal tumors must be dissected out.
Care is required to avoid injuring the adjacent synovial lining of the
joint.
BUNION.
When a normal or an adventitious bursa upon the toes becomes in-
flamed the condition called bunion is said to exist. Bunions are usually
secondary to displacement of and pressure upon the toes, arising from
muscular and osseous derangement and the wearing of
FIG. 70. ill-fitting shoes.
The metacarpo-phalangeal joint of the great toe is
the most frequent seat of bunion. This toe is very
liable to a chronic subluxation at this joint, and
thus becomes bent toward the middle line of the foot.
Upon the prominence made at the distorted joint by
the head of the metacarpal bone a bursa is developed
by the pressure of the shoe. When this bursa, or the
normal one situated nearer the plantar surface of the
joint, becomes irritated and inflamed, a bunion exists.
It is said that this deformity of the great toe is due
Distortion of toe and g e tº robably
punion.(Bryan, ) to wearing narrow and short shoes, but this is probably
a. untrue, since marked subluxation is exceedingly com.
mon in the lower classes, who do not take pride in exhibiting small feel.
A more probable explanation is that of Key, who believes it due to exce"

B U N IO N. 181
sive standing which, when the arch of the foot is weak, causes distortion
because of the obliquity of the pressure upon the inner side of the sole.
Tight shoes cause the development and the inflammation of the bursa,
and thus lead to the bunion, but probably do not act as the primary
cause of the deformity.
Club-feet usually have bursae developed upon their prominences, but
even if these bursae imflame they are seldom dignified by the special title
bunion.
The skin over a bunion may have a corn developed upon it, which, of
course, increases the painfulness of the affection. A bunion may suppu-
rate, leaving a foul ulcer or fistulous opening; may open into the joint
cavity, causing arthritis and disorganization
of the articulation; or may, in decrepit pa- FIG. 71.
tients, be the starting-point of erysipelas or \
gangrene. The preventive treatment of bunion
consists in maintaining the correct axis of the
toe, and restoring it when deflection first oc-
curs. The first is to be done by avoiding con-
tinuous standing during youth, and wearing
shoes with flat heels and broad soles, and al-
most straight along the inner edge. The true § /
Waukemphast pattern fulfils these indications. Á
Restoration of a distorted toe may be accom- Æ
plished by steel springs and elastic traction, so Aº
arranged as to be worn constantly.
Tenotomy of muscles which act as dis- º A $. i.
placing causes, division of the ligaments, ex- | d ſ § 3
cision of the joint, or amputation of the toe º
may be justifiable if the deformity and the Fºº
resulting inflammation and necrosis cause tºº
great disability. Bigg's apparatus for replacing
The bursitis must be managed by rest, ele- toe.
Vation of the foot, anydyne lotions, painting -
With mitrate of silver or tincture of iodine, and the local and general
measures detailed in the chapter on Inflammation.
The formation of pus requires an incision, but in all operations in this
region in old and debilitated patients it must be remembered that the
circulation here is feeble, and that unhealthy inflammation and gangrene
are not unusual after surgical interference. The treatment of bunion, then,
is identical with that of inflamed bursae elsewhere.
A radical cure can sometimes be effected by introducing a tenotome at
* distance and cutting up the bursal sac, as is occasionally done in thecal
ºysts. , Laying open the sac by a free incision or excising it may at
times be justifiable operations.

C H A P T E R XV.
DISEASES AND INJURIES OF THE NERVO US CENTRES AND
NERVES.
DISEASES AND INJURIES OF THE BRAIN.
Meningocele and Encephalocele.
THESE are congenital tumors due to the protrusion of a portion of the
meninges in the one case, and of a part of the encephalon and its cover-
ings in the other case, through an opening in the cranial bones. The pro-
trusion may occur at a suture, a fontanelle, or an abnormal orifice in the
skull. The most common seats for such unusual tumors are the occipital
and frontal regions. In pathology
TIG. 72. these tumors resemble hydrorachis
or bifid spine.
A meningocele being a pouch
of brain-membranes containing
sub-arachnoid fluid, resembles a
cystic tumor of ordinary kind.
Encephalocele is often asso-
ciated with other congenital mal-
formations, and usually is more
solid than the tumor just de-
Meningocele. scribed.
- As a fatal issue generally occurs
in these congenital hernias of the brain and its membranes, encephalocele
and meningocele are of little importance except that the surgeon must
think of them when diagnosticating tumors of the head.
Their partial or complete reducibility, their immobility, the location of
the neck of the tumor upon the cranial bones, the variation in distention
as the child is quiet or excited, and in encephalocele, the occasional ex-
istence of pulsation, will aid in the diagnosis.
Pressure, aspiration, ligation, and excision are methods of treatment
indicated, but are in most instances valueless.
º:
2:…ºs
2. N
s
Hydrocephalus.
Hydrocephalus is a dropsical condition of the brain, consisting of an
abundant accumulation of serous fluid in the ventricles or the arachnoid
space, or in both. It is a chronic condition, usually occurring as a con-
genital disease. Acute hydrocephalus, so called, is of different pathology;
for the term is variously applied by authors to tubercular meningitis and
to cerebral dropsy due to renal disease. The amount of fluid in chronic
hydrocephalus varies from half a pint to several pints, and produces
enlargement of the head, especially in the antero-posterior diameter,

I N F L A M M ATION OF T H E B R A. IN . 183
spreading of the sutures and thinning of the cranial bones. The pecu-
liar squareness of the cranium and relatively small face give the child a
characteristic appearance. The intracranial pressure and want of brain
development cause lack of intelligence, paralysis, convulsions, retinal
changes, and other cerebral symptoms. There is apparently little pain
felt by the infant. &
The most improved remedies are mercury and iodide of potassium,
which have at times seemed to yield good results. Early death follows
hydrocephalus, as a rule, when the dropsy is great and situated in the
ventricles. Dropsy located in the cerebral membranes has a more favor-
able prognosis.
Tapping the distended skull with the aspirator, whether or not followed
by injections of dilute tincture of iodine, has not been very satisfactory.
It is better to repeat the tapping than to attempt to evacuate all the
serum at once, and the fluid should each time be drawn off slowly. The
instrument should not be introduced in the median line of the sagittal
suture because the superior longitudinal sinus would be punctured. The
wide separation of the bones gives opportunity to pierce the cranium at
one side of the median line. Moderate pressure by an elastic bandage
may be employed after tapping, or even as an independent treatment.
If convulsions occur during the progress of the disease, bromide of
potassium is the proper remedy.
Intentional puncture of the ventricles themselves has been done by
Keen in a case of hydrocephalus. Death finally occurred after apparent
benefit from the operation.
INFLAMMATION OF THE BRAIN FROM SURGICAL CAUSEs.
VARIETIES.–Inflammation of the cranial contents is termed encephali-
tis. The pathological process may be located in the meninges or mem-
branes (meningitis), in the nervous tissue composing the various parts of
the brain (cerebritis), or may involve both structures (meningo-cere-
britis). -
These three conditions, therefore, are merely varieties of encephalitis
or intracranial inflammation. It is rare to find severe meningitis with-
Out Some involvement of the underlying brain substance; and, unless the
Cerebritis is limited to the deep parts of the brain, local meningitis, at
least, is a usual accompaniment of inflammation of the nerve tissue.
Celebritis strictly should not include inflammation of the cerebellum, to
Which the term cerebellitis ought to be applied.
PATHoLOGY.-In meningitis inspection of the membranes shows vascular
Sºgorgement of the dura mater and pia mater, cloudiness or opacity of
the arachnoid, and greenish or yellowish lymph deposited upon and between
the membranes. The arachnoid membrane and its cavity show with
*t frequency the existence of pathological changes; but puriform lymph
*d pus will be found smeared upon the dura mater or in the meshes of
the pia mater if the inflammation reaches a high grade. The relative
Pºon of these morbid deposits, as to the dura and pia mater, depends
much upon the starting-point of the encephalitis. Thickening of the
membranes occurs with the progress of inflammation. Cerebritis, and
the term is used to signify inflammation of the cerebellum and pons as
Well as of the cerebrum, is exhibited by increased vascularity, a change
* Color from gray or white to a pinkish or dirty yellow or a leaden hue,
184 DI SEASES AND IN J U RIES OF N E R V OUs CENTREs.
turbid serum in the ventricles, and softening of the nerve structure. If
the disintegration continues pus will be formed, constituting a cerebral
abscess, which may contain several fluidounces of fluid.
CAUSES.—The causes of surgical encephalitis are fracture, caries, and
necrosis of the skull involving directly or indirectly the cranial contents;
wounds of the membranes; concussion, contusion, lacerations and other
wounds of the brain; and pyaemia.
SYMPTOMS.–The symptoms of meningitis and of cerebritis are not, as
a rule, sufficiently distinct to make a differential diagnosis possible.
Fortunately, their treatment would be identical in the majority of cases,
even if such a diagnosis was made. Acute traumatic encephalitis gives
rise to headache, pain, and elevation of surface temperature at the seat of
injury, contracted pupils, intolerance of light and sounds, restlessness,
delirium, general fever, full and frequent pulse, constipation and perhaps
vomiting. As the disease progresses twitching of the muscles, strabismus,
convulsions, stupor increasing to absolute coma, and relaxation of the
sphincters of rectum and bladder supervene. Great circulatory depres-
sion, as shown by feeble, irregular, and very frequent pulse, clammy
sweating and dilated pupils proclaim serious involvement of the brain,
which will, in all probability, speedily terminate in death. The paralytic
symptoms are due usually to the exudation of inflammatory products,
which cause a condition similar to compression from extravasation of
blood in depressed fracture. Rigors occasionally happen and suggest the
formation of an intracranial abscess or of pyaemic infection from inflam-
mation having involved the diploic structure of the cranial bones. Sub-
normal temperature is thought to be indicative of abscess.
Acute encephalitis occurs in from one to three days after the receipt of
injury, and usually leads the surgeon to believe that there has been a
general injury to the brain in addition to the evident local lesion. In
other words, symptoms of acute encephalitis generally mean contusion or
laceration of one or more parts of the brain distant from the point of
impact with the vulnerating body. Laceration by counter-stroke at the
side opposite the injury is a not unusual factor in the etiology of acute
inflammation.
The condition occurring after injuries and called irritation of the brain
is probably a minor degree of encephalitis affecting special regions of the
brain substance. It is characterized by restlessness of the patient, who
lies curled up on one side with his limbs flexed and his eyes tightly
closed. If aroused from his semi-insensibility he shows a momentary
mental irritability, and then relapses into a restless sort of sleep.
Chronic encephalitis causes headache, vertigo, hebetude and intellectual
dulness, insomnia, epileptiform seizures, choking of the optic disks or
papillitis, paralysis, and coma. The symptoms are less violent than in
acute inflammation, but are similar, though coming on insidiously and at
a period varying from weeks to months. Tain at the seat of injury and
a local rise in surface temperature are grave symptoms in old head in-
Ull’I6S.
J Death occurs in emcephalitis from pressure due to morbid deposits or
from blood extravasated from diseased vessels; from destruction of ner-
vous centres by softening or abscess; from interference with blood-supply
by thrombosis, and from pyaemic injection of the general system. e
A diagnosis between meningitis and cerebritis is, as a rule, impossible,
because the two conditions are so frequently associated that we are not
assured of the symptoms pertaining exclusively to each. If the local pain,
IN F L A M M ATION OF T H E B F A IN . 185
the restlessness, nausea, and hyperaesthesia of the optic and auditory
nerves are especially marked, it is probable that inflammation of the
meninges is the prominent pathological change. Cerebritis is to be sus-
pected if convulsions, jerking of the muscles, trembling, and sudden dis-
turbances of the special senses are observed. The suspicion is strength-
ened if the muscular symptoms are unilateral, and if coma and actual
paralysis of one side rapidly occur.
TREATMENT.-Acute inflammation of the brain requires active treat-
ment. The entire scalp should be shaved to permit full examination for
fracture, contusion, or other injury; the head should be elevated, cold
should be applied to the cranium by means of a bladder or rubber bag
containing cracked ice, or by means of cold water passing through a coil
of tubing encircling the head several times, and the patient should be
kept in a darkened and quiet room. If the pulse is hard and frequent,
the face flushed, and the carotid arteries evidently carrying a large
amount of blood to the head, venesection at the bend of the arm is valu-
able. The bleeding should be supplemented by free purging, large doses
of bromide of potassium (3iij to 3v in twenty-four hours) and cardiac de-
pressants, such as tincture of aconite root (m.j to iij every two or three
hours), or tincture of veratrum viride (m.j to iij every two or three hours).
The best purgatives are calomel and jalap (gr. v to x each), or two or
three compound cathartic pills. Many do not require bleeding, but are
judiciously treated by the other remedies mentioned, with or without wet
cupping at the nape of the neck. Digital or instrumental pressure upon
the carotid arteries has been suggested as a means of diminishing the
intracranial circulation. Some high authorities advise the use of mer-
curials and opiates to combat encephalitis, and give calomel (gr. 4) and
morphia (gr. Tº) every few hours, for their antiphlogistic and quieting
effect. I have been accustomed rather to rely upon the revulsive action
of purgative doses of mercury and other drugs, and the cerebral anaemia
and quiet produced by large doses of bromide of potassium. When there
are great restlessness and brain irritability, morphia in moderate doses is
indicated. Chloral (gr. v to xv) or hyoscine hydrobromate (gr. Thr)
may be employed to meet this symptom. The diet should be limited in
quantity, and restricted to milk or other non-stimulating food.
In the later stages, when exudation has probably occurred, blisters may
be used locally, and iodide of potassium (gr. v to x) and mercury (green
iodide, gr. # to #) given internally several times in the twenty-four hours.
When great depression supervenes some alcoholic stimulant may be
employed, but usually this stage presages death, which cannot be, and per-
haps could not, have been averted. In all cases the bladder should be
Watched, and catheterized if the urine is not passed. The patient is per-
haps unconscious, and the attendants may neglect to call attention to the
fact that no urine has been passed unless the surgeon makes inquiries.
Subacute and chronic encephalitis demand similar though less active
*atment. The measures mentioned for the later stages of the acute
disease are especially applicable. Mercury, iodide and bromide of potas-
sium, blisters, and laxatives are usually employed. If an acute inflam-
**on is engrafted upon a chronic one, it must be met by active and
V**ous measures, as though it had been an acute affection primarily.
In all gases of suspected brain disease the condition of the urine should
be *Yºstigated, since renal changes will induce uraemic symptoms, simu-
*ing intracranial inflammation.
Patients who have recovered from encephalitis due to surgical causes,
186 I) ISE A SES AND IN J U RIES OF N E R V O U S CENTRE S.
may suffer for many weeks from vertigo, headache, sleeplessness, mental
aberration, and other sequels pointing to deranged nervous activity.
These symptoms are to be combated by the long-continued use of altera-
tives, such as the preparations of mercury and iodine, and by the tem-
porary administration of bromide of potassium, chloral hydrate, and
similar medicines.
Chronic encephalitis is a not uncommon symptom of tertiary syphilis,
and is frequently associated with syphilitic inflammation of the spinal
cord. Mercury (green iodide gr. j to gr. ij, during twenty-four hours),
with iodide of potassium (gr. lxxv to gr. c in twenty-four hours), is
especially indicated in such cases. All chronic cases should be subjected
to antisyphilitic treatment, as should all cases of supposed brain tumor.
OPERATIVE TREATMENT.--When it is possible to locate the exact seat
of the intracranial inflammation, operative interference may sometimes
be undertaken with the hope of removing the spicule of bone or the
foreign body which has caused and is keeping up the morbid process, or
with the expectation of evacuating the collection of blood or pus which is
threatening the life of the patient.
Trephining the skull, incising the membranes and puncturing the brain
tissue are the modes of operation that may be adopted. Such procedures
are much more frequently justifiable in chronic than in acute encephalitis,
because the former is more likely to be local in its causation and in its
lesions, and, therefore, more accessible by operation. The reader must
recollect that in this connection I am speaking of trephining as a mode of
treating eacisting traumatic inflammation of the brain, and not of preven-
tive trephining, which is undertaken to prevent the consequences of punc-
tured and other forms of fracture of the cranium. The method of using
the trephine will be described under fractures of the skull.
Operation may be done to give exit to an extravasation of blood or
a purulent collection within the cranial cavity; to remove a foreign body,
such as a bullet, supposed to be buried in the brain or membranes, and
to endeavor to find and get rid of the cause of an inflammation which is
suspected to be due to a splintered condition of the inner table or to
localized bone disease. t
Collections of pus or of blood may lie between the bones and membranes
(subcranial), in natural or abnormal cavities formed between layers of
membranes (intermeningeal), or in the substance and ventricles of the
brain (cerebral). Subcranial and cerebral extravasations and abscesses
are usually circumscribed, and, therefore, more amenable to operative
treatment than intermeningeal collections, which are, as a rule, diffused.
LOCALIZATION OF BRAIN LESIONS.–Until within a few years the Sur-
geon had little to guide him in attempts at ascertaining the precise loca:
tion of cerebral lesions; and, therefore, operations upon the skull and
brain were seldom justifiable in cases where there was no fissure or open-
ing in the cranium. A localized puffy swelling of the scalp, or separation
of the pericranium exposing yellowish or dry bone, with hemiplegia of
the opposite side of the body, and especially if rigors had occurred, might
induce a bold operator to trephine and endeavor to evacuate the abscess;
but there were no rules founded on physiological and clinical observation
to guide him in the less obscure cases.
The recent study of cerebral localization by Ferrier, Charcot, Horsley,
and other neurologists, however, has made it possible to determine the Site
of many lesions of the cerebral cortex, or surface, by the local tempera-
ture and the character of the paralytic and other nervous symptoms.
I N F L A M M ATION OF T H E B R A IN. 187
The special symptoms belonging to irritative and destructive lesions of the
various parts of the interior of the brain have not yet been established
with much accuracy; and, indeed, the exact locality of many of the
nervous centres upon the surface is still doubtful. Nevertheless, enough
has been done in this direction to aid the surgeon very much in determin-
ing, from the symptoms, where to apply the trephine in suspected abscess,
extravasation, or impacted splinters of bone.
FIG. 73.
S U P E R O R F R O N TAL Fls su R = 0 3 Ro LAN Do
*
•
2- c5 L Los o M A R G in Al-
.." 2^4. F | 5 S U R E
&
INT CR PA R E TAL
... 5 F is s U R E
NF E R J D R P A R N E T Q
FR 0 NTAL_1 tº . Tº - - O C G | F | T A L
F 1 S S U R E. gº ºz_* 4. 4–-º-- F | S S U R E.
. ... " -: RITAL
... PA R A L L E La
F 1 S S L R Es
£
F 1 S S L R E G F
S Y L. V J U S
Diagram of skull, showing relation of convolutions to bones.
The relation of the important landmarks of the brain to the external
conformation of the skull is found in the figures.
It is important to distinguish lesions of the surface of the cerebral
hemispheres from those of the interior of the brain, because the former,
unless at the base, are more easily reached by operation. Cortical lesions
Cause usually not a loss of motion of an entire side (hemiplegia), but a
paralysis of only a special group of muscles, as of the hand, forearm, or
leg (monoplegia), and there is quite frequently early rigidity of the same
muscles. Jacksonian epilepsy, or convulsive action of a single group of
muscles, as of a thumb, occurring alone, or occurring as a prelude to a
general epileptiform convulsion, gives indication that there is a lesion of
that particular cortical centre, and points to the advisability of an explora-
ºry, operation in that region. Local pain, which may be felt only when
the head is percussed over the lesion, is also a symptom of cortical disease,
*d, finally, unconsciousness is not so often associated with the paralysis
from cortical lesions, as is the case in paralysis from lesions of the central
Portion of the brain.
he portions of the cortex in which the nervous centres of motion are
located are the bases of the three frontai convolutions, the convolutions









188 DISE A SES AND IN J U RIES OF NERV O U S CENTRE S.
along the fissure of Rolando and the paracentral lobule, while the centres
of sensation seem to be in the parietal, temporal, and occipital lobes of the
cerebrum. Recent investigations go, however, much further than this,
and locate with considerable certainty centres governing many special
motions. From this knowledge it is possible to diagnosticate with a great
degree of certainty the location of the inflammatory process which is pro-
ducing the symptoms in a given case.
FIG. 74.
3:
*:::...ſº
- * ſº ,”
I * & --~~
º Zºe'> **
=4, N fºrm
º §) t º
Diagram of skull, showing lines of fissure of Rolando, middle meningeal artery and cortical
centres.
The symptoms pertaining to lesions of limited areas still require further
differentiation, but the value of cerebral localization to surgical treatment
FIG. 75. FIG. 76.
Broca's square. Broca's square applied.
has so rapidly increased that even now it is incumbent upon all surgeons to
recognize its utility. As an example, let me state that paralysis of an arm











IN FL. A M M ATION OF T H E B F A IN. 189
alone (brachial monoplegia) indicates disease of the upper part of the
ascending frontal convolutions of the opposite side. Here then would be
the place to trephine, if the other symptoms rendered the occurrence of
abscess or intra-cranial bleeding probable.
It is always important to determine upon the shaved head the location
of the fissure of Rolando before undertaking any operative procedure
based on cerebral localization. This may not be necessary if an external
injury or scar indicates the probable seat of lesion. This fissure has its
upper end 50 or 55 millimetres behind the bregma or junction of the in-
terparietal and coroneal sutures, but does not quite reach the middle line
of the skull. The bregma is found by drawing a vertical plane through
the two external auditory openings. The lower end of the Rolandic fis-
sure is about six centimetres above and a little behind the external audi-
tory canal. It makes an angle of 67 degrees with the median line drawn
from the glabella, or smooth spot at the root of the nose, to the external
occipital protuberance, or inion, and has its upper end beginning on a line
with a spot situated 55 ºr per cent. of the total distance from the glabella
to the inion. The illustrations show two methods of determining the
location of the Rolandic sulcus: that by Broca's square and that by
Wilson's cyrtometer.
FIG. 77.
*
*
.
s
*
*
*
|
|
g
%
9
*
%
º
a ºn
z A%jºſ.
,” , ~~ 23. º %
a *...*.*. * . . . .” %
* 2° 2 Stº 2}{2^22% %. % º
* * , 2 2 ''2' >.2_32%.4%% ºft
22.2%. , 2 × 3.22%.3%
%2 2.É. º º
% ºf º
* 2: ...” ºv
.32
% gº
ſº . § - A
ſ ...?3.3
ºffſhº Aºſiºriſmº •
ºngº
Diagram showing one method of locating the fissure of Rolando. (NAxcREDE.)
}-
Some general rules may be formulated that are well worth attention."
In injury or disease in the neighborhood of the fissure of Rolando,
which is the motor region, operation is indicated when monoplegia is
present, except when anaesthesia accompanies the paralysis of motion;
then it is contraindicated, because the lesion is evidently so extensive
FC $88,0perative Surgery of the Human Brain, by John B. Roberts. Also papers of C.
l •r, { { * * * * * s
V. i * º Roswell Park in Trans. Congress of American Physicians and Surgeons,
Ol. l. l. 389. º *- -



































190 DISE ASES AND IN J U RIES OF NER V O U S CENTRE’s.
that sensory as well as motor centres are involved. When paralysis or
convulsive movements occur in connection with disease of the sensory
region, operative interference is improper, since the pathological change is
not limited to the sensory centres, but involves the motor region. An
exploratory trephining, if properly carried out with antiseptic precau-
tions, is so devoid of danger that many surgeons would operate notwith-
standing the co-existence of motor and sensory symptoms.
Paralysis on the same side as the injury of the head should be consid-
ered an indication against operation at the point of injury, because there
is probably a lesion at the opposite side of the brain, due to counter-stroke.
Again, very profound loss of motion points to non-interference, because
it is likely that the injury involves deeper tissues than the cortical cen-
tres of motion. Paralysis of the cranial nerves, Cheyne-Stokes respira-
tion, choked disk, and symptoms referable to injury of the base of the
brain contra-indicate surgical procedures.’
FIG. 7S.
[l)
Wilson's cyrtometer, consisting of a steel tape to encircle the cranium and sliding upon
it another tape making with it an angle of 67°. Both tapes are marked with a scale.
(PARK.)
The occurrence of aphasia betokens an abscess, pressure from a clot,
or injury from a spicule of bone, located near the base of the third
frontal convolution and the island of Reil, and usually on the left side.
Right-sided loss of motion in addition to the aphasia, while showing a
more extensive lesion, perhaps, fixes the lesion at the left side of the brain.
In such cases trephining gives a reasonable hope of reaching and remov-
ing the cause of the threatening symptoms,
When the symptoms and principles just discussed furnish sufficiently
clear evidence to satisfy the surgeon as to the probable seat of the lesion,

IN J U R IB S OF T H E B F A IN . 191
it is proper, if the case present a serious outlook, to trephine without
delay. Delay is dangerous if the lesion is chronic encephalitis, with
abscess; and equally so if there are symptoms of a large extravasation of
blood, or of a local inflammation due to spicules of bone. After the
skull has been bored the pus or blood
will be evacuated if it lies between
the bone and dura mater. If none is
found, and the dura bulges into the
opening and does not show pulsation
an incision should be made through
this membrane with the object of
reaching any collection beneath it. If
the symptoms of cerebral abscess have
been very characteristic and death is
imminent it is justifiable to puncture
the brain in various directions with
an aspirator needle or grooved direc-
tor in order to reach the purulent
deposit. In the event of discovering
a large hemorrhagic effusion from a
meningeal vessel, torsion of the artery
may be required. If this fails a tre-
phine may be again applied over the
course of the vessel, and a ligature
applied after removal of the disk of
bone. After reaching an abscess of
the brain the surgeon must be on the
alert to keep the orifice open and not Cyrtometer applied, showing G, gla-
let it become closed by granulations. belia, R, junction of line of Rolandic fis-
Injections of carbolized or other anti- sure with median line from glabella to
septic solutions into the abscess cavity inion. (PARK.)
and the use of drainage-tubes will
contribute to the successful treatment of such cases. There are now on
record numerous instances of trephining and brain puncture for extrava-
sated blood, cerebral abscess and for the removal of brain tumors, which
have been followed by recovery.
INJURIES OF THE BRAIN.
Under this heading I shall discuss wounds, concussion, and compression
of the brain, leaving fractures of the skull to be treated in the chapter
on Diseases and Injuries of Bone.
SCALP Wounds.--It is usual for writers to devote a section or two in
this connection to descriptions of scalp wounds. The proximity of the
brain to the part wounded and the possibility of the vulnerating force
having fractured the skull or caused brain injury at the time the scalp
wound was inflicted should make the surgeon cautious in watching symp-
toms and careful in the treatment of scalp wounds; but there is nothing
intrinsically special in such injuries. They should be rendered aseptic
and be approximated by sutures, and their complications, such as hemor-
rhage, abscess, and erysipelas met as in ordinary wounds. The pin suture
is a favorite of mine as it controls the bleeding, which is apt to be profuse
because of the great vascularity of the scalp. It is easy, however, to con-

192 DIS E A SES AND IN J U RIES OF NERVO US CENTRES.
trol hemorrhage by a tight bandage around the head, for the cranium
gives a firm surface against which to make pressure.
Wounds of THE BRAIN.—Wounds of the brain are usually accom-
panied by fracture of the skull. Such is not the case, however, when
laceration from sudden jarring occurs, or when punctures are received
through the fontanelles or other openings in or between the bones.
Wounds of the anterior and superior region are less serious than those of
the base or posterior part of the encephalon. Very serious wounds result
when fragments of a fractured cranial bone are driven into the meninges
and brain substance. Gunshot wounds are also very destructive.
The symptoms of brain wounds depend upon the situation of the injury
and the amount of nervous tissue involved, as is easily understood from
the foregoing remarks on cerebral localization. Shock, paralysis, and
perhaps unconsciousness, in varying degrees, are the early symptoms of
brain wounds, and are soon followed by local or general inflammation of
the brain. Portions of brain material may be cut off by the surgeon or
carried away by extensive injury and recovery be not only possible but
even probable if the parts are kept or soon rendered aseptic.
TREATMENT.-The treatment of brain wounds is embodied in two pre-
cepts: Remove the foreign body, if any exists and it can be withdrawn
without inflicting grave additional injury; and prevent, or at least limit,
the secondary inflammation that is liable to follow the wound, by antisepsis
and most thorough drainage.
Probing brain wounds to discover the locality of a bullet or any missile
should be done only with great care and with aseptic precautions. A large-
headed probe of aluminium is the best instrument and should be allowed
to follow the bullet-track by its own weight when the patient's head is so
placed that gravity will carry the probe in the course of the wound.
Trephining to give access to the foreign body is proper, and thorough
drainage by means of rubber tubes is essential to cure. Measures calcu-
lated to combat encephalitis should be employed. Secondary abscess
must be diagnosticated and treated as described in the section on cerebral
inflammation. Recent observation has shown that the brain can be
punctured, incised and excised with a great degree of impunity, provided
the internal ganglia are undisturbed and these operations are rigidly
aseptic.
It occasionally happens that through the opening in the membranes and
skull there occurs during the progress of inflammation a fungoid protru-
sion of brain matter mingled with lymph, pus and blood. This consti-
tutes the condition called hernia, or fungus, of the brain, which is liable to
continue until either exhaustion or the damage done the nervous centres
by inflammation causes a fatal issue.
Fungus of the brain demands no special line of treatment; but clean-
liness in removing the discharges and the use of antiseptic dressings are
proper. Moderate pressure upon the mass may be attempted, but it is
liable to do harm by causing retention of the secretions within the cranial
cavity. To cut off the protuberance is not infrequently good surgery.
The possibility of fungus of the brain occurring must be remembered
when operations are performed which are liable to divide the dura mater;
hence, the dura mater should be carefully sutured after the removal of
tumors of the brain. It is understood that provision for drainage must
be made through the dural incisions, by tubes, or strands of catgut or
horsehair.
C O N C USS I O N OF TH E B R A. IN. 193
CONCUSSION, CONTUSION, AND LACERATION OF THE BRAIN.
DEFINITION.—The term concussion has long been used to designate the
symptoms which follow vibration of the brain consequent upon blows
received directly upon the skull or transmitted there through the spinal
column. It was supposed that a man might die instantly from concussion
of the brain, without receiving any physical lesion of the brain substance.
PATHOLOGY.—This assumption I believe to be false, for fatal cases of
so-called concussion of the brain exhibit, on careful examination, con-
tusion or laceration of the brain, separation of the dura mater from the
bones, compression from clot, or some distinct lesion of the contents of the
cranium. Death in cases in which no such evidence of brain injury has
been found, has not infrequently been attributed to concussion of the
brain, without an investigation of the spinal cord and heart. Fatal
changes would probably have been found there. I admit the possibility
of the vibration causing a molecular change in the nervous cells, the
capillaries, or the cerebro-spinal fluid, which could not be appreciated by
our ordinary methods of investigation, and which still might be capable
of producing the symptoms found in slight concussion; but when death
occurs in cases denominated concussion of the brain, I believe that dis-
tinct lesions, if carefully sought for, will always be found.
If a vessel containing jelly, of the consistence of the brain and contain-
ing similar cavities, was forcibly struck, fissures could easily be produced
in the mass by irregular transmission of the vibrations of force. So, I
believe, do lacerations and contusions of the non-homogeneous brain
OCCUll’.
In my opinion, then, concussion of the brain is not a functional condi-
tion, but is used to designate organic changes. The term, therefore,
should be discarded for contusion or laceration.
Cases of slight concussion very much resemble a similar degree of that
obscure condition called shock. It is, perhaps, possible that a sudden
moderate force applied to the head, containing cerebro-spinal and sympa-
thetic nerve centres, causes pallor, vertigo, and confusion of ideas by the
same pathological change that occurs when peripheral nerves are injured.
When greater violence is offered to the brain it is to be expected that,
in addition to the condition of shock, symptoms will be presented due to
the laceration which necessarily occurs because of the jelly-like consist-
ence of the brain. This view is partially substantiated by the statement
of some surgeons that, in all instances of concussion severe enough to cause
unconsciousness, serious symptoms are liable to ensue. This theory would
place under the head of shock those temporary symptoms now called
slight concussion, and would class all other instances of brain injury of
a similar character as contusion or laceration of the brain.
Lacerations and contusions of the brain may be multiple, giving rise to
numerous minute extravasations of blood, scattered throughout the brain
and scarcely distinguishable from the normal vascular points seen on
Section. On the other hand, hemorrhage from the torn vessels may be so
great and so diffused as to produce symptoms of compression of the brain,
thus greatly obscuring the diagnosis. The irregularity of the base of the
skull causes laceration to occur most frequently in the corresponding region
of the encephalon.
CAUSES.–Direct violence to the head, or force applied to the legs or
buttocks and transmitted through the spinal column to the cranial bones,
I 3
194 DISE ASES AND IN J U R IES OF NERVO US CENTREs.
are the causes of contusions and laceration of the brain. A blow on one part
of the cranium will often give rise to laceration of the brain at the oppo-
site side without there being any marked injury to the cerebral tissue im-
mediately underlying the bone struck. This is due to the soft consistency
of the brain, and is termed contusion by counter-stroke.
SYMPTOMS.—When a slight blow has been received by the brain the
patient at once becomes giddy, is confused in his ideas, feels weak, staggers
and perhaps would fall if not steadied by grasping some neighboring sup-
port. At the same time his face becomes pallid, and his heart's action
feeble. There is a feeling of nausea, and vomiting sometimes actually
occurs. These slight cases do not exhibit actual unconsciousness, but the
patient is “stunned,” and for a moment is not able to collect his thoughts.
He in a moment promptly returns to his normal state.
This is the condition in which it is possible, perhaps, that no laceration
of mervous structure or blood vessel occurs; and such cases are those that
resemble surgical shock of slight severity.
The violent shaking of the brain caused by the application of a severe
force is followed by symptoms of gravity, which are due, in my opinion,
to the production of contusion or laceration of the brain or its membranes.
The patient is almost, but, as a rule, not completely, unconscious; lies
motionless with a cold, pallid skin, has a feeble, fluttering pulse and
heart, and sometimes passes urine and feces involuntarily. The insensi-
bility is not a complete coma, for usually the patient can be roused by
loud questioning to utter a monosyllable or a groan. The pupils vary
in different cases as to contraction or dilatation, and the two eyes may not
be alike in this respect. Usually the pupils react to the stimulus of light.
The breathing is quiet, though it may be feeble and shallow ; there is no
hemiplegia, and the limbs if pricked with a pin will be withdrawn, though
probably in a lazy manner. Vomiting is liable to occur as the patient
begins to react from the semi-unconscious condition which has immediately
succeeded the injury. Convulsions sometimes take place after such cere-
bral injuries. The location of the contusion is an important factor in the
determination of special symptoms. The symptoms just described may
last a few hours or a day, before signs of recovery or of progressive in-
flammation supervene. When return to health is to ensue, the symptoms
of brain contusion slowly subside and the patient’s functions assume their
normal condition. It often happens, however, that headache, vertigo,
impaired memory, and other cerebral sequelae remain. . When the issue
of the injury is to be an unfavarable one, the patient either sinks into a
comatose state, without reacting, or, if he does react, soon presents the
characteristic symptoms of encephalitis.
The prognosis is grave in all cases of contusion of the brain, because it
is impossible to define accurately the extent of the lesion, and because
even slight lacerations and contusions are liable to impair the mental
functions and the special senses. All injuries producing vibration or con-
cussion of the brain that are followed by the semi-unconsciousness men-
tioned are serious, because there is organic lesion of the brain tissue.
Some writers speak of three stages of concussion of the brain—namely:
collapse, reaction, and inflammation.
I object to this division, and, indeed, ignore entirely the term concussion
of the brain, since I do not believe in the existence of a functional dis-
turbance of the brain without organic lesion. Concussion of a muscle or
bone causes a definite lesion called contusion, laceration, fracture; so
concussion of the brain, if it produces symptoms, must cause an organic
C O M P R E SSI O N OF T H E B R A. I. N. 195
lesion. In cases subjected to careful autopsy such lesions are found,
though it is possible that instances may occur in which organic change is
too slight to be appreciated by our present knowledge and means of in-
vestigation.
Concussion or vibration of the brain should not be considered a condi-
tion of disease of the brain, but merely a cause of contusion and lacera-
tion of the organ. Let the term concussion, as usually employed, be
dropped, and contusion or laceration substituted, and such symptoms as
those I have been describing will be better understood and better treated.
The three stages of concussion, called the stage of collapse, that of reaction,
and that of inflammation, are relics of the old nomenclature, and are un-
necessary. If concussion is synonymous with contusion or laceration, as
it should be, the occurrence of reactionary and inflammatory phenomena
is readily intelligible.
TREATMENT.-As the symptoms are those of shock, combined with
those of brain contusion and laceration, the treatment is obviously clear.
At first absolute quiet in the supine position, with the feet elevated slightly
and the head low, should be enjoined. A darkened room and an oppor-
tunity to sleep should be afforded. Stimulants will rarely be needed, and
should be avoided if possible; because, after the shock of injury has
passed away, cerebral excitation and plethora will tend to produce hem-
orrhage from the torn vessels, and to set up inflammatory engorgement.
Agents, such as ammonia, that stimulate momentarily, are preferable to
the more lasting alcoholic preparations. External applications of heat
or of mustard to the general surface may be available to relieve the
depression. When the pulse shows increasing strength, or there is evi-
dence in the reddening of the skin that reaction has commenced, the sur-
geon must adopt measures to prevent the occurrence of cerebral inflamma-
tion. The head should be elevated, cold applied locally, and bromide of
potassium, purgatives, and other remedies employed in the manner described
when speaking of inflammation of the brain from surgical causes. Even
bloodletting may be required, though in the early hours after the injury
such treatment might prove fatal. It requires the exercise of great judg-
ment to manage such cases. The measures appropriate for the first few
hours' treatment of contusion of the brain are diametrically opposed to
the line of treatment required after reaction has been induced. It is a
nice question to know when the change should be made. -
All cases of contusion of the brain, however slight, require surgical
Supervision for a long time. Indiscretions in mental work, in diet, or in
physical exercise may be very deleterious.
COMPRESSION OF THE BRAIN.
DEFINITION.—Compression of the brain is said to exist when pathologi-
cal lesions or changes exert such pressure upon the organ as to displace
the cerebral substance or cause flattening. The symptoms are probably
due, to a great extent at least, to the pressure impeding cerebrai circula-
tion and causing a local deficiency of blood supply. It is certainly not
likely that the amount of force exerted by extravasated blood, which so
often gives rise to compression symptoms, is sufficient actually to compress
and condense the brain substance. It would require comparatively little
* however, to interfere with the calibre of the capillary blood-
vessels.
196 DISE A SES AND IN J U R IES OF NERV OU S CENTRES.
CAUSES.–The causes of compression of the brain are: 1. Extravasa-
tion of blood upon the surface or in the interior of the brain. 2. Fractures
of the skull, accompanied by depression of the fragments. 3. Foreign
bodies driven through the skull upon the surface of or into the brain.
4. Inflammatory deposits of serum, lymph, or pus. In the second and
third instances bleeding, due to laceration accompanying the fracture or
wound, has frequently much to do with the occurrence of compression.
A comparatively sudden pressure seems to be requisite to produce com-
pression symptoms. If blood, for example, be slowly extravasated, the
brain seems to accommodate itself to its new relations, unless the amount
of blood be great.
SYMPTOMS.-A patient suffering with compression of the brain is dead
to external impressions, but the organic functions of respiration and circu-
lation continue. He lies on his back, totally unconscious and immovable,
with pupils unaffected by light, and one or both of them usually moder-
ately or considerably dilated. The respiration is slow (ten to sixteen per
minute), snoring, and accompanied by a peculiar whiff or puffing out of
the cheek at the corner of the mouth. The stertor is due to paralysis of
the palate muscles. It may be greatly diminished by turning the patient
on his side, so that the relaxed soft palate will not hang unsupported in
the current of air. The puffing out of the cheek is due to loss of power
in the buccal muscles. The pulse is slow and rather full, beating perhaps
not more than forty or fifty times in a minute. The urine is retained
until the paralyzed bladder becomes so distended that there is a dribbling
overflow. Constipation, followed by relaxation of the anal sphincter and
consequent incontinence of feces, is often found. Hemiplegia of the side
opposite the injury is usual. This cannot be determined in cases where
reflex sensibility is destroyed, unless it is evident from the distortion of the
face. The condition of the pupils and the extent and character of the
paralysis depend upon the situation of the compressing lesion. The group
of symptoms given are those found in typical cases of compression, and are
those of cerebral apoplexy, which is a form of compression.
Symptoms of compression due to depressed bone or to foreign bodies
lodged in the brain arise immediately after the receipt of injury. Extrav-
asation of blood, unless profuse, causes a gradual supervention of symp-
toms, while compression from inflammatory products appears only at a
later period. It is probable that a factor in many cases of compression
from depressed fracture is the concomitant occurrence of inflammation,
whose symptoms are blended with those due to the pressure which often is
too slight to cause in itself serious symptoms.
If the pressure is not relieved by treatment, and the cerebral mass fails
to accommodate itself to the new relation of parts, coma deepens, the
organic functions become gradually involved and death occurs. The time
occupied in the fatal invasion and destruction of these functions is usually
a few days, though it may extend through weeks.
DIAGNOSIS.—Typical cases of compression of the brain are readily dis-
tinguished from contusion or laceration (so-called concussion) of the brain
of moderate severity. If a laceration or contusion is sufficient to cause
much hemorrhage, however, compression symptoms will coexist and com-
plicate the diagnosis. So, on the other hand, laceration and contusion of
the brain substance is liable to result from the same force that produces a
depressed fracture and a consequent depression. Hence, it is often impos-
sible to determine accurately the pathological lesion.
C O M P R ESS I O N OF T H E B R A IN .
197
The points upon which a differential diagnosis may be founded in uncom-
plicated cases are given in the following table:
Compression.
1. Symptoms may not be immediate
after injury.
2. Complete unconsciousness and total
insensibility to impressions upon
organs of Sense.
. Respiration slow, stertorous, and puff-
I 110.
. Pulse slow and full.
. No vomiting.
. Retention of urine and often of feces.
. Paralysis, usually hemiplegia, of op-
posite side.
. Pupils insensible to light.
. Deglutition impossible.
;i3
Contusion or Laceration
(Comcussion).
Symptoms always immediate.
Partial unconsciousness and only impaired
sensibility to impressions upon organs of
SCI). SČ.
Respiration quiet.
Pulse frequent and feeble.
Sometimes vomiting.
Incontinence of urine and feces.
No paralysis.
Pupils react somewhat to light.
Deglutition possible.
In the absence of a history or the patient before unconsciousness
occurred, it is frequently difficult and sometimes impossible to discriminate
between coma due to compression of the brain, alcoholic or narcotic
poisoning, uraemia, apoplexy, sunstroke, and hysteria. An unconscious
man with bruises upon the head, picked up in the streets, may be suffer-
ing from brain compression due to injuries received while intoxicated;
or may have fallen from an elevation because of an apopletic seizure or
sunstroke, and thus have sustained secondarily a depressed fracture of the
skull. In such cases the head should be shaved, and careful examination
made for signs of injury to the skull; the urine should be examined for
albumin and tube casts, alcohol, opium, and other poisons; the tempera-
ture should be taken, and tests of electro-muscular sensibility and con-
tractility should be instituted.
The ophthalmoscope will sometimes be of service in disclosing albu-
minuric retinitis and choked disk, or other changes in the fundus.
The existence of paralysis in compression of the brain usually serves to
distinguish it from the conditions named, with the exception of apoplexy.
It is the compression produced by the hemorrhage in an apoplectic seizure
that induces many of the symptoms; hence, a diagnosis is impossible
unless the history and evidences of injury afford direct information. The
treatment, however, is identical in such conditions.
The odor of poisons, the contracted pupils of opium narcosis, the oedema
of chronic Bright's disease, the high temperature of sunstroke, and the
sex in hysteria will aid in the differentiation of some obscure cases. Such
evidence is fallible, however, and it may be that the surgeon’s opinion
must be suspended until the progress of the case clears up the obscurity.
º: patient may indeed be suffering from two conditions at the same
III) e.
... TREATMENT—Compression of the brain demands removal of the cause
if this can be done without inflicting more serious brain injury. Depressed
bone should be elevated; foreign bodies extracted; pus evacuated by
trephining ; extravasated blood removed and further bleeding prevented
by opening the skull, turning out the clots, and tying the vessel. These
9perative procedures are proper only when the existence of compression
is clearly established, and its cause and location known. Investigations
of the localization of cerebral lesions and improved methods of treating
198 DISE A SES AND IN J U RIES OF NE R Vous CENTREs.
wounds have made such operations more frequently justifiable than was
formerly the case. When such measures are not deemed wise, the patient
should be treated on the general principles laid down for the prevention
of encephalitis.
Purgatives, bromide of potassium, iodine and its compounds, mercury,
and bloodletting are the remedies to be employed. If hemorrhage is
supposed to be the cause of compression, the head should be elevated.
Enemas may be given to empty the lower bowel. The catheter must be
introduced twice or thrice daily to withdraw the urine from the paralyzed
bladder.
TUMoRS OF THE BRAIN.
Tumors of the brain may be fibromas, sarcomas, carcinomas, cystic
tumors, etc. They may have their seat between the dura and the cerebral
convolutions, or they may be more or less deeply imbedded within the
brain tissue. The symptoms depend upon the position of the growth and
its size. Epileptic convulsions, local paralyses and spasms, choked disks,
aphasia, and intellectual aberrations all occur. It is the simultaneous or
consecutive occurrence of these and other symptoms which enables the
neurologist to localize the position of the growth. If such a tumor does
not involve the basal ganglia, nor occupy a position so far under the base
of the brain as to make access impossible, it is proper to attempt its re-
moval by opening the skull and excising it. Such operations should be
done with the strictest antiseptic precautions and by means of a large
trephine and gnawing forceps. Provision must be made for drainage,
even if the opened dura mater is subsequently sutured, as it usually
should be, and if the button of bone cut out by the trephine is replaced
before the scalp flap is sutured into position. The details of such opera-
tions will be found in the various monographs which have recently been
written on this subject. -
Growths situated at some distance below the surface of the convolu-
tions are not accessible until the surgeon has incised the brain tissue.
This procedure is justifiable, if punctures carefully made with a probe or
grooved director give evidence of a tumor below the surface. When the
clinical history of the patient shows evidence of multiple brain tumors or
of a tumor which is evidently a secondary malignant growth, it is scarcely
proper to attempt removal. The diagnosis in cases of suspected brain
tumor is very difficult and requires the most careful consideration of the
skilled neurologist. It is probably true that surgeons usually have not
the special knowledge which enables them to make an absolute diagnosis
as to location. Hence, examination of the eye grounds, of the paralytic
symptoms, and of the epileptiform seizures should be made by those who
are trained to such matters. When a reasonable diagnosis has been made
by such expert observation, it is proper to perform an exploratory opera-
tion.
DISEASES AND INJURIES OF THE SPINAL CORD.
Hydrorachis or Bifid Spine.
Hydrorachis is a congenital protrusion of the membranes of the spinal
cord and sometimes of a portion of the cord itself or of the spinal nerves
through an opening in the posterior part of the vertebral column. The
DISE As Es AND IN J U RIES OF THE SPIN AL CO R D. 199
deficiency of the bony wall is due to imperfect development of the
laminae and spinous process of one or more vertebrae; hence, the name of
bifid spine. The protruded membranes are distended by cerebral spinal
fluid forming an elastic and sometimes fluctuating tumor. A more proper
name would be spinal meningocele. Those protrusions containing por-
tions of the cord would then be called myeloceles. The deformity occurs
most frequently in the lumbo-sacral region.
Section of
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Dissection of hydrorachis. (BRYANT.)
The tumor varies in size and in tenseness with the position of the child,
and in occasional instances has no cutaneous investment whatever, being
a mere sac of thin spinal membranes. It is apt to become more tense or
larger when the child cries. The fluid can sometimes be pressed back
into the spinal canal so that the edges of the fissure in the bones can be
distinctly felt. Hydrocephalus and other deformities are often found in
the same infant. Paralysis is not uncommon. Death generally occurs
from meningitis, convulsions, or paralysis, or from rupture or ulceration
of the sac.
Support and moderate pressure by means of elastic bandages or cup-
shaped pads afford proper palliative treatment. When the growth is
rapidly increasing a portion of the fluid may be withdrawn by an aspira-
tion-needle, introduced at the side of the median line where nerves are
not likely to be situated. If the orifice of communication with the spinal
canal is small, injections of tincture of iodine, ligation with the elastic
ligature, or excision may be practised. All tumors over the spine in
children are not cases of bifid spine; but the possibility of this condition














200 DISE ASES AND IN J U RIES OF NER V OU S CENTRES.
existing should always be in the surgeon’s mind before undertaking
Operation.
INFLAMMATION OF THE SPINAL CORD FROM SURGICAL CAUSEs.
VARIETIES.—The inflammatory process may be located in the mem-
branes (spinal meningitis), or in the substance of the cord (myelitis). It
frequently happens that meningitis and myelitis are associated.
PATHOLOGY..—In traumatic cases the inflammation is usually local, but
the pathological changes may gradually spread along the spinal marrow.
Injection of vessels, effusion of serum, exudation of lymph, formation of
pus, and softening of nervous structure are the results found at the after-
death examination. Sclerosis may occur in chronic cases.
CAUSES.—Intraspinal inflammations of surgical causation arise from
contusions or lacerations, and other direct wounds of the contents of the
vertebral canal; and from fracture, caries, and necrosis of the vertebrae.
SYMPTOMS.–There are certain differences in the symptomatology of
meningitis and myelitis which will be discussed in speaking of diagnosis.
Here the symptoms of spinal inflammation in general will be described.
As the cause is local the inflammation is limited ; hence, chills, high
fever, and great constitutional disturbance are unusual. Pain in the
spinal region, aggravated by motion or pressure, and often reflected along
the nerve trunks, is exhibited. Burning and tingling sensations and a
feeling of insects creeping over the body; local hyperaesthesia of the
surface; more frequently cutaneous anaesthesia; delay in perceiving the
contact of points; and a sense of constriction about the body marking the
upper limit of the disease are common symptoms of inflammation of the
cord and its coverings.
Muscular jerkings and spasms, and Subsequently permanent muscular
contractions, affecting the muscles supplied from the diseased region, are
especially associated with meningitis. Motor paralysis below the seat of
lesion is usually present, being much more permanent and complete in
myelitis.
The palsy, as a rule, involves both sides, and is due to division, com-
pression, or disorganization of the nerve fibres of the cord. If paraplegia
occurs immediately after the receipt of injury, it indicates that the fibres
are divided, or have been compressed by displaced bone or extravasated
blood. A slowly determined paralysis suggests inflammatory pressure or
disorganization. Injury of one side of the spinal marrow would give rise
to unilateral palsy on the same side. It is possible in lesions of the cervico-
dorsal area of the cord to have motor paralysis of the arms and not of
the legs. As the cord terminates at the level of the second lumbar ver-
tebra, injuries below this point are accompanied by no paralysis, or by a
slight and temporary form only which depends upon lesions of the loose
bundle of nerves called the horsetail. The Small diameter of the cord
immediately above its lower end and the envelopment of this termination
in the nerve roots going down the vertebral canal serve to prevent severe
involvement of the cord, even at a somewhat higher level than the lumbar
vertebra mentioned.
The seat of the cord lesion can often be determined by the limitation of
the motor or sensory paralysis. The muscles and regions supplied by
branches given off from the spinal marrow below the injury are usually
the only ones that lose their innervation. On account of the downward
distribution of the nerves as they leave the cord, the lesion is generally
IN FL. A. M M AT I O N OF T H E S P J N A L CO R D . 201
somewhat higher than the horizontal line marking the upper limit of the
palsy. An exception to this may occur when the terminal nerve filaments
are distributed upward. This occurs especially in the skin.”
The paralyzed parts are exceedingly liable to severe bedsores. These
are due to the impaired innervation and circulation and to the unrecog-
nized irritations which the insensible and immovable parts receive. The
local temperature of the palsied limbs is often high. Atrophy soon occurs.
Bedsores and atrophic changes are more marked the longer the patient
survives. Hence, in injuries low down in the cord these nutritional
changes are exceedingly conspicuous.
Retention of urine occurs nearly always. When the paralyzed blad-
der has become fully distended, there is a dribbling overflow, which
is an indication for an immediate catheterization, lest rupture of the
bladder or other harm result. After a few days’ incontinence of urine
relaxation of the sphincter supervenes. The bladder is thus kept nearly
empty. At the same time the urine exhibits chemical changes, becoming
alkaline, turbid, ammoniacal and filled with mucus and phosphates.
Inflammation of the bladder is usually found at this period, due either to
the distention and catheterization, or the alkaline urine, or perhaps to
both. Other changes, such as the presence of sugar, are occasionally
witnessed.
Priapism, either spontaneously exhibited or following catheterization
and handling of the genitals, occurs in many instances where motor palsy
is a symptom. It has no connection with sexual feelings, and only exists
when loss of motion is present.
Incontinence of feces is seen when the sphincter is paralyzed by injury
to the lowest region of the cord. If the damage is effected higher up,
constipation is the condition exhibited. This may subsequently be
followed by looseness of the bowels.
Dyspnoea and hurried respiration result when the spinal inflammation
is located in the upper dorsal and cervical regions because of paralysis of
the intercostal and serrated muscles. If the injury disorganizes the cord
above the origin of the phrenic nerve, or if inflammatory destruction
ascends thus far (to the third or fourth cervical vertebra), death occurs
instantly from paralysis of the diaphragm. Difficulty of respiration is
experienced in intraspinal troubles in the lower dorsal region ; first,
because there is paralysis of the abdominal muscles which aid expiration,
and also because the loss of muscular tonicity here allows tympanitic dis-
tention of the intestines to occur and interfere with the descent of the
diaphragm.
When the sympathetic cardiac nerves are interfered with by lesions in
the cervico-dorsal region, the pneumogastric nerve can then exert its in-
hibitory function unrestrained, and the heart's action is slowed. Other-
wise the pulse is influenced merely by the general state of the patient.
There are many other symptoms of intraspinal inflammation which
depend upon the location of the lesion and the nervous centre consequently
involved. From these the location of spinal lesions is established with
considerable certainty. It must be remembered, however, that in some
cases brain injury has been associated with the spinal hurt. It is occa-
sionally difficult to differentiate the spinal from the cerebral symptoms.
* See Spinal Localization in its Practical Relations. Therapeutic Gazette, May and
June, 1889, by Dr. Charles K. Mills.
202 DISE ASES AND IN J U RIES OF NERV OU S CENTREs.
Unconsciousness, when present, renders the diagnosis of cerebral involve-
ment clear.
DIAGNOSIS.–Memingitis and myelitis are often combined, but the pre-
dominant affection can, at times, be diagnosticated by the character of the
symptoms. In meningitis there is more pain on motion, more cutaneous
hyperasthesia, more twitching and permanent contraction of muscles, less
impairment of motility, less involvement of the bladder and rectum. Effu-
Sion occurring in meningitis may cause paraplegia by pressure on the cord,
but the paralysis is not as complete as in myelitis, and varies in its degree.
In myelitis the loss of power occurs earlier and is more marked, electric
contractility and reflex movements are soon impaired, and the sense of
constriction about the trunk is conspicuous. Priapism, urinary complica-
tions, bedsores, and nutritive changes are usual.
PROGNOSIS.—The higher the seat of inflammation the graver the prog-
nosis as to prolongation of life, because more of the vital functions are
impaired. Myelitis is a much more serious affection than meningitis, and
is seldom followed by restoration of the paralyzed limbs. If the injury is
low down in the spine, or if, when higher, it implicates a limited area of
the cord, recovery of a fair amount of health occasionally takes place.
Contractures and paralysis, however, usually remain. Sensation is usually
regained sooner than motion.
TREATMENT.-Intraspinal inflammation requires a line of treatment
similar to that recommended in encephalitis. Rest, preferably in the
prone position, the ice-bag, leeches or wet cups locally ; hydragogues,
iodide of potassium (gr. X to 3.j), or mercury to slight ptyalism, and fluid
extract of ergot (fºss to fºj), given internally several times daily, are the
proper measures in acute cases. Morphia and bromide of potassium may be
employed to relieve pain and induce functional rest. Atropia is an appro-
priate remedy in meningeal congestion. When the condition is subacute,
blisters or the actual cautery may be applied to the spine and the induced
current to the paralytic muscles with advantage. Hammond says that in
acute partial myelitis he has got benefit from large doses of ergot, and the
actual cautery applied along the sides of the spinous processes. Strychnia
is to be avoided in spinal meningitis. The paralyzed muscles of chronic
myelitis should be treated by means of electricity, massage, the hot and
cold douche, and subcutaneous injections of strychnia, in the endeavor to
prevent atrophy and restore power. Syphilitic meningitis and myelitis
especially call for mercury and iodide of potassium in active doses.
Suspension by the shoulders and head from a tripod, so as to extend
the spinal column by the weight of the lower limbs, has been advocated in
some forms of chronic disease of the cord.
When retention of urine exists, the catheter must be passed three times
daily. The cystitis that arises later and is accompanied by phosphatic
urine, is alleviated at times by carefully washing out the bladder with
mitric acid and water (mºv to fj). Even if incontinence has occurred, it
is well to pass the catheter once every three or four days to empty any
decomposing residual urine.
An attempt at preventing bedsores should be made by seeing that there
are no folds in the sheets, by bathing the prominent points of back and
limbs with alcohol, and by keeping them free from contact with the urine
and feces. It is well to place the patient as soon as possible upon an air
or water bed. A good water bed can be improvised by partly filling a
long tank or tub with water, and nailing a rubber blanket over the top, so
that it will rest upon the surface of the water.
N E U R ITIS, OR IN FLA M M ATION OF NER V E S. 203
If a clear diagnosis of abscess within the spinal canal was made, it
would be justifiable to trephine the vertebra, or to saw away the laminae
in an effort to evacuate the pus. In localized inflammation due to frac-
ture or other cause, trephining followed by separation of the adherent
membranes and cord might possibly give relief to the symptoms. Explo-
ratory operations here, as in brain diseases, are justifiable."
WOUNDS OF THE SPINAL CORD.
Wounds of the spinal marrow may be produced by gunshot injuries, by
fractures of the spinal column with displacement, or by pointed instru-
ments thrust between the vertebrae. The symptoms will be those pre-
viously detailed as occurring in injuries and inflammation of the cord.
They will vary with the locality of the wound. Such wounds, involving
a limited portion of the diameter of the cord will be followed by a limited
paralysis, corresponding with the fibres divided. t
The treatment of wounds of the cord is such as is detailed for arresting
and treating intraspinal inflammation. When fragments of the vertebra
are driven in upon the cord instrumental elevation is justifiable, but the
diagnosis of such compression is often difficult. Exploratory operation
may then be demanded. s
CONCUSSION OR CONTUSION, AND LACERATION OF THE CORD.
Shocks, whether direct or indirect, to the spinal column are not trans-
mitted to the cord as readily as similar blows are to the brain, because
the cord hangs loosely in the canal, and is surrounded by the spinal fluid.
I believe that cases denominated concussion of the spine are really in-
stances of contusion or laceration of the cord or its membranes or of
extravasation from rupture of the spinal veins. The progressive spinal
symptoms described by Erichsen as occurring after the jarring of railway
accidents, and attributed by him to so-called spinal concussion, are, in my
opinion, probably due to slight contusion or laceration of the contents of
the spinal canal.
Contusion and similar injuries of the cord require treatment adapted to
preventing and allaying inflammation of this nervous centre.
NEURITIS, OR INFLAMMATION OF NERVEs.
CAUSES.–Neuritis, which may be acute or chronic, arises from expo-
sure to cold and wet, wounds, strains causing laceration of the nerves,
rheumatism, gout, and syphilis. Acute neuritis is particularly liable to
follow laceration of nerve-trunks; and yet nerves may often be exposed
to considerable traumatic irritation without becoming inflamed.
PATHOLOGY..—An inflamed nerve shows changes in the neurilemma
and nerve-fibres. Hyperaemia, increased connective tissue, serum, lymph,
and pus are the inflammatory changes associated with the former; while
granular and fatty changes followed by softening and atrophy occur in
the latter. In acute neuritis the nerve-trunk is swollen from the depo-
sition of inflammatory fluids, and pus may be found within the sheath.
* See Surgery of the Spinal Cord, by Dr. J. William White. Annals of Surgery, July,
1889.
204 I) IS E A S E S A N ID IN J U R IES OF N E R W E S.
If the nerve is superficial a hardened cord is often felt beneath the skin.
In chronic inflammation an increase of the connective tissue, leading to
Sclerosis and consequent nerve atrophy, is the usual pathological change.
SYMPTOMS.–Inflammation of nerves causes disturbance of physiological
function, hence the symptoms vary as the nerve-trunk is motor, sensory,
or mixed. Inflammation of nerves of special sense, such as the optic and
auditory, is not discussed here, but belongs to the domains of ophthal-
mology and otology.
The first effect of inflammation is to increase the irritability of nerves,
but, as it continues, a diminution of nervous excitability is induced.
Hence, in motor neuritis, twitching and spasm of the muscles occur at
the time of invasion, and are followed by paresis or complete loss of power
if the inflammation is not speedily arrested. Sensory neuritis exhibits
mainly pain and hyperaesthesia followed by analgesia and anaesthesia.
When the inflammatory process resides in a mixed nerve, as it generally
does in cases met by surgeons, these classes of symptoms are combined.
Reflex influences may at times, however, cause the appearance of symp-
toms of a motor character, even when a purely sensory nerve is inflamed.
For example, neuritis of the trifacial will be accompanied by twitching
of some of the muscles of the face. The term causalgia is applied to the
peculiar burning pain of some nerve inflammations.
Inflammation as found in neuritis of the sciatic, radial, and similar
nerves, then, is exhibited by pain, of a remittent, but not intermittent,
character, increased by pressure, often worse at night, and especially
severe when due to traumatism. There will perhaps be reflex symptoms
such as pain in other parts of the body. The painful sensations are felt
in the peripheral distribution of the nerve, and may exist even when the
skin has become anaesthetic. Reflex excitability and electric contractility
are soon diminished. The local temperature of the parts supplied is
increased, and the skin over the course of the trunk is red, and sometimes
the seat of a bullous eruption. A hard, painful, cord-like swelling is felt
along the course of the trunk, if it is a superficiul nerve that is involved.
Clonic spasms, loss of power, hyperaesthesia, anaesthesia, and atrophic
changes are supplementary symptoms.
Fever and other constitutional symptoms occur, varying in intensity
with the acuteness of the neuritis.
Chronic neuritis causes much less pain, but the other functional dis-
turbances are those already mentioned.
Neuritis may spread along the trunk to nerves nearer the nervous cen-
tres. This is called ascending neuritis. In a similar way changes may
occur above and spread downward, constituting descending neuritis. Neu-
ritis may be followed by ulceration, deformity of joints, and other second-
ary pathological conditions.
DIAGNOSIS.–Neuritis is distinguished from neuralgia by the continuous
pain, which may remit but does not intermit; and by the fact that the
pain is usually less severe than the paroxysmal pain of neuralgia. In
neuralgia, moreover, there is not the local elevation of temperature, the
muscular spasm, the paralysis of motion or sensation that have been
mentioned as symptomatic of neuritis.
TREATMENT.-Acute neuritis demands absolute rest and elevation of
the part, ice-bags locally, and, perhaps, local abstraction of blood, Deep
subcutaneous injections of morphia (grain to £) with atropia (grain ºw)
over the painful nerve, and the application of the primary galvanic
I N J U R.I.ES OF N E R W E S. 205
current has been useful. The general disturbance will probably necessi-
tate at the same time the use of diaphoretics and laxatives.
Chronic inflammation of nerves is to be treated by blisters, electricity,
the actual cautery and increasing doses of iodide of potassium, Hypo-
dermic injections of chloroform, solutions of osmic acid or of cocaine
may at times be serviceable. Nerve-stretching is a recently introduced
operation for chronic pain of nerve-trunks. The nerve is exposed by an
incision and stretched by being forcibly pulled out of its bed by the
surgeon's finger or a hook.
If the inflammation is due to rheumatism, alkalies and Salicylate of
sodium are indicated; if to gout, colchicum ; if to syphilitic causes,
mercury and iodide of potassium.
The actual cautery has been used also in acute neuritis with alleged
benefit.
The atrophied muscles are to be subjected to massage, electricity,
douches, and hypodermic injections of Strychnia (grain ºw).
Tomics and similar remedies will often be of value in chronic neuritis.
INJURIES OF NERVES.
Nerves are liable to be bruised and lacerated as occurs when the ulnar
is compressed against the internal condyle, and when the circumflex is
torn in dislocation of the head of the humerus.
They may be punctured, incised, completely divided, or have a portion
excised.
SYMPTOMS.–The symptoms in such injuries, whether open or subcuta-
neous, vary with the degree of damage done to the nerve-fibrils. Slight
contusions cause pain at the point of injury and tingling or numbness
along the peripheral branches. Other wounds give rise to pain followed
by paresis or paralysis. Sometimes pain is absent. A foreign body
impacted in a nerve is apt to cause spasmodic action of the muscles in
addition to the pain and other symptoms.
Subsequent to the receipt of injury the symptoms of neuritis occur.
Neuralgia is often developed as a sequel to nerve wound. This is espe-
cially the case in hysterical subjects. When the nerve is compressed or
dragged upon by the cicatrix of the wound in the other tissues, nutritive
changes take place in the parts deprived of innervation. These consist in
atrophy and contracture of muscles; alterations in the nails; and changes
in the skin, which may become shining and swollen or eczematous; low-
ered local temperature; loss of hair; and subacute arthritis.
The ends of a divided nerve retract, become bulbous from the deposi-
tion of lymph, and, after the lapse of several weeks or months, are
re-united by the development of nerve tissue, thus having their function
restored. This will at times happen even when a considerable piece of
nerve has been cut out. Hence, when it is desirable, after operation for
neuralgia that union should not occur it is necessary to excise a long piece
of nerve trunk or turn back the distal end. During the period required
for restoration of function the neighboring nerves seen at times to fulfil,
in part at least, the duties of the injured trunk in much the same manner
as the collateral circulation is carried on when an artery is obstructed.
TREATMENT.-Subcutaneous nerve injuries need only such treatment as
will prevent or allay the resulting neuritis. Hypodermic injections of
morphia and atropia, cold, or perhaps hot applications, and galvanism
206 D IS E A S E S A N D IN J U R IES OF N E R W E S.
locally, with quinine or other appropriate remedies internally, are judi-
cious measures. Other local remedies of value are belladonna extract,
menthol, chloroform and aconitia, used as lotions or ointment, blisters,
leeches, and the actual cautery. In open wounds, where there is a
tendency to considerable separation, union can very properly be hastened
by suturing the extremities together with catgut. No special manner of
introducing such stitches is required, if only approximation is accurately
made.
The after-treatment is that calculated to prevent neuritis. If a wound,
in which there was a large nerve divided has healed and permanent paral-
ysis remains, it may be justifiable to expose the nerve, cut off the bulbous
or atrophied extremities, and apply sutures. Considerable success has
been obtained in restoring motion to limbs, the subject of traumatic
paralysis from accidental nerve section. Pieces of nerve tissue from the
rabbit may be sutured in the gaps left by destruction or excision of
nerve trunks.
Neuralgia, due to cicatricial pressure, is treated by excising the innod-
ular tissue, and thus getting rid of the scar and the pinched nerve. Other
neuralgias after nerve injuries require the treatment detailed in the article
on Neuralgia.
Newralgia.
DEFINITION.—The term neuralgia was introduced into medical language
to signify pain referred to the course of a nerve without apparent lesion.
The pain was said to be functional. Pathological observation, however,
has shown that many instances of pain, formerly called neuralgia, are
really due to inflammation or compression of the nerves, or to other defi-
nite organic changes. Neuralgia should, therefore, be restricted to nerve
pain in which no lesion is evident, though more accurate pathological
knowledge will doubtless still further lessen the cases to which the name
is appropriate.
Neuralgia then may be defined as pain, usually paroxysmal, situated
not in the brain or cord but in the nerves themselves, and due to no dis-
coverable organic lesion.
CAUSES.—The chief constitutional cause of neuralgia is debility. When
the powers of life wane from old age, or when anaemia exists in young or
old, there neuralgia is liable to appear as an unwelcome visitor. Malaria
is a very frequent cause of neuralgia, especially of the trifacial nerve.
Hysteria, exposure to wet and cold, reflex irritation from uterine disease,
syphilis, rheumatism, and gout are considered factors in the etiology of
neuralgia. Some of these probably cause nerve-pain by inducing neuritis
and not true neuralgia. The same fallacy is likely to underlie cases of
neuralgia attributed to diseased teeth, necrosis of bone, and periostitis.
Compression of nerves by tumors and periostial thickening gives rise to
neuralgic pain.
SYMPTOMS.—The most frequent situations for neuralgia are the terminal
branches of the three divisions of the trifacial nerve, the sciatic nerve, and
the intercostal nerves. Neuralgia may be seated in a number of small,
nervous twigs, distributed to an organ or surface of considerable size;
thus, we have neuralgia of the breast, of the testicle, and of joints.
The pain of typical neuralgia is sudden and paroxysmal. It occurs as
a tearing, darting shock or pang followed by an interval of more or less
complete absence of pain. In many instances there is a dull, aching pain
N E U R A L G. I. A. 207
continuously, to which are added at irregular intervals the painful ex-
acerbations. Muscular exertion generally, and pressure sometimes, though
not usually, aggravate the pain. Neuralgia shows quite a tendency to be
unilateral, and often there is exhibited marked cutaneous hyperaesthesia.
Points of tenderness on pressure can, as a rule, be found along the
course of the nerve. These are situated where the nerve passes through
a bony foramen, pierces the deep fascia, or comes near the surface of the
body. Occasionally tenderness is exhibited over the part of the spinal
cord from which the nerve takes its origin.
Local muscular spasm is found associated with some neuralgias, as are at
times a hot, red, swollen skin and increased secretion of the neighboring
lachrymal or salivary glands. The peculiar vesicular eruption called
herpes zoster is developed over the line of a neuralgic nerve.
Patients who have once suffered with neuralgia are liable to similar ex-
perience at every exposure to the exciting cause.
The location of the neuralgia may vary with each attack. Indeed, the
pain is very liable to change from one nerve to another.
Neuralgia, particularly of the trifacial nerve, is often very intractable,
but it is not a disease dangerous to life.
DIAGNOSIS.–It is easy to differentiate a typical neuralgia from marked
organic disease. There are no alterations in shape or volume, no signs of
inflammation, no fever, but paroxysmal pain, cutaneous hyperaesthesia,
and a history of debility, malaria, or hysteria. Firm pressure frequently
relieves neuralgic pain, if it is continued until the hyperaesthetic skin has
become accustomed to the contact of the hand. The tendency of neuralgia
to be transferred from one nerve to another is a valuable point in diag-
nosis. In many cases, however, neuralgia can only be presumed to exist,
because the pain cannot be attributed to any other affection. Muscular
and fascial pains due to rheumatism or syphilis are often mistaken for
neuralgia.
TREATMENT.-As the constitutional condition underlying neuralgia is
usually either debility or malaria, quinine and its congeners are the most
useful internal remedies that we have. Quinine should be given in full
doses even when no malarial history can be obtained. Twenty to thirty
grains in the twenty-four hours may be curative when less doses have
accomplished nothing. If this drug fails, recourse should be had to
arsenic. The solution of arsenite of potassium should be given in doses
of five to ten minims three times daily after eating, and be gradually in-
creased. The same preparation may be employed hypodermically in
about half this amount, diluted with water and also increased by degrees.
Iron, strychnia, and cod-liver oil in large doses frequently repeated, gal-
Vanism, good nutritious diet, fresh air, sea bathing, change of scene and
climate are valuable agents in combating the tendency to neuralgia. In
hysterical subjects, valerian, bromide of potassium, and assafoetida may be
available; in rheumatic cases, alkalies; in those of gouty diathesis, col-
chicum ; and in syphilitics, iodide of potassium or mercury. Ergot and
phosphorus have been recommended by high authority. -
Uterine or other affections giving rise to neuralgia by reflex influence
should be remedied by appropriate measures.
To relieve an attack of neuralgia, when present, morphia, atropia,
chloral, hyoscyamus, bromide of potassium, alcohol and the inhalation of
anaesthetics have a positive value. The use of such remedies is to be
deprecated and their repetition avoided as far as practicable, because of
the early necessity of increasing the dose and the liability of inducing in-
208 DIS E A SES A N D IN J U R IES OF N E R W E S.
temperance in their employment. Neuralgic patients, for this reason,
should not be informed of the name of the remedy administered. Aconitia
may be given in doses of gr. 3 #5 and gradually and very cautiously in-
creased. The benumbing effect of this powerful drug on the peripheral
nerve is well known. Menthol locally gives at times relief.
The local treatment of neuralgia deserves attention. Any suspected
local cause, such as diseased teeth or cicatricial pressure, should be re-
moved. In many of these instances, however, the pain is probably due to
a neuritis and, hence, is not true neuralgia. Hypodermic injection of
morphia (gr. #-gr. 4) into the nerve trunk or in its in mediate neighbor-
hood is a potent remedy and may not only palliate, but by repetition even
cure. The needle of the syringe should be thrust deeply into the tissues
and, if possible, into the nerve. Atropia (gr. Gº-gr. jº) alone or com-
bined with morphia, ether (m, x-xxx), chloroform, or bromide of ethyl,
or solution of osmic acid may be employed in a similar manner. These
and other sedatives may also be used in the form of liniments and oint-
ments. Aconitia (gr. v to 3.j of ointment), veratria (gr. xx to 3.j of oint-
ment), and menthol are often very efficacious local applications. Heat
and cold vary in different cases as to the amount of relief they afford.
The primary galvanic current is at times useful. Blisters, strong water
of ammonia. the actual cautery, and similar counter-irritants have a
positive value in some instances. Acupuncture and galvano-puncture
have been recommended.
Nerve-stretching, nerve-section (neurotomy), and nerve-excision (neu-
rectomy) are proper surgical expedients only when the neuralgia is very
severe and intractable.
Nerve-stretching is performed by making an incision over the trunk, iso-
lating it and lifting it out of its bed by a hook or the fingers. Strong
traction is then made upon it in the direction of the peripheral branches,
that is, away from the cerebro-spinal end, a considerable increase in the
length of the loop is apparent. If the operation is done without ether,
or if only local anaesthesia has been employed, the traction is to be con-
tinued until numbness of the periphery is experienced by the patient.
The operation is only painful on account of the cutaneous or muscular
incisions. The numbness and paresis of the parts to which the nerve is
distributed soon pass away. Nerve-stretching has accomplished many
cures of neuralgia. It has also been done for spasm of muscles. Strong
compression of a nerve against a bone or by a screw clamp may relieve
neuralgia by crushing the nerve fibrils.
Simple section of a nerve is of little value in obstinate neuralgia,
because union soon takes place; hence, excision of one or two inches is
much more successful. The neurectomy or excision should remove a por-
tion of nerve as far as possible behind the seat of pain, for this gives the
best chance of getting above the seat of pathological changes. The distal
end of the divided nerve may be turned back, or a portion of muscle may
be interposed between the ends to prevent union and recurrence of pain.
If the neuralgia depends upon peripheral nerve change, these operations
are usually permanently beneficial; but if the pain arises from altera-
tions in the nerve centres, nerve-stretching and neurectomy give only tem-
porary comfort. The absence of pain for several months, however, is
often a great boom. The palsy after neurectomy is generally permanent.
It has been suggested to cut out the cortical brain centre, from which the
painful nerve has its origin, if this can be determined by central locali-
zation.
T E.T A. N. U. S. 209
The three divisions of the trifacial are often excised. The supraorbital
nerve is reached by an incision along the supraorbital arch, after which
the nerve should be cut off as far back in the orbit as possible. If the
nerve comes through a distinct foramen, this foramen may be converted
into a groove by cutting out the edge of the bone with a chisel and then a
hook can be passed above the globe of the eye so as to enable the surgeon
to drag the nerve forward. The infraorbital may be reached in a similar
manner; by trephining both the anterior and posterior wall of the antrum
this nerve may be cut off close to the exit of the main trunk from the
round foramen in the sphenoid bone. It can be torn off nearly this far
back by swiftly cutting away with a chisel the edge of the orbit and
seizing it with strong forceps in the floor of the orbit. The inferior dental
is best reached by trephining the ramus of the lower jaw and exposing
the nerve in its canal. Another method is to lay bare the mental foramen,
and by means of the disk of the surgical engine, or with chisels, to remove
the roof of the inferior dental canal as far back as is deemed necessary.
It must be recollected that the alveolar process in old persons, in whom
these operations are especially demanded, is generally absorbed, and the
canal is relatively further from the lower border of the bone than in
young adults.
TETANUs.
DEFINITION.—Tetanus is a disease characterized by persistent and
painful muscular contraction due to abnormal excitability of the medulla
oblongata and spinal cord, which is probably dependent upon inflamma-
tion of the central gray matter of these organs.
PATHoLOGY..—The weight of evidence was until recently in favor of
considering tetanus a disease of the nervous system, and not a blood
affection, due to the introduction of some poisonous agent into the circu-
lation. The pathological condition was thought to be probably inflamma-
tion of the gray matter of the medulla oblongata and spinal cord.
Hyperaemia, extravasation, exudations, and softening have been detected,
especially in the posterior horns of gray matter and in their immediate
vicinity. When the disease is caused by injuries to the lower extremities
these changes are said to be found in the lumbar enlargement; when the
Wound is situated upon an upper extremity, in the cervical enlargement
of the cord. Sometimes the nerves in the neighborhood of the wound are
found inflamed, but this peripheral neuritis does not seem to be an essen-
tial lesion. The most recent investigations seem to indicate the probability
that tetanus is due to a microörganism, which would explain its occasional
contagiousness and many points in its clinical history.
CAUSES.–Traumatism is the usual exciting cause of tetanus, but it
may, especially in hot climates, occur idiopathically. The latter is some-
times termed rheumatic tetanus. Occasionally tetanus seems to be
endemic.
A sudden change from a high to a low temperature, with dampness, is
liable, especially in military practice, to be followed by cases of traumatic
tetanus. Traumatic tetanus often occurs in vigorous patients who have
Sustained injuries, but it is probably more frequent in those of lowered
nervous tone from shock, hemorrhage, deprivation of food, and want of
fresh air. It is said to be more common in the negro than in the white
race. There is no direct relation between the severity of the injury and
the tetanic symptoms. The slightest bruise, puncture or surgical opera-
& 14 - r
210 DISE AS ES AND IN J U RIES OF NER V OU S CENTRES.
tion may be followed by the most violent form of tetanus. Burns and
lacerations are more apt to give rise to this complication than incised
wounds. It is doubtful whether wounds of the feet and hands are
especially prone to cause tetanus, though some authorities believe that
such is the case. Tetanus in newly-born infants has been ascribed to the
ligation of the umbilical cord, and to pressure upon the cranial bones
during birth. ^
SYMPTOMS.–The symptoms of idiopathic tetanus are identical with,
though usually less severe than, those of the traumatic form. The treat-
ment is the same in both varieties, except that in one attention to the
wound is required. *
The time of appearance of traumatic tetanus is usually from five to ten
days after the receipt of the injury; though the initiatory symptoms may
be exhibited in a few hours, or delayed until several weeks have elapsed.
The early cases are apt to be more acute in their progress, violent in symp-
toms, and fatal in prognosis. Digestive disorders, or general and indefi-
nite uneasiness may perhaps be observed, or possibly the wound may
become dry and unhealthy before the characteristics of tetanus are devel-
oped. In many instances, however, nothing unusual attracts attention
until stiffness and pain in the muscles of mastication or pain in the epi-
gastrium, proclaim the advent of this serious complication. It is rarely
that the muscular spasm shows itself primarily in the wounded limb.
Pain in the epigastrium from spasm of the diaphragm, or painful rigidity
of the muscles that close the mouth and of the back of the neck, is the
usual initiatory symptom. The muscles thus primarily affected are those
supplied by the motor branch of the trifacial nerve, the facial, and the
spinal accessory nerves. The muscular spasm is continuous, or tonic,
though there are occasional paroxysms of increased contraction. The
contraction is exceedingly powerful. The voluntary muscles, except those
of the hands, feet, eyeball, and tongue, generally become rigid soon after
the incipiency of the disease. The epigastric pain is attributed to spasm
of the diaphragm, and it is believed by some that death may occur from
cardiac spasm. These are possible examples of the tetanic spasm occur-
ring in muscles of involuntary innervation. The pain accompanying the
muscular spasm is severe, resembles that of ordinary cramps, and shows
exacerbations at the times when the rigidity increases. When the poste-
rior muscles are more especially affected the patient's head and legs are
bent backward, until he assumes such an arched position that, if placed
in the supine posture, only his occiput and heels would touch the bed.
This condition is called opisthotonos. The term emprosthotomos is em-
ployed to designate a similar flexion forward, and pleurothotonus to denote
lateral deflection. Opisthotonos more or less marked is the common pos-
ture; the others are very rare. The inability to open the mouth gives
tetanus the popular name of locked-jaw. The medical term for the spasm
of the jaw muscles is trismus. The power of tetanic spasm must be seen
to be appreciated. Muscles may, at times, be ruptured by the violent
contraction, and the patient becomes unconscious from the unendurable
alſl,
p The patient suffers from difficulty in swallowing, dyspnoea, and sleep-
lessness. There is sometimes aphonia, and occasionally the tongue is
bitten by a sudden paroxysmal spasm of the temporal muscle. On ac-
count of this danger the surgeon should avoid requesting the protrusion
of the tongue. Viscid saliva may collect in the mouth and annoy the
patient. The mind is perfectly clear, but the facial expression is charac-
T ET A N US. 211
feristic. The sardonic grin of tetanus, as it is called, consists in retrac-
tion and elevation of the corners of the mouth, closed teeth, transverse
furrowing of the forehead, dilatation of the nostrils, and a fixed, anxious
expression of the eyes. Constipation and retention of urine are usually
present. Reflex excitability is so great that the noise of a suddenly closed
door, a draft of air, the touch of the surgeon's hand, or a flash of light may
induce an exacerbation of spasm. Respiration is embarrassed and quick-
ened, and the pulse feeble. In the early stage there is little fever, but
toward the termination of the disease high temperature and profuse
sweating are not infrequent. Instances of very high temperature have been
observed, and cases have been reported in which the bodily heat rose even
after death.
The exhaustion arising from the continuous muscular action is very
great, and is often the cause of death, before which relaxation may take
place. The fatal issue may occur from spasm of the respiratory muscles,
and possibly from spasm of the heart. Fatal cases terminate usually in
from three to five days.
DIAGNOSIS.—Local rigidity of the masticatory muscles, due to cold, or
diseased teeth, is distinguished from tetanus by the absence of pain, the
non-occurrence of paroxysmal increase of spasm, the absence of hardness
of the abdominal muscles and of other tetanic symptoms, and, finally, by
its curability, particularly after removing the cause. Spinal meningitis
has a different history, gives rise to rigidity of the extremities and neck,
rather than to trismus, and is followed by paralysis. -
In hydrophobia we see a convulsed and restless face instead of the knit
brow and grinning mouth of tetanus. Moreover, there is delirium, and
the spasms are intermittent or clonic. The profuse secretion of saliva
and the convulsive attacks following attempts at deglutition are not a part
of the clinical history of tetanus.
Hysteria assumes the characteristics of tetanus. It may be differentiated
by considering the sex and character of the patient, and by observing the
absence of pain, the intermission or irregularity of the tonic rigidity, and
the transient nature of the spasm when the application of the actual cau-
tery is suggested.
Strychnia poisoning, particularly when produced by the repeated admin-
istration of Small toxic doses, greatly resembles tetanus. Here, however,
spasm occurs in the limbs sooner than in the jaw, epigastric pain is absent,
and opisthotonos arises at an earlier time than in tetanus. There is,
moreover, no history of traumatism, which, however, is absent also in
idiopathic tetanus. In most cases of strychnia poisoning, death or
recovery occurs within a short period ; and there can usually be elicited
a suspicious history of suicide or homicide.
PROGNOSIS.—Tetanus arising within nine days of the time of injury is
almost invariably fatal. Recoveries from tetanus, which are rare, are
usually instances of the disease that have arisen nine days or more after
the receipt of injury, and that have shown symptoms of but moderate
violence. If the patient survives the fourteenth day of tetanus, recovery
may be expected. High temperature is an unfavorable symptom.
TREATMENT-Although the death-rate of tetanus is very high, treat-
ment that lessens peripheral irritation and diminishes spinal excitability
always palliates suffering, and may at times be followed by cure. The
patient should be kept in a quiet, darkened room, free from draughts of air,
and should be supplied with concentrated liquid food because of the ex-
haustive character of the disease. Food can be introduced by a flexible
212 DISE A SES AND IN J U RIES OF NER V OU S C E N T RES.
tube passed between the cheek and the teeth, so that the liquid may enter
the mouth behind the molars; or by a similar tube passed into the pharynx
through the nostril. Usually, however, there are crevices between the
teeth which admit the entrance of milk or soup. Such alimentation is
preferable to rectal feeding, though the introduction of partially digested
liquid food into the rectum may be valuable. Freedom from noise may
be obtained by putting cotton in the patient's ears.
Iron, quinine, and stimulants may be desirable to sustain the failing
powers. Laxatives or enemas may be required. Active purgation is in-
jurious. The best remedy to control reflex excitability is, in my opinion,
hydrate of chloral, which should be given in ten or twenty grain doses
every one, two, or three hours. These doses may be increased if the
patient does not become quiet and sleep. I have had good results follow
this treatment, but it must be admitted that the cases were not of the
most violent type. Extract of physostigma (gr. j. every two hours and
increased), or its active principle, eserine, hyoscine, urethan, etc., are
worthy of consideration if chloral in large doses does not seem satisfactory.
These remedies should be given early, and in doses as large as experience
shows can be tolerated before resorting to other drugs. Chloral has been
successfully used by enema, and eserine is very readily administered by
hypodermic injection. Opium has some reputation in the treatment of
tetanus, but it is probably better to use it as an adjunct to the chloral, to
relieve pain. Bromide of potassium, cannabis indica, conium and similar
substances, and the inhalation of anaesthetics have been advocated.
Hammond strongly recommends, in addition to internal treatment, the
application of the ice-bag to the spine. Local measures should be adopted
to prevent peripheral irritation. The wound should be freed from foreign
bodies impacted in it, made aseptic, and dressed with 'antiseptic gauze.
Stretching, incision, and excision of the nerve trunks have been employed,
as has amputation, with varying results. When the nerve supply cannot
be definitely fixed it has been proposed to make a deep incision down to
the bone and thus divide all the nervous filaments. All these operations
are regarded as of doubtful expediency by most authorities, though they
are, perhaps, justifiable in such a hopeless condition. As such operations
cannot be resorted to until tetanus has arisen, and as the symptoms prob-
ably depend upon a microbic cause, I doubt the utility of their perform-
ance. Neurectomy is apparently the most judicious procedure if any
operation is done. Tracheotomy has been advised to meet the possibility
of death by laryngeal spasm.
HYDROPHOBIA.
DEFINITION.—Hydrophobia is a disease of fatal prognosis, character-
ized by sudden spasm of the respiratory muscles upon attempts at deglu-
tition and by other nervous phenomena, and which is generally believed
to be a blood disease due to inoculation with a specific virus contained in
the oral secretions of rabid animals, though there is some evidence sug-
gestive of the symptoms being manifestations of central nervous disease,
initiated in traumatic cases by the peripheral irritation of the injured
nerve branches.
CAUSE.-If the generally accepted theory be correct, the cause of hy-
drophobia is a peculiar poison contained in the secretions of the mouth
of animals affected with rabies. The disease is believed to be generated
H Y I) R O PHO BIA . 213
spontaneously only in the canine family, in the cat, and a few other
animals; but it can be communicated by inoculation to others, whose oral
secretions then become virulent. It has not been proved that it can be
communicated from one human being to another. Innoculation with other
fluids of affected animals does not produce the disease. It has been sug-
gested that bites by female animals in heat are, perhaps, more likely to
cause hydrophobia than those of males or females under other circum-
stances. Microörganisms have been described as found in the secretions
from the mouths of rabid animals, and to these fungi the communicability
of the disease has been attributed. Many persons bitten by rabid dogs
experience no unusual sequences, possibly because the saliva was absorbed
by the clothing through which the injury was inflicted.
Another theory of the obscure disease called hydrophobia is that it is
a reflex neurosis; in other words, that the wound, for hydrophobic symp-
toms are usually consecutive to a wound, causes irritation of the peripheral
nerves, which, in turn leads to molecular and vascular changes in the
medulla oblongata and pons Varolii.
If this theory is true, it follows that hydrophobic symptoms can
probably occur after other peripheral irritation than that of bites of
rabid animals. In fact they could arise when no injury had been received,
provided the necessary changes in the medulla oblongata and pons
Varolii were incited. There is some evidence that seems to point in this
direction.
PATHOLOGY..—Changes, such as congestion, extravasation, softening,
and granular degeneration have been found in the medulla oblongata,
cord, and brain of patients dying with hydrophobia. These lesions are
apt to be conspicuous in the medulla oblongata and its vicinity. They
may, however, be secondary, and not the essential morbid changes of the
disease. In some instances chronic alterations have been discovered in
the nervous centres, which may have been the cause of the susceptibility
to hydrophobic symptoms when peripheral irritation was induced. These
cases seem to support the second theory of the nature of hydrophobia.
SYMPTOMS.–Rabies is first exhibited in dogs by listlessness followed by
restlessness, but there is no disposition to bite. Afterward the animal
may become excited, as is exhibited by barking in a hoarse tone and snap-
ping at the air, biting and licking sticks and stones; or he may show
symptoms of melancholy and refuse to eat, drink, or observe his sur-
roundings. Paroxysmal excitement, spasm of respiration and deglutition,
protruding tongue and constant escape of Saliva from the mouth, paral-
ysis of the legs, convulsions and tremors may precede death. Rabies is
not more common in summer than in other seasons, nor do mad dogs
have the dread of water which is exhibited by men with hydrophobia.
Much of the animal's excitement is doubtless in many cases due to his
being chased by persons desirous of destroying him.
In man the period of incubation is usually, it is said, not longer than
Seven months. Cases have been reported when only a few days elapsed,
and others are recorded in which no symptoms were shown until years
had passed. Many of these cases will not bear searching investigation.
The wound made by the teeth of the rabid dog usually heals readily;
but may, just before the advent of the general symptoms, become the
seat of stinging pain or of inflammation.
The initiatory symptoms are physical and mental discomfort, stiffness
of the throat and tongue, anxiety and irritability of disposition. Then
occur spasms of muscles of deglutition and respiration, especially when
214 DISE ASES AND IN J U RIES OF NERVO US CENTREs.
attempts at Swallowing water and other fluids are made. This symptom
gives the name to the disease. Solids are swallowed more readily than
fluids. Cutaneous and sensory hypergesthesia, wild delirium, convulsed
features, hawking and spitting of an abundant viscid fluid, attacks of
Suffocation caused by drafts of air and attempts at deglutition, hoarse
cough, sleeplessness, maniacal excitement, and at times paralysis, or
general tetanoid or epileptoid convulsions complete the distressing picture.
The pulse is frequent, the temperature high, and the urine often albu-
minous or saccharine. Death occurs from spasm or exhaustion about the
third day.
It is said that dread of water is not always present, and that this symp-
tom may occur in other affections.
DIAGNOSIS.–Hydrophobia sometimes much resembles tetanus, and,
indeed, a variety of the latter disease has been described as hydrophobic
tetanus. The differential diagnosis of tetanus and hydrophobia has been
discussed in the preceding article. Hysteria may assume the aspect of
hydrophobia, but there is a want of consistency in the symptoms and an
absence of high temperature. Moreover, the hydrophobic patient tries to
conceal his fears from his friends, while the hysterical one endeavors to
call attention to them. Hysterical hydrophobia is developed soon after
the injury.
TREATMENT.--The preventive measures, to be adopted after an injury
has been inflicted by the teeth of a mad dog or other animal is the im-
mediate excision of the tissues around the wound, or suction followed by
cauterization with strong nitric acid, or better with the red-hot iron.
The application of a tight bandage to the limb above the wound until
excision or cauterization has been effected is proper. The fears of the
patient may be allayed by these precautions, even if the time elapsed has
been too considerable to give an opportunity to prevent absorption by
such means. I believe the application of nitrate of silver to be perfectly
valueless. The animal should never be killed, but kept in confinement
that the existence of rabies may be verified or disproved. Bromide of
potassium in large doses has been recommended during the period of
latency. When the symptoms have appeared, treatment, as a rule, exerts
little influence in averting death. Nourishment and perhaps stimulation
by the rectum, ice to the spine, perfect quiet and freedom from excitement
are indicated. Worara (grain Hº to #) or pilocarpine (grain # to #)
given hypodermically, nitrite of amyl or chloroform by inhalation, chloral,
morphine and bromide of potassium, hyoscine hydrobromate, and similar
remedies may be tried, but must be employed in large doses.
Pasteur has shown that dogs and some other animals may be protected
from rabies by inoculation with attenuated virus of rabies in much the
same way as men are protected from smallpox by vaccination. He has
asserted that human beings who have been bitten by rabid animals may
be protected from the disease by a similar preventive inoculation. His
views have not as yet been accepted by the entire medical world.
TRAUMATIC DELIRIUM TREMENs.
DEFINITION.—This is a nervous affection characterized by muscular
tremor and a peculiar restless delirium, which not infrequently follows
the receipt of injuries by those accustomed to alcoholic stimulation.
CAUSES.—Some writers under the terms traumatic delirium and nervous
T R A U M A. T I C D E L I R. I U M T. R. E. M. E. N. S. 215
delirium describe a condition, frequently very similar to delirium tremens,
which is said to occur in patients free from the alcohol habit and to de-
pend upon nervous prostration, often associated with shock and hemor-
rhage. It is possible that failure to investigate previous habits with
judicial acumen has allowed to arise a confusion between delirium de-
pendent simply upon traumatism and delirium induced by traumatism in
alcohol drinkers. The muttering delirium and muscular twitching that
supervene in nervous prostration or asthenia from surgical as from medi-
cal causes, and the noisy delirium after injury, that is usually exhibited
by quick, rapid, and full pulse and by febrile reaction, are two very
different conditions to which the name traumatic delirium may with pro-
priety be applied. These forms of mental disturbance—better in my
opinion called, in the one case, nervous or asthenic traumatic delirium,
and, in the other case, septic or inflammatory traumatic delirium—arise
without reference to personal habits. These two conditions are possibly
often intermingled with alcoholic traumatic delirium or traumatic delirium
tremens, as I here term it.
The group of symptoms which I propose describing as traumatic
delirium tremens, is found especially, if not exclusively, indeed, in those
whose nervous systems have undergone, prior to injury, the deterioration
due to absorption of alcohol. I have not been convinced by my experience,
which I admit to be somewhat limited, nor by my reading that such a
concatenation of symptoms can occur after traumatism in the absolutely
abstemious. The amount of drinking requisite to induce the predisposi-
tion varies with the individual. The repeated ingestion of quite small
Quantities of alcohol may give rise to the delirious susceptibility. It is
possible that a similar deterioration of constitution and consequent lia-
bility to trembling delirium may be caused by the opium, chloral, tobacco,
and other similar habits; but it is difficult to differentiate these, because
of their frequent association with alcoholic excess.
Traumatic delirium tremens may follow even slight injuries, but com-
pound fractures and burns seem to have a special tendency to develop
this serious complication. Its occurrence should not be ascribed to the
restraint imposed upon the patient's habits by the injury, but to a trau-
matic disturbance of a previously unstable nervous equilibrium. The
medical authorities vary in their appreciation of the causative influence
exerted by sudden deprivation of accustomed stimulants in exciting attacks
of ordinary delirium tremens. It is probable, however, that in a vast
majority of such cases the directly exciting causes are the deficient assimi-
lation of food, the anxiety and the nervous strain which go hand in hand
With a period of debauch, and which persist after the ingestion of alcohol
is stopped. Neither is the recurrence of the malady to be imputed to the
directly poisonous effect of a large amount of consumed alcohol, since
acute alcohol poisoning in persons unaccustomed to the use of alcohol
gives rise to stupor and death, but not to delirium.
Traumatic delirium tremens occurs because obscure chronic changes in
the nervous tissue or blood, or perhaps in both, have rendered the alcohol
drinker susceptible to such an outbreak upon the application of any dis-
turbing influence. The receipt of injury is a sufficiently perturbing
force, especially if the patient be on the verge of an idiopathic attack. It
has been thought that the use of beverages containing amylic alcohol
(fusel oil), especially predisposes to delirium tremens.
PATHOLOGY..—The alteration in nerve structure or blood, which is the
essential pathological factor of delirium tremens, is unknown to us. An
216 DISE ASES AND IN J U RIES OF NERVO US CENTRES.
abnormal amount of serum is usually found in the substance and within
the ventricles of the brain, meningeal congestion and hemorrhage are
often seen ; the cells of the gray matter, the cerebral connective tissue,
lymph spaces and vessels show sclerotic or fatty changes, and the liver,
kidneys, and digestive tract exhibit the characteristic lesions found in
chronic alcoholism, but there is nothing to which we can point as the
distinctive lesion of delirium tremens.
SYMPTOMS.–The initiatory symptoms of traumatic delirium tremens
are sleeplessness at night and slight tremor, which is readily noticed by
ordering the patient to hold out the hand with widely distended fingers.
Subsequently restlessness, insomnia, and tremor increase, and delirium is
shown.
The delirium, which is often first exhibited at night, is peculiar. The
patient sees numerous small animals or insects creeping over the bed and
about his person, or is pursued by some hideous spectre. Hence, he is
constantly endeavoring to eject the vermin from his clothing, or trying to
escape the persecutions of his tormentor. He may, in his efforts to get
rid of these disgusting and distressing annoyances, leave his bed and fall
from a window or down a flight of steps. The mental condition is one of
depression, trepidation, and great activity. He is exceedingly restless,
and is constantly chattering in a low tone; but though he may cry out
because of fear, he shows little or no maniacal excitement. He is good-
natured. not prone to violence, and can often be aroused by emphatically
spoken words to an understanding of his surroundings; but he soon relapses
into the previous incessant chattering and motion. Very often a single
idea recurs again and again to his delirious fancy, and not infrequently
the delirium has a comical or tragico-comical aspect. The muscular
tremor is not like the twitching of tendons seen in asthenic conditions, but
resembles the shakiness, from want of coördination, seen in cerebro-spinal
sclerosis. Often there is hurry in movement, and the limbs or tongue
will then be thrust forward with a jerk. The tremor of delirium tremens
reminds one much of the movements that would be expected in an asso-
ciation of chorea with sclerosis of the nervous centres.
During these symptoms the patient is unable to sleep, is incessantly in
motion, and has a bright eye with dilated pupils and an unsteady, rest-
less look. He exhibits a moist, flabby, tremulous tongue, with a whitish
fur; desires no food; has constipated bowels, and passes a scanty, high-
colored urine. In idiopathic delirium tremens of moderate severity there
is no great acceleration of the pulse, and the temperature does not rise
much above 100°, except during active muscular exertion. In those
graver cases, which Magnan calls febrile delirium tremens, the bodily
heat is apt to remain in the neighborhood of 102°–105°, though there is
no incurrent affection to keep up the temperature, and the pulse rate is
also increased. In traumatic delirium tremens the constitutional disturb-
ance, due to the wound, affects the pulse and temperature. The patient
will often remove the dressing from his wound, or subject the injured
limb to violent motion without appearing to experience pain.
Traumatic delirium tremens, as a rule, arises within two or three days
after the receipt of injury and lasts usually not more than five or six
days. The illusions are apt to continue during the night, even after the
patient has become convalescent and quite rational in the daytime.
DIAGNOSIS.—The peculiarity of tremor and delirium renders the diag-
nosis easy, except from the condition called above nervous or asthenic
traumatic delirium. The existence of the described symptoms is, there-
T R A U M A TIC I) E I, IIR IU M T R E M E N S. 217
fore, not absolute evidence of previous habits of stimulation, since it is
possible that great nervous strain prior to injury may lead to a similar
delirium. Usually, however, alcohol seems to be the predisposing cause,
though it is not always wise to mention the suspicion, nor to call the
disease delirium tremens, since the patient's friends may be unaware of
the existence of such habits.
PROGNOSIS.—Death may occur from exhaustion, coma, or some inter-
current affection ; and is sometimes inexplicably sudden. The character
of the traumatism may determine the mode of death. Pneumonia is fre-
quently associated with delirium tremens. It is often, in fact, the exist-
ing cause of the delirious outbreak, and, of course, in traumatic cases
greatly diminishes the chances of recovery. When the temperature shows
a tendency to remain high without a sufficient traumatic cause, and espe-
cially when the tremor affects all the muscles of the trunk as well as
those of the head and extremities and is not arrested during sleep, the
prognosis is bad.
A history of previous attacks of the disease renders the outlook more
grave. -
TREATMENT.-It is important to bear in mind that delirium tremens is
an asthenic condition. There is action, but it is the activity of weakness
not of power. Depressants are, therefore, injurious. Five or ten grains
of calomel or one or two Seidlitz powders may be administered in the
beginning of the disease, or when its occurrence is feared, because of the
anorexia and gastric derangement.
Concentrated liquid food with bitter tonics and capsicum add to the
patient's strength and tend to give tone to the impaired digestive organs;
bathing, Turkish baths if possible, and mild diuretics may be prescribed
in the endeavor to eliminate the alcohol that has entered the system.
Hydrate of chloral (gr. x-xx) with bromide of potassium (gr. xxx–
xl) should be given every two or three hours as soon as sleeplessness and
slight tremor is noticeable. No visitors should be allowed in the room.
If the development of the attack is not prevented, the same treatment is
continued, but the dose may be increased. The object is to quiet the
nervous system and produce sleep. In this endeavor an occasional dose
of morphia (gr. 4–4) may be combined with the chloral and bromide of
potassium. The excessive use of opiates is undesirable for it is not nar-
cotism that is desired, but sleep. Cerebral congestion is induced by over-
dosing with morphia. If fatty heart exists opiates should be pushed,
perhaps, rather than the chloral and bromide of potassium. The com-
bination treatment by the three hypnotics allows the surgeon to diminish
or increase each element according to indications. Tincture of digitalis
(m. X-m, XXX) is valuable in cases of weak but not fatty heart, where there
are pallor and cyanosis with probable anaemia of the brain. Strychnia has
been recommended in delirium tremens. Hyoscine hydrobromate (gr.
Tºw) and other hypnotics may prove serviceable.
Mechanical restraint with straps and the straight-jacket is only to be
adopted when efficient watching and soothing by attendants are imprac-
ticable. All such apparatus excites the patient and is very liable to in-
terfere with respiration. The best appliance is a loose, but strong, gar-
ment consisting of trousers and shirt in one piece, with loops attached for
fastening the patient in bed. Fractures should be dressed with plaster-
of Paris bandages, because ordinary splints will probably be displaced by
the patient. If failure of vital powers is to be feared, alcoholic stimu-
lants in small amounts, administered only when food is given, are judi-
218 DISE ASES AND IN J U RIES OF NERVO US CENTRE S.
cious, because in chronic drinkers digestion will sometimes not go on
efficiently without the aid of alcohol. The failure of assimilation in
delirium tremens may turn the scale against the patient. Whiskey or
brandy (fāij to fiv daily) in the form of milk punch or eggnog is .
probably the best form of administration. Many patients will not require
any stimulants whatever.
Vomiting occurring in delirium tremens is to be treated by milk and
lime water, cracked ice, effervescing drinks, submitrate of bismuth, pep-
sin, and carbolic acid mixtures.
Nervous traumatic delirium is to be treated by bromides, chloral, hyos-
cine, and nerve tonics, and presents a favorable prognosis.
Septic or inflammatory traumatic fever requires judicious antiseptic
treatment to combat the local infection with septic products; cold to the
head and hypnotic remedies. It occurs when the septic fever is at its
height and is often more conspicuous at night; resembling in this latter
respect alcoholic traumatic delirium.
C H A P T E R XVI.
DISEASES AND INJURIES OF THE HEART AND BLOODVESSELS.
DISEASES AND INJURIES OF THE HEART AND PERICARDIUM.
Wounds of the Pericardium and Heart.
PUNCTUREs and small incisions of the pericardium, if uncomplicated with
injury to the internal mammary artery, heart, or lungs, present no marked
symptoms, and are usually soon repaired by a local pericarditis. Such
wounds are made almost with impunity in treating pericardial effusions
by aspirations and incision.
Larger wounds are much more serious by reason of the suppuration
that is liable to occur and the involvement of neighboring structures.
The treatment of pericardial wounds consists in rest, antiseptic dressings,
and, if suppuration takes place, free exit for the pus by incision, drainage
and frequent irrigation. If pericardial effusion occurs after a contusion
or laceration of the membrane, blisters, diuretics, and hydragogues should
be employed as in rheumatic pericarditis. If the effusion persists and
the symptoms become urgent, pericardicentesis should be performed.
Wounds of the heart are generally, but not necessarily, fatal. Patients
have survived many years with foreign bodies buried in the cardiac walls.
The diagnosis is obscure, though signs of internal hemorrhage, or profuse
external bleeding with syncope, or great shock, with irregular and feeble
action of the heart occurring after a wound of the pericardium make it
probable that the heart has been injured.
Small cardiac wounds may not be followed by much bleeding, because
the peculiar interlacing of the muscular fibres causes the opening to be
closed as by a valve. In other cases the pericardium may become filled
with blood to such an extent as to make the cardiac sounds and beat
almost imperceptible. Death may arise from interference with the heart's
action in this manner when the wound itself is not necessarily fatal. The
hemorrhage from the heart may be slow or be arrested by a clot forming
in the orifice. This may be washed out when reaction from shock occurs
and secondary hemorrhage and death thus take place. Men may even
walk after wound of the heart. Dyspnoea, pain, pericardial distress, and
a systolic-bellows sound have been observed in heart wounds, but these
Symptoms and signs are not always present.
It should be remembered that the heart lies obliquely between the upper
margin of the third costal cartilage and the top of the sixth cartilage, and
that it extends from a line about one inch inside of the left nipple to a
point a little beyond the right margin of the sternum. Wounds of the
auricles are more dangerous than similar injuries to the ventricles.
Wounds of the heart must be treated by absolute rest in the supine
position, by cold to the front of the chest, morphia, atropia, and digatalis.
hen it is certain that clots in the pericardium are doing harm, incision
of that sac, removal of the clots, and antiseptic injections may be advan-
220 DISE A SES A N L) IN J U R IB S OF H E A R T .
tageous. Experimental suture of the heart has been done successfully, it
is said, in the lower animals. I should not hesitate to open the pericar-
dium and attempt to suture a heart-wound in the human subject, if evi-
dence of such a wound was strong. Resection of the costal cartilages
might be necessary in order to gain access to the parts.
Tapping the Pericardium or Pericardicentesis.
In pericarditis with effusion, and in cases of hydropericardium from
renal disease, the pressure exerted upon the heart by the accumulated
fluid is at times a mechanical cause of death. Hence, it may become,
necessary to withdraw the fluid by aspiration. In all cases of pericardial
effusion which present dangerous symptoms of heart failure, aspiration
should be performed as soon as it is evident that medication is not lessen-
ing the embarrassment of the central organ of circulation. It is bad prac-
tice to delay operation until exhaustion, pulmonary engorgement, and
degeneration of the cardiac muscle render permanent relief impossible. A
moderate quantity of serum suddenly effused will exert more pressure on
the heart than a much larger amount poured out in so gradual a manner
as to allow the pericardium to become stretched. Hence, the symptoms,
and not the amount of serum, must be the guide to operation.
If there coexists pleural effusion of considerable amount, the pleural
sac should be aspirated first, because it is difficult to discriminate between
respiratory distress due to pulmonary pressure and that resulting second-
arily from interference with cardiac action. This rule applies to pleurisy
of the right side as well as of the left.
When the amelioration of symptoms following pericardial aspiration is
not permanent, because reaccumulation takes place, the operation should
be repeated. It is better to vary the point of puncture, lest, on account
of adhesion of the layers of pericardium at the original point, the heart
be wounded at the second tapping. Should repeated tapping be demanded,
I should be inclined, after the third operation, to inject some irritating
fluid, such as tincture of iodine, into the sac, with the idea of producing
adhesion of the two layers of pericardium.
When aspiration has shown the pericarditis to be distinctly purulent,
it is practically certain that repetition of the operation will be demanded.
In such an event the introduction and retention of an antiseptic rubber
drainage-tube, after a free incision has been made, strike me as the most
judicious kind of surgery. The cavity can be washed out daily with anti-
septic solutions, and purulent accumulation with its attendant dangers of
pressure on the heart and septicæmia avoided.
Incision may be useful in certain cases as a diagnotic procedure, when
doubt exists as to the condition being dilated heart or pericardial effusion.
The best point for aspiration' of the pericardium is in the fifth inter-
space, just above the sixth rib, about five or six centimetres (2–2} inches)
to the left of the median line of the sternum. In a child it should be
nearer the sternum. The ordinary aspirating needle or the aspirating
trocar which I have devised may be employed. In all cases the vacuum
chamber should be attached to the puncturing instrument as soon as its
point is buried beneath the skin, in order that the flow of fluid may indi-
cate the moment when the pericardium is entered.
1 Paracentesis of the Pericardium, by John B. Roberts. Philadelphia, 1880.
H E M O R. R. H. A. G. E. 221
The pericardial aspirating trocar recommended consists of a moderate
size aspirating needle, within which slides a canula with a flexible end.
During penetration of the chest wall the canula is retracted, so that the
FIG. 81.
- ------ * - - A n y g - - -
- *-* ... "... ? <-- ~~~-ºr--- - - - - - - - -- *- - 9 - > -----
Roberts's aspirating pericardial trocar.
flexible end is contained within the needle. Afterward it is thrust for-
ward to guard the sharp point of the needle and prevent scratching of
the heart's surface when withdrawal of the fluid causes the pericardial
sac to collapse.
DISEASES AND INJURIES OF THE ARTERIES, VEINS, AND CAPILLARIES.
Hemorrhage.
DEFINITION.—An escape of blood from the vessels is called hemor-
rhage, and is either spontaneous or traumatic. When the blood is dis-
charged, not upon the surface of the body or into a cavity, but into the
meshes of the connective tissue, the term extravasation is generally used.
An extravasation into the connective tissue beneath the skin is often
designated a subcutaneous hemorrhage.
VARIETIES.–Traumatic hemorrhage is primary when it immediately
follows the receipt of wound ; intermediary when it occurs after reaction
from the shock of injury, and before the lapse of twenty-four hours; and
secondary, when it takes place between the end of the first twenty-four
hours and the completion of cicatrization of the wound.
Intermediary, often called recurring, hemorrhage arises because the
force of the circulation has, from the establishment of reaction, become
sufficient to displace the clots which, during the previous condition of
feeble circulation, prevented bleeding.
It may, therefore, occur from small vessels that did not, at the time
the wound was dressed, seem to demand ligatures or other treatment; or
from larger ones to which ligation, torsion, or acupressure was carelessly
or imperfectly applied, or in which the wound was so small that no hemor-
rhage supervened until the circulation had fully regained its force.
Secondary hemorrhage may be due to any constitutional condition,
such as hematophilia, septicæmia, pyamia, hepatic disease, and renal dis-
ease, which interferes with the plastic changes and organization of the
internal clot that constitute Nature's method of permanently sealing
wounded vessels. Hence, when the ligature is absorbed, or the wail of
the vessel ulcerated through at the point of ligation, bleeding supervenes.
Secondary bleeding may also be caused by an unrecognized contusion
or abrasion of the vessel wall which has subsequently given away at the
injured spot, by failure of the surgeon to secure the distal end of the
artery or to tie a wounded branch situated just above the ligature. In
the last two instances the establishment of the anastomotic circulation
may be followed by bleeding. Sloughing in the wound, atheroma of the
arterial wall, septic processes due to septic ligatures or dressings, badly
applied ligatures, premature softening of a ligature, and the rush of the

222 ID IS E A SES AN ID IN J U R I ES OF BI, O O D W E SS E L S.
blood-current through a large branch given off just above the point of
ligation are frequent cause of secondary hemorrhage. Secondary bleeding
usually does not occur earlier than one week, or later than three weeks
after the time of injury or operation. Septic causes are responsible for the
majority of cases of secondary hemorrhage. Aseptic surgery has almost
made secondary hemorrhage unknown. This serious complication must,
therefore, be carefully provided for about the fourteenth day, especially
after ligation of arteries in continuity for aneurism. In such cases the
secondary hemorrhage is more apt to occur at the distal than the cardiac
side of the ligature, because internal coagulation and cellular changes
occurring there are less effective than in the proximal or cardiac portion
of the artery, and probably, also, because the ligature interferes with the
small vessels supplying the arterial coats below the seat of constriction.
The rapid healing of wounds under aseptic and antiseptic treatment has
made secondary hemorrhage much less frequent than formerly.
The occurrence of profuse secondary bleeding is generally preceded by
a slight flow of blood, which, when observed during the progress of cica-
trization or suppuration, should always be looked upon as a warning of
grave import. There may be several slight hemorrhages from the wound,
and then, when the surgeon flatters himself that he has nothing further
to fear, a profuse bleeding quickly destroys the enfeebled and anaemic
patient. The treatment of secondary hemorrhage is of exceeding impor-
tance, and will be considered after the discussion of the treatment of pri-
mary bleeding.
Blood starts from a wounded artery in a rapid stream, and, as each
beat of the heart gives an increased impulse to the blood-current, the jet
gains force, and is propelled further synchronously with the cardiac pul-
sations. The blood is of a bright-red color, unless the patient is deeply
anaesthetized or partially asphyxiated; then respiration and oxygenation
are imperfectly performed, and the blood is dark. When an artery has
been completely divided, the hemorrhage from the end further from the
heart may not be rhythmical until the collateral circulation is well estab-
lished.
Venous hemorrhage is characterized by a steady flow of dark blood,
which is not affected by the heart's action. The stream may show a ten-
dency to rise and fall in a sluggish manner with each respiratory act, but
never spurts. If the bleeding occurs at the bottom of the wound the
blood may become reddish from admixture with air before it reaches the
surface.
Hemorrhage from capillary vessels, called parenchymatous hemor-
rhage, occurs as an oozing of blood. The steady stream has a color less
red than arterial and less purple than venous blood.
CAUSES.–Solution of continuity of vascular walls is the common cause
of hemorrhage, but bleeding does occur at times from mucous and serous
surfaces without apparent lesion. Here the quality of the blood is prob-
ably at fault. Cirrhosis of the liver and poisoning by phosphorus and
some other substances are said to cause this form of blood transpiration.
It must be recollected that hemorrhage from any part may be vicarious
to menstruation or other customary loss of blood.
CoNSTITUTIONAL EFFECTs of HEMORRHAGE.-It is exceedingly im-
portant that the surgeon should recognize the general symptoms of hemor-
rhage. In certain cases no blood is visible externally, though a sufficient
quantity to cause fatal anaemia has been poured out into the intestines,
uterus, or abdominal cavity; or into the cellular tissue surrounding the
H E M O R. R. H. A. G. E. 223
perforated vessel. Such concealed hemorrhages are to be recognized by
the constitutional effects produced by the withdrawal of blood from the
vascular channels.
The general symptoms of hemorrhage are influenced by the constitu-
tional characteristics of the patient and the vessel from which the blood
flows, but depend more especially upon the quantity of blood lost and the
rapidity of its escape. An insignificant bleeding may prostrate even to
syncope a debilitated or frightened subject, while a considerable hemor-
rhage will in some others give rise to no prominent symptoms. Children
and the aged are very impressible by loss of blood. Arterial hemorrhage
may be expected to produce greater depression than a similar loss from
veins, for the obvious reason that venous blood is, in a certain degree, an
effete fluid.
When a violent and profuse gush of blood occurs from rupture of a
large arterial trunk, death is rapid. The blood in all the arteries has a
recurrent tendency, and, instead of being forced by arterial and cardiac
contraction into the peripheral vessels, it flows toward the wound; hence
there is a consequent venous stagnation which gives a livid tinge to the
otherwise pallid surface. The patient, who has fallen to the ground in a
state of syncope, gasps for breath, throws his limbs about restlessly, and,
after convulsive twitchings of the facial and other muscles, expires.
Profuse hemorrhage from a large venous trunk causes death in a some-
what similar manner. A less impetuous loss of blood, whether arterial
or venous, causes a feeble and rapid pulse, sighing respiration, pale con-
junctivae and lips, a cold clammy skin, dilated pupils, restlessness, and a
confused mind. The patient feels weak and thirsty, is giddy, has im-
paired vision and hearing, or, perhaps, sees luminous spots or hears
unusual noises, experiences a sense of suffocation, but feels no special
pain, and rather suddenly loses consciousness. During this state of syn-
cope the breathing is almost entirely diaphragmatic, and the heart's
pulsation can scarcely be detected. This lowering of circulatory tension
gives an opportunity for coagulation in the wounded vessel, and the bleed-
ing is arrested. The patient now recovers from the condition of insensi-
bility, and, perhaps, vomits as he returns to consciousness. The increasing
force of the heart's action, however, is soon sufficient to cause the blood-
current to force the clot from the interior of the injured blood vessel, and
hemorrhage, with the train of symptoms mentioned above, recurs. This
alternation of bleeding and spontaneous arrest is kept up until death
occurs from anaemia of the nervous centres. Sometimes delirium, con-
Vulsions, and hemiplegia precede the fatal termination. In very slow
hemorrhage there arises great debility, with waxy-looking skin, oedema of
the dependent parts, and a tendency to syncope on assuming the erect
posture.
After death from prolonged or repeated hemorrhage the tissues are
Soft and flabby, because the fluids have been absorbed to fill the emptied
blood vessels. This explains, also, the thirst felt by the patient. After
serious hemorrhages have been stopped a stage of reaction often supervenes,
to which the name hemorrhagic fever has been applied. The symptoms are
febrile manifestations and a frequent, quick pulse, accompanied by irrita-
bility and restlessness of mind and body. Occasionally hemorrhage is
followed by a chronic anaemia, which is extremely rebellious to treatment.
The febrile state, above mentioned, is to be met by rest, sponging the
surface, cold to the head, nutritious fluid food, and tonic remedies.
224 DISE A SES A N ID IN J U R IES OF B L O O D W E S S E L S.
NATURE's MoDE OF ARRESTING HEMORRHAGE.--Obscure is the
means by which spontaneous cessation of hemorrhage is determined in
those unusual cases of oozing, without apparent lesion of the bleeding
surface, which have been mentioned.
Hemorrhage, from vessels in whose walls a solution of continuity has
been produced by accident or operation, often ceases spontaneously. It
usually does so in veins, except those of great calibre, and in arteries
smaller than the radial and facial. The method employed by Nature in
arresting hemorrhage is the same in arteries and veins, though in the
latter the sluggish blood-current does not demand such active contraction
and retraction of the walls of the vessel.
When an artery has been completely divided, Nature promptly insti-
tutes steps, which are intended to cause a temporary arrest of the escape
of blood until a permanent occlusion of the open extremity can be
accomplished. The same series of changes occur in both the cardiac and
distal ends of the cut vessel. The temporary means consist of: (1) Con-
traction and retraction of the cut end; and (2) clotting of the escaping
blood in and around the sheath of the vessel.
The permanent means are: (1) The formation of a clot within the
artery; (2) plugging of the orifice and union of the edges of the cut
extremity by the ordinary process of repair; and (3) cicatricial contrac-
tion of the walls of the vessel by which an impervious fibrous cord is
produced.
TEMPORARY MEANS.—The contraction of the walls of the vessel,
which extends up to the first branch, gives its section a flattened or ovoid
shape, and, by diminishing the calibre, lessens the size of the blood-
stream. At the same time, the retraction of the cut end of the artery
within the sheath leaves a space between it and the wound in the non-
retractile sheath, which detains the escaping blood and encourages
coagulation. Coagulation also takes place outside of the wounded
sheath. Lacerated vessels, by the irregularities of the torn ends and of
the sheath, encourage this clotting, and may even, if large, soon stop
bleeding. º
FIG. 82.
CLOT IN SHEATH
ºłse--
§ ºr.
Pºrt-
º:
É: i. T
º l ; * łł *
22 #. : 'OU
#
# O
!"OUTSIDE
;
$
ARTERY
Diagram of Nature's temporary method of arresting hemorrhage.
These provisions of Nature may at first fail to stanch the bleeding,
because the force of the heart is sufficient to drive enough blood through
the contracted vessels to wash away the intra- and extra-vascular clots.
As the continuing hemorrhage increases the coagulability of the blood
and weakens the cardiac power, perhaps to syncope, the time arrives
when these temporary expedients of Nature stop the flow. Cardiac
strength then returns and may, by the increased intravascular pressure,
cause recurrence of the bleeding. In many instances, however, the tem-







H E M O R. R. H. A. G. E. 225
porary means are effective until permanent changes can be brought about
to repair the vascular traumatism.
PERMANENT MEANS.—When a temporary check has been given to the
flow of blood, a coagulum gradually forms within the artery. This is
conical in shape, with its base situated and fixed at the opening, while its
apex, lying loose in the lumen of the artery, extends as high as the first
branch. The base of this internal clot corresponds in size with the in-
terior of the vessel, which it fits like a cork.
FIG. 83.
Aft
Aft
AE
Aft
Aft sheath
|
internal clot
Diagram of intermal clot formed in Nature's method for the permanent arrest of
9
hemorrhage.
After the deposition of this internal coagulum, and sometimes without
its formation, for it may occasionally be 'absent, an exudation of inflam-
matory lymph occurs in the stump of the artery and around it and the
sheath. This plastic material unites the edges of the wound and seals the
orifice by a button-like plug of exudate. The internal blood coagulum is
at its base more or less intimately associated and commingled with the
plastic deposit. Organization of the exudate, disappearance of the blood-
clot, and permanent cicatricial contraction of the vessel to the first im-
portant collateral branch go on until finally from the first branch above
nothing remains but an impervious fibrous cord.
Hemorrhage from a wound partially dividing an artery is controlled in
a similar but not identical manner. Contraction and retraction of the
vessel cannot occur; but blood is effused within and around the sheath
and thus, unless it rapidly escapes to the exterior of the body, causes
pressure upon the wounded artery. This causes temporary arrest of the
blood escape. An internal coagulum may then be formed. Lymph is
subsequently effused, the cavity of the vessel is occluded, and fibrous
metamorphosis with obliteration of the vascular channel is permanent.
When the wound is less in extent than one-fourth the circumference of
the vessel, or if it is longitudinal and consequently gapes very little,
hemorrhage may cease and repair occur by plastic exudation, without
much encroachment upon the lumen of the vessel. In such cases, how-
ever, the internal and middle coats are seldom firmly united, and the
force of the circulatory current is very apt eventually to cause stretching
of these tunics. Thus may arise traumatic aneurism.
CoLLATERAL CIRCULATION.—When the passage of blood through an
artery is arrested by division, ligation, or any form of obstruction, the
parts beyond receive, at first, less blood. As a consequence, absence of
pulsation, lowered surface temperature, and impaired muscular power re-
Sult. Soon, however, the anastomosing branches and capillaries of the
same and of the neighboring arteries dilate by a vital process and carry
more blood to the part than is normal. This is shown by increased red-




15 -
226 DISE A SES A N D IN J U R I ES OF B L O O D W E SSE L S.
ness and unnatural elevation of temperature, which, in the case of ob-
struction of large arteries, only occurs after the lapse of many hours.
After a time the duty of supplying the distal region becomes relegated to
a few branches, which remain permanently enlarged. The functions of
the part are then carried on exactly as they were previous to interference
with the blood-supply.
Collateral circulation after wound of artery and ligation.
The establishment of the collateral circulation necessitates a reversal of
the blood-current in some vessels, but this is not opposed to physiological
processes. In aged subjects, whose vessels are apt to be rigid and
atheromatous, dilatation of the arteries and capillaries cannot always be
rapidly and readily effected, Hence, in such subjects gangrene of the
peripheral region from deprivation of blood is more frequent than in the
young. The collateral circulation is usually effected by the anastomosis
of the branches on the same side of the body and not by inosculation
with branches coming from vessels across the median line. Thus, when
the right common carotid artery is ligated, the exterior of the head is
supplied by the inferior thyroid, a sub-branch of the subclavian, furnish-
ing blood to the ramifications of the superior thyroid, a branch of the
external carotid. The current in the superior thyroid is reversed, and
the blood emptied into the external carotid, which carries it to the face
and scalp. The interior of the head is nourished by the vertebral, a
secondary branch of the subclavian, communicating within the skull with
the cerebral branches of the internal carotid. Little dilatation occurs in
the branches inosculating with the corresponding vessels of the left side.

H E M O R R H A G. E. 227
When a vein is obstructed collateral circulation is readily established
in a similar way. If there is failure in effecting this result, venous con-
gestion and oedema occur in the parts below, and may be the cause of
moist gangrene.
HEMORREIAGIC DIATHESIS.–In some persons a peculiar constitutional
tendency, often inherited, causes profuse and almost uncontrollable bleed-
ing from slight wounds, such as simple punctures and tooth-extraction.
Spontaneous hemorrhage from the nostrils, kidneys, intestines, or bron-
chial tubes, and large extravasations into the cellular tissue after bruises,
may occur in such subjects. Hemorrhagic diathesis or hematophilia is
usually exhibited in childhood, and is frequently unknown until a trivial
injury discloses its existence, for such patients often enjoy vigorous health.
A liability to joint affections similar to rheumatism, and to inflammations
of the lungs, has been said to coexist with the hemorrhagic diathesis.
As age advances the bleeding tendency may disappear. In some instances
there are attacks of spontaneous hemorrhage, though wounds may be in-
flicted with impunity in the intervals.
Males are much more frequent subjects of hematophilia than females.
The cause of the condition is unknown. There at times appear to be de-
ficient coagulability of the blood, and unusual thinness of the internal
coat of the vessels.
The tendency to hemorrhage is to be combated by saline laxatives,
iron, ergot, lead, and opium. Quinine in large doses has been recom-
mended. All operations are to be avoided. If wounds occur and bleed,
pressure by bandage, ligature, or acupressure must be employed. The
actual cautery is a valuable local agent.
TREATMENT OF HEMORRHAGE. Constitutional Measures.—Before
referring to the local means of checking hemorrhage, the constitutional
or general measures must be mentioned; though they are much less im-
portant. It is, in fact, only after the bleeding vessels have been con-
trolled, or when hemorrhage is feared, but has not yet occurred, that
general measures obtain much consideration. The patient should be kept
quiet and recumbent, with the head low, in order to lessen the activity of
the heart and prevent anaemia of the brain. Sudden elevation of the
head may be followed by fatal syncope when much blood has previously
been lost.
The supply of blood to the nerve-centres can be kept up, in those who
have suffered collapse from profuse hemorrhage, by encircling the four
limbs with rubber bandages, as in the bloodless method of operating.
This drives the entire volume of blood to the head and trunk. The
elastic pressure can be continued, as we know from experience in opera-
tions, for at Jeast an hour without harm to the extremities thus deprived
of blood. If several limbs are bandaged, it is well to remove the pres-
sure slowly and from one at a time; lest the sudden rush of blood into
the limbs cause recurrent anaemia of the brain. This process is called
auto-transfusion, because the patient has his own blood forced into the
Centres of organic life. If rubber bandages are not at hand, flannel or
muslin bandages may be used; or digital compression of the abdominal
aorta or of the subclavian and axillary arteries will prevent the exit of
º: to the limbs, and thus leave more for distribution to the head and
l’Ull] K.
Morphia, quinine, ergot, gallic acid, lead and iron, in full doses, have
been recommended as internal hemostatic remedies, but I have little faith
228 DIS E A SES AN ID IN J U R IES OF B L O O D W E S S E L S.
in them in surgical hemorrhages. The local treatment is far more impor-
tant and effective.
In order to diminish arterial tension and thus hasten the arrest of blood,
Detmold has suggested temporary withdrawal from the general circula-
tion of some of the blood. This is accomplished by applying bandages
around the upper arms and thighs with firmness sufficient to prevent
venous return, but not so great as to interfere with the ingress of arte-
rial blood. The limbs are thus engorged with blood which cannot return
to the heart. Hence there is less blood-pressure at the point of hemor-
rhage, and spontaneous arrest is encouraged. This device is ingenious,
and may perhaps be serviceable in inaccessible hemorrhage of the trunk
and viscera.
Hemorrhage renders patients thirsty because of the draining of the
liquids of the body. Hence water and liquid foods are acceptable and
valuable. Perhaps water containing saline ingredients would be prefer-
able to simple water. Tonics, stimulants, and concentrated diet should
be administered subsequent to profuse hemorrhage, to replenish the loss
of the vital fluid.
TRANSFUSION.—When death from violent hemorrhage is imminent,
transfusion of blood taken from another person who is vigorous and
healthy is proper. Venous or arterial blood may be used, and it may be
injected into a vein or an artery. Venous blood is generally preferred,
because more readily obtainable, and is usually transfused into a vein of
the arm. If the blood is transfused from the donor to the receiver with-
out being subjected to manipulation, the operation is direct transfusion.
The indirect method consists in drawing the blood into a receptacle, re-
moving the fibrine by whipping, and, after straining the defibrinated
blood, injecting it by a syringe into the circulation of the patient.
In performing the operation it is important to avoid the injection of
portions of clot, and to prevent the entrance of air into the patient's
circulation. The quantity of blood transfused should not exceed eight
or ten fluidounces, and should be injected very slowly. It is not unusual
for a marked chill to follow the procedure.
Direct transfusion is readily accomplished by Aveling's apparatus.
This consists of a rubber tube, with a bulb without valves in the centre,
and metallic caps with stopcocks at each end; and two canulas or metal
tubes for insertion into the veins of the donor and recipient. The canulas
can be attached at will to the caps of the rubber tubes by an air-tight
joint. When transfusion is to be done, the rubber tube and bulb are
filled with warm water and the cocks turned to prevent its escape. The
largest vein at the bend of the elbow of the patient is then opened by a
flap incision made with a sharp bistoury, and a canula filled with warm
water introduced into the vein with the point directed toward the
patient's shoulder. The external opening of this canula must be closed
by an assistant's finger to prevent escape of the water. A similar vein
in the donor's arm is immediately opened and the other canula inserted
with its point toward the hand. From this a little blood should be allowed
to flow to drive out the air. The rubber tube, or syringe, filled with
warm water is now attached to the two canulas and both stopcocks opened.
The canulas must be held in place by assistants or by the veins being tied
around them. The surgeon with a thumb and finger presses together the
sides of the tube at any point between the bulb and the donor's arm, and
then compresses the bulb. By this manoeuvre the warm water in the
apparatus (fāj) is injected into the patient's circulation. The thumb
H E M O R R H A G. E. 229
and finger are then applied to the tube near the recipient's arm, and the
bulb is allowed to dilate. Thus about two drachms of blood are sucked
out of the donor's arm, and are, by a repetition of the previous process,
thrown quietly and slowly into the vein of the patient. If the surgeon
refers, he can force the water out of the syringe and let it and the tube
fill with blood before connecting the apparatus with the patient's canula.
Then no water is transfused, except the very small amount contained in
that canula.
Apparatus for direct transfusion.
Indirect transfusion is accomplished by withdrawing, as in ordinary
venesection, about ten fluidounces of blood from the donor and receiving
it in a small vessel surrounded by hot water (110°). The blood, thus
kept warm, is deprived of its fibrine by whipping with a fork or bundle
of straws. After being filtered through a cloth or strainer the defibrinated
blood is slowly injected by means of an ordinary syringe attached to a
canula, which has previously been inserted into the vein of the patient.
The syringe and canula must have the air expelled. Elaborate apparatus
has been devised for facilitating these steps, but it is not always possible
to obtain such instruments when needed, and the simple means described
is efficient.
In both modes of transfusion it is often preferable to isolate the
patient's vein before opening it, and to apply a ligature around it and
the point of the canula after the latter is placed in position. These pro-
cedures must be carried on under rigid asepsis.
Instead of human blood, lamb's blood, milk, and saline solutions have
been transfused with some apparent benefit.
LOCAL MEASURES.–In all cases of bleeding the first step is to clean
the wound and remove the loose clots. Afterward that means of check-
ing hemorrhage is selected which, while securing immunity from recur-
rence of bleeding, best assists Nature's efforts and offers least obstruction
to rapid healing. When operating, the surgeon should bear in mind that
many fluidounces of blood can be lost without very serious injury, and
also that no artery or vein can bleed if it is compressed by the fingers.
These facts give assurance that there is always time and means to control
the bleeding, at least temporarily. Many arteries that spurt freely when

230 D IS E A S E S A N D IN J U R IES OF B L O O D W E S S E L S.
first divided soon stop bleeding. Venous hemorrhage usually requires no
treatment for it, and unless from large veins, ceases spontaneously.
Elevation of the part has a tendency to check arterial bleeding, and
loosening of tight clothing or constricting surgical dressings will often
cause venous oozing below the constriction to cease. In the first case the
force of the arterial circulation is lessened; in the latter the impediment
to the upward flow of blood is removed and the consequent distention of
the veins prevented. Exposure of the bleeding surface to the air or the
action of cold water or ice induces contraction of the vessels and diminu-
tion of hemorrhage. Laying open a bleeding cavity or removing the
warm, poultice-like clots from a wound has a tendency to check loss of
blood from small arteries and capillaries. Ice may be thrust into bleed-
ing cavities, but its chilling and depressing influence must be watched.
Chemical agents with astringent properties are employed in surgery as
blood-arresters, under the name of styptics, because of their tendency to
promote contraction of the vessels and surrounding tissues, and because
of their inducing rapid coagulation of the blood. The most common
styptics are subsulphate of iron, perchloride of iron, alum, the salts of
copper, zinc and silver, tannic acid, gallic acid, and various combinations
of these with other ingredients. They are employed, either in powder or
solution, upon a sponge or piece of cloth, which is applied to the bleeding
surface. If the hemorrhage is from veins, capillaries, or small arteries,
styptics may arrest it, but are needless because pressure by means of com-
presses or bandages is better.
If arteries of any importance are the source of bleeding, styptics are
inefficient and, therefore, worthless. Hence, as they are either needless
or inefficient, and are apt to be means of infecting the wound with
bacteria, I regard styptics as useless agents for controlling such bleeding
as is met in general surgery.
They are objectionable because practitioners resort to them and lose
valuable time when ligation, torsion, or acupressure is required. Many
of them, moreover, by irritating the surface and covering it with pasty
clots, or by infecting it with pyogenic or putrefactive germs, prevent union
by first intention. Hot water of about 120° F., locally applied, causes
blanching of the surface and cessation of hemorrhage. It has the advan-
tage over ice of not depressing the patient. All the methods thus far
mentioned are greatly inferior to pressure and to occlusion of each indi-
vidual vessel by ligation, torsion, or acupressure. These merit careful
description, for they and the actual cautery are the only scientific and
satisfactory modes of dealing with the hemorrhages usually observed by
the surgeon.
When, as in deep cavities without bony walls, it is difficult or impossible
to use ligatures or pressure, the cautery iron, heated only to a black or
dull red color, may be employed to seal the vessels by converting the
tissues into a dry eschar. Lidell advises in parenchymatous hemorrhage
water of not less than 160°F. before resorting to cauterization. The
water probably acts by coagulating the albumen.
Pressure is well adapted for temporarily arresting hemorrhage until
ligation, amputation, or other operative measures can be performed. It
is also of great value in the permanent arrest of bleeding in those cases
when there is no vessel of sufficient importance to require ligation, torsion,
or acupressure. In my opinion, pressure and ligation are the only hemo-
static agents that the surgeon needs. Applied to the main artery in its
continuity, pressure limits the flow of blood to the wound and thus checks
H E M O R. R. H. A. G. E. 231
bleeding. This, which may be called arresting hemorrhage by indirect
pressure, is generally accomplished by means of a tourniquet, or by
pressure of the fingers. The pressure may also be obtained by using a
conical bag of shot, or a pyramidal compress with a coin at its apex, or by
placing a roll of cloth in the flexure of a joint and bandaging the joint
in a strongly-flexed position. These methods are liable to do harm
because they often interfere with the return circulation in the veins and
thus induce congestion and oedema of the structures between the wound
and the point where pressure is made upon the artery. They must be
watched. Direct pressure upon the bleeding vessels in the wound is far
better. An elastic bandage applied over a crushed and bleeding foot will
stop all hemorrhage, and is far better than a tourniquet applied to the
femoral artery, because, when reaction occurs and amputation is advisable,
all the structures above the injury are in good condition and free from
Oedema.
A compress and an ordinary bandage, applied evenly and with mode-
rate firmness, will arrest hemorrhage from capillaries, veins, and the
smaller arteries. A bleeding cavity should be plugged with aseptic gauze
or compressed sponge, which may, at times, be held in position with a
bandage. No styptic is required, for the pressure causes approximation
of the vascular walls, which is followed by internal coagulation, fibrinous
exudation, and finally, by obliteration of the vessel. In wounds that are
expected to heal by first intention the pressure is made upon the integu-
ment, after the parts have been properly adjusted. When healing by
granulation is evidently the only method of repair possible, as is the case
in wounds made in removing carious bone, the pressure is made upon the
open vessels by filling the wound with gauze, and applying a retaining
bandage.
In using pressure the surgeon must recollect that great force is not
required, and that gangrene may result from tight bandaging. The
oozing of blood-stained serum through the dressings must not be mistaken
for a continuance of the hemorrhage. Enough gauze dressing should be
applied to prevent the possibility of this serum reaching the surface, and
becoming septic between the surgeon's visits. A considerable degree of
pressure may be made with impunity if there is a voluminous gauze-
dressing over the wound, because the elasticity of the dressing prevents
the constriction from coming directly upon the tissues.
When bleeding from a wound is profuse, digital or instrumental pres-
sure should be made upon the main artery, while the surgeon is tying or
Securing the vessels in the wound. The pressure can then at intervals
be relaxed momentarily to allow the bleeding vessels to become distin-
guishable.
The common carotid artery is controlled by pressure made at the inner
border of the sterno-mastoid muscle, on a level with the cricoid cartilage,
and directly backward and inward against the cervical vertebrae.
The subclavian artery is controlled by pressure made above the clavicle
at the outside of the sterno-mastoid muscle, and directly downward, and a
little inward against the first rib.
The acillary artery is controlled by pressure made along the inner border
of the biceps muscle and directed, through the upper part of the artery's
Course, outward against the shaft of the humerus.
The femoral artery is controlled by pressure made below the middle of
Poupart's ligament, and directed upward and backward against the head
of the femur and ramus of the pubic bone.
232 D IS E A SES A N D IN J U R IES OF B L O O D W E S S E L S.
OCCLUSION BY LIGATION, TORSION, AND ACUPRESSURE.--When hem-
orrhage comes from arteries, whose calibre equals or exceeds that of the
facial, or from veins which are so situated that pressure cannot be well
applied, each vessel must be separately treated. The methods employed
to bring the walls of the artery or the vein into apposition, and thus close
the lumen, are ligation, torsion, and acupressure. The best and most fre-
quently used is ligation.
Ligation is simply tying a string tightly around the vascular tube, and
thus completely closing its calibre. Ligatures are usually round cords of
silk or catgut ; though wire, tendon, and other materials are occasionally
employed. Flat ligatures are, as a rule, not desirable. Catgut ligatures
are best prepared by the method described for the preparation of anti-
septic sutures in the chapter on Essentials of Practical Surgery. They
should be kept stored in alcohol, and soaked in a beta-naphthol or subli-
mate solution before being used. Silk ligature must be made aseptic by
boiling, or antiseptic by soaking in an antiseptic solution before use. A
convenient length for a ligature is eight to ten inches, since such a cord
can be readily drawn into a firm knot by the fingers.
When an artery is tightly tied with a ligature the external coat is deeply
grooved by the constricting cord, while the middle and inner tunics are,
on account of their brittleness, cleanly divided. The coats thus cut curl
up more or less within the lumen of the artery, and aid the coagulation
and fibrinous exudation which permanently seal the vessel. If the liga-
ture is septic, or becomes so, the external coat of the vessel gradually
ulcerates at the constricted point, so that, in the course of a few days or
weeks, the noose of thread is found lying loose in the wound. Sometimes
a little slough from the external coat is found in the noose when the liga-
ture becomes detached. Aseptic or antiseptic catgut and similar absorb-
able ligatures become absorbed in a week or two, and do not cause ulcer-
ation of the outer tunic. Wire and silk ligatures, if not septic, may
become encysted. Septic wounds are more liable to secondary hemor-
rhage than aseptic wounds, because of this possibility of ulceration and
sloughing occurring in the vessels.
Veins have such pliable coats, that none, as a rule, are divided by the
ligature, but all are simply corrugated at the point of constriction.
When a divided vessel in a wound is to be ligated the surgeon either
seizes the bleeding end with a pair of catch forceps and draws it out from
Granny knot, which is never used in Flat or reef knot. (J. D. BRY ANT.)
surgery. (J. D. BRYANT.)
the cellular and muscular tissue in which it is imbedded, or thrusts 8,
sharp hook, called a tenaculum, into the wall of the vessel, or the tissue
surrounding it. The vessel is then isolated from other structures, as much

H E M O R. R. H. A. G. E. 233
as possible, and the ligature tied beyond the forceps or tenaculum, in a
reef, or flat knot. (Figs. 86 and 87.) Care should be taken not to include
any nerve in the ligature. The accompanying veins and the muscular
tissue around an artery are usually separated from it before the ligature
is applied; but in smaller arteries it does no harm to include these in the
knot.
When the knot is tightened, the forefingers or thumb should be placed
upon the string close to the artery and firm, steady traction made. (Fig.
88.) The amount of force required to tie even a large artery is not very
great, and it should be done without jerking.
FIG. 88.
Manner of tightening ligatures.
The giving away of the inner and middle coats is often distinctly felt
by the surgeon. Ligation, as a rule, merely corrugates the inner coats of
the veins. Catgut ligatures should be given an additional third tie, be-
cause of the liability of the knot when made with catgut to become
loosened; or they should be tied in the so-called friction or surgical knot.
The ligature should have both ends cut off about one-tenth of an inch
from the knot.
The method of applying ligatures to arteries in continuity, for the arrest
of hemorrhage at a distant point and for the treatment of aneurism, will
be described in the section which treats of the special ligations.
There are five rules to guide the surgeon in the use of ligation for
arresting arterial hemorrhage:
I. In cases of primary hemorrhage do not ligate arteries which are not
actually bleeding at the time, but have the patient carefully
watched.
Reasons for this rule:
1. It is very possible that bleeding has permanently ceased.
2. It is difficult to be sure from which arteries the bleeding came.
3. All manipulations in wounds are to be avoided unless demanded.
Exceptions to this rule:
1. When a large vessel is plainly seen pulsating in the wound.
2. When the occurrence of even slight secondary hemorrhage would
º be disastrous; as in a very anaemic patient.
3. When, as in transportation, the patient will necessarily be away
from surgical scrutiny. &

234 IDIS E A S E S A N ID IN J U R IES OF B L O O D W E S S E L S.
II. In cases of primary and of secondary hemorrhage the ligature
should be applied when practicable in the wound at the point
where the artery bleeds, and not in the continuity of the vessel,
Reasons for this rule:
1. It is frequently impossible to know which artery is injured until
the wound is opened.
2. Secondary hemorrhage may occur, even after ligation in con-
timuity from the establishment of the collateral circulation.
This secondary bleeding may come even from the proximal end
of the cut vessel, if a branch of considerable size is given oft
between the wound and the point of ligation.
3. Ligation in continuity makes a second wound, and adds the pos-
sible complication of this wound to the patient's original
dangers.
4. Ligation in continuity remains, as a reverse step, still possible, if
ligation in the wound fails.
Exceptions to this rule :
None.
III. If the artery is completely severed both ends should be tied ; if it
is partly divided or punctured, a ligature should be applied to
the vessel on each side of such wound.
Reason for this rule:
The collateral circulation will probably cause secondary hemorrhage
from the distal portion of the vessel, unless double ligation be
adopted.
Exception to this rule:
When the distal end cannot be found, pressure must be made in its
neighborhood.
IV. If a large artery is wounded near its origin, tie it below the
wound, and tie the trunk, from which it arises, both above and
below the point of origin of the branch. If a trunk is wounded
near the origin of a large branch, tie the trunk with two liga-
tures in the ordinary manner, and apply a third ligature to the
branch.
Reasons for this rule:
The force of a large current of blood near the internal coagulum
may lead to its displacement, and cause secondary hemorrhage
when the silk suture causes ulceration of the external coat, or the
catgut or flat ligature is absorbed.
Exception to this rule:
None.
V. When it is impossible or impracticable to tie the vessel in the
wound, as in deep wounds of the pelvis, ligation in continuity
may be permitted.
Torsion consists in occluding the cut end of the vessel by twisting it
on its long axis. This is done by seizing the end of the cut artery with a
pair of catch forceps, drawing it out of the sheath and giving it four or
five sharp rotations. This twisting in the case of large arteries, like the
femoral, should be repeated until the sense of resistance has ceased; but
the end should not be twisted off. By this manoeuvre the middle and
inner coats are lacerated and curl up within the lumen of the artery,
while the external tunic is twisted into a cord. This acts as a temporary
plug until the internal coagulum and exudation of lymph are enabled to
prevent hemorrhage and permanently close the orifice.
H E M O R. R. H. A. G. E. 235
The twisted end is sometimes thrown off as a small slough ; but if kept
aseptic it becomes blended with the adjacent structures and is converted
into fibrous tissue. In dealing with small arteries the ends may be
twisted entirely off with impunity.
IFIG. 89. FIG. 90.
Z77272/2 N.
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Arºzy. ‘.2
º Zºsted end
* @^Aztery.
i | -
Azzyżed choſo/*#vier 6%ač's
Torsion of an artery. (BRY ANT.) Effects of torsion on arterial coats.
Some operators perform limited torsion instead of the free torsion just
described. Limited torsion is performed by drawing the vessel out and
grasping it transversely a little above the end with a second pair of for-
ceps. When rotation is then made by means of the first forceps the effect
of the twisting cannot extend above the point held by the second pair.
This method is convenient when the artery is loosely connected with sur-
rounding parts.
The chief advantage claimed for torsion is that it leaves no foreign
material in the wound as does the ordinary ligature.
Aseptic catgut or silk ligatures being either absorbed or encysted do
not act as foregin bodies, but allow the wound to be at once closed. It
is, therefore, in this respect comparable to torsion; hence, as ligation is
much safer than torsion, I greatly prefer ligation to any form of twisting,
except for vessels of inconsiderable size. When the hemostatic forceps,
used to arrest hemorrhage from cut vessels during the continuance of an
operation are to be removed, a few preliminary twists given to the vessels
will often avert the necessity of ligature.
ACUPRESSURE.-Hemorrhage from a divided vessel may be arrested by
introducing a long needle or pin into the surrounding tissues in such a
manner as to compress the artery or vein. This compression, called
acupressure, may be increased by adjusting a wire or thread around the
ends of the pin as in the harelip suture, or by twisting the tissues and the
artery during the insertion of the pin. The pins, which must be aseptic,
must not be permitted to remain in the tissues longer, at the furthest, than
three days. Usually they should be removed in twenty-four or forty-
eight hours. The time depends upon the size of the artery. Large arte-
ries require longer pressure than small ones, to insure against secondary
hemorrhage. Herein lies the chief objection to acupressure. If the pins
are removed too soon, secondary hemorrhage may supervene; if they are
allowed to remain too long, they may cause irritation or interfere with the
dressings, and there is nothing gained over the use of the ordinary ligature.
Acupressure is a valuable means of arresting bleeding when the surgeon
has no assistants and is in a hurry. It stops the hemorrhage until better
methods can be applied. It is also useful as a preliminary to operations
which must of necessity divide definite vessels. Thus the facial artery can
be compressed before cutting into the cheek. So also the tissues around

236 D IS E A SES AND IN J U R IIES OF B LOO D VES S E L S.
vascular tumors can be thus compressed by pins with threads wrapped
around the ends before their éxcision is begun.
Acupressure acts as a hemostatic by bringing the vascular walls together
and thus shutting out the blood current until repair goes on by exudation
of lymph at the cut extremity of the vessel. An internal coagulum forms
above the point of acupressure, but does not seem to play any part in the
function of the permanent repair. Permanent closure is effected entirely
below the constriction caused by the pin in the same manner as in nature's
method of arresting bleeding and repairing cut arteries. If the pin
remains long enough to destroy the structure of the inner coat, the same
changes occur as after ligation.
Acupressure pins are removed by seizing the head and gently rotating
and withdrawing the pin from the tissues while the parts are supported
with the other hand of the surgeon.
Of the many methods of obtaining pressure upon an artery by means of
a needle or pin thrust into the tissues there are only four that deserve
special attention and description:
1. The point of the pin is introduced through the skin perpendicular
to the course of the vessel, the free end of the pin is depressed, the point
is then carried across behind artery until it emerges from the skin at the
FIG. 92.
º º III,
ſº ºft
First method of acupressure. (BRYANT ) Second method of acupressure. (BRYANT.)
opposite side of the vessel. The elastic skin exerts sufficient'tension upon
the pin to cause approximation of the arterial walls. If complete con-
striction is not thus induced a silk or catgut thread may be wrapped
around the exposed ends of the pin, as is done in the pin or harelip
suture. This reinforcement of pressure may become especially necessary
when pins are introduced from raw surfaces, in which the elasticity of the
skin does not exist. •
2. The pin is thrust through a thick fold of muscular tissue at one side
of the vessel, carried across the front of the artery and thrust through a
second thick fold of the tissue at the other side. The pin is thus pressed
back upon the artery by the tension of the transfixed muscular masses.
This method obliterates the calibre of the vessel best when firm struc-
tures, such as bone, fascia, or skin, lie behind the artery and furnish
counterpressure.
3. The pin is introduced parallel to the axis of the artery through a
fold of tissue near one side of the vessel; the free extremity of the pin is
rotated in the horizontal plane through one-quarter of a circle, and the
point is then carried across the front of the artery and fixed by being
deeply buried in the soft structures on the other side. The artery is thus
closed by the twisting of its coats and of the surrounding tissues.
4. The pin is inserted at right angles to the axis of the artery through
a fold of tissue; the point is then carried across the front of the artery,
and the free extremity of the pin rotated in the vertical plane through a
half circle and the point fixed by being deeply buried in the soft struc-

H E M O R. R. H. A. G. E. 237
tures behind the vessel. Occlusion is accomplished somewhat as in the
previous method by the twisting induced by the rotation of the pin.
FIG. 93.
Third method of acupressure.
FIG. 94.
Fourth method of acupressure.
Acupressure is, in my opinion, far inferior to ligation, which method,
when aseptic catgut or silk ligatures are employed, secures the greatest
safety and has no tendency to retard primary union.
When it is difficult to apply ligatures or acupressure in deep wounds,
the hemostatic forceps may be used to seize and close the arterial wound
and then be allowed to remain so attached as clamps for one or two days.
If aseptic they do no harm, except to make dressing of the wound a little
inconvenient.
TREATMENT OF SECONDARY HEMORRHAGE.-The prevention of sec-
ondary hemorrhage is to be secured by obtaining rapid union in wounds.
Hence, absence of pus is a primary factor. Consequently antisepsis and
provision for free drainage are absolutely demanded.
When secondary bleeding is feared the patient should be kept abso-
lutely quiet, and undue circulatory activity controlled by aconite, low
diet, laxatives, and possibly venesection. Morphia and ergot given in-
termally in full doses are beneficial from this point of view. So also is
partial compression of the main arterial trunk supplying the injured
region, and elevation of the limb in which bleeding is feared.
In dealing with secondary hemorrhage the surgeon must not delay. In
primary hemorrhage it is injudicious to take active steps when bleeding
has already ceased, unless the circumstances are exceptional. The case is
different in secondary bleeding. The first escape of blood, even in small


238 DISE ASES AND IN JURIES OF BLOODVESSELs.
quantity, calls for action, which may, it is true, be limited to elevation of
the part and compression of the wound and main artery by compresses
and bandages; but the second actual outbreak of hemorrhage impera-
tively calls for prompt surgical measures. If healing of the wound is
still quite incomplete the sutures should be withdrawn, the clots turned
out, and the vessel from which bleeding has come securely ligated. As
it may be somewhat difficult to determine the exact source, every sus-
picious point should be ligated. If the softened or sloughy condition of
the wound surfaces prevents satisfactory application of ligatures, the
actual cautery may, perhaps, be available.
Opening the wound is the proper procedure even if union is well ad-
vanced, for the escaping blood has usually distended the wound cavity
before the existence of bleeding has been detected, and by this action,
moreover, the surgeon obtains the most accurate information possible of
the character of the complication with which he has to deal. Acupressure
applied by the first method described on page 236, is often a valuable
means of arresting the bleeding either before or after the wound is re-
opened. By thrusting the pin deeply through the tissues and reinforcing
the pressure with a strong thread wrapped around the ends, the surgeon
is enabled to compress parts in which one or more bleeding arteries are
situated. This manoeuvre may be employed to avert the necessity of lay-
ing open the partially cicatrized wound, or to secure vessels whose patulous
mouths cannot be found on the surface of the wound because of spon-
taneous cessation of bleeding. 4.
Instead of an acupressure pin a strong ligature may be carried through
the tissues by means of a long needle ; by tying the ends of this cord
together constriction may be effected that will restrain hemorrhage,
though not sufficiently great to cause strangulation and gangrene.
The elastic bandage applied with only moderate firmness over the
wound at times proves a valuable aid in resisting secondary bleeding.
When secondary hemorrhage persists despite the direct treatment ap-
plied at the seat of trouble, it is proper to ligate the main artery in con-
tinuity, as is done in dealing with aneurisms. Such ligation should be
performed as near the seat of hemorrhage as possible unless the anatomical
relations of the regions make it known that the arterial anastomosis will
soon establish such a collateral circulation that hemorrhage will probably
recur in the original locality. Then it becomes necessary to select a
higher point for the deligation. In secondary hemorrhage of the palm,
for example, it is usually better surgery to ligate the brachial artery than
to tie at the wrist the radial or ulnar or both ; this is a fact because the
anastomosis between the arteries of the forearm is so free.
Secondary hemorrhage may supervene after an arterial trunk has been
tied in its continuity for the cure of aneurism or the arrest of hemorrhage
at a lower point. Here the first step is to apply pressure to the seat of
ligation by a graduating compress, or by plugging the wound. If this
fails the wound must be opened and a ligature applied at each side of the
orifice in the vessel, which must then be completely divided between the
ligatures, if the original injury did not do so, in order to allow retraction
and contraction of its walls. In the event of this being followed by re-
currence of hemorrhage, either a second deligation in continuity at a
higher point, with or without contemporaneous ligation of one or more
anastomosing branches, or amputation of the limb must be performed.
Gangrene is apt to occur when a second ligation is done in the lower
extremity, because the collateral circulation is rarely sufficient to main-
W O U N DS OF W E IN S. 239
tain the vitality of the distant parts. Hence, some high authorities have
recommended amputation rather than second ligations for persistent Sec-
ondary hemorrhages under such circumstances.
When the original source of secondary hemorrhage is a vessel near the
aorta, pressure at the seat of bleeding is the only resource. Indeed,
pressure, judiciously applied by pads, plugging, and shotbags, has at
times been efficacious when ligation above the seat of hemorrhage has
failed. This is due to the circumstance that the escape of blood comes
very frequently from the distal portion of the injured vessel, to which the
anastomosing branches have given an abundant blood-current.
WOUNDS OF VEINS.
The discussion of hemorrhage has involved some consideration of
wounds of veins, but a few points remain that deserve more extended
attention. The dangers from wounded veins are hemorrhage, septicaemia,
diffuse phlebitis, and entrance of air into the heart.
The bleeding from large venous trunks is as fatal as arterial hemor-
rhage, but that from small veins usually stops spontaneously unless there
is some source of constriction upon the cardiac side of the wound. Good
examples of this are seen in the constricting bandage placed above the
elbow in cases of venesection, in order to obtain a prolonged and free
flow of blood from the wounded vein; and in protruding hemorrhoidal
tumors pinched by the sphincter of the anus, which will continue to bleed
until the anus is dilated by the fingers or the tumors replaced within the
rectum. Blood flows from wounded veins in a dark, rapid stream without
showing the pulsatile action of the heart; it has, however, an increase in
its force during each act of expiration, if the seat of hemorrhage is near
the trunk. Pressure made on the cardiac side of the wound causes an
increased flow of blood. This may be of diagnostic value in deep wounds,
for blood from arteries may be dark during anaesthesia, or when the
bleeding comes from the distal end of a divided artery in one of the
extremities. *
Subcutaneous rupture of a vein from violence may occur. The ex-
travasation of blood, even if large, is usually absorbed in a few days or
weeks; but it may cause inflammation leading to abscess, if pyogenic
bacteria gain access to it, or become encysted in a fluid state, giving rise
to the fluctuating tumor called hematoma. Contusions of veins, as of
arteries, may be unaccompanied by symptoms of special import until
secondary hemorrhage occurs from the ulceration or sloughing of the
injured vessel wall.
When veins are completely divided slight contraction and retraction of
the coats occur, but not in a sufficient degree to restrain hemorrhage from
the larger vessels.
Incision and puncture of veins, when not fatal, usually heal rapidly
and perfectly by first intention, leaving no scar and not encroaching on
the calibre of the vessel. Such is not the case in arterial wounds which
are followed by obstruction of the vessel at the seat of puncture. This
is well illustrated by the wound of the median basilic vein made in vene-
Section. Small wounds of varicose veins or of the larger trunks may
prove fatal from anaemia, if the bleeding is not arrested by pressure or
ligation. Injurious secondary results may follow when the blood is
poured into the cavity of the cranium, thorax, or abdomen. Often this
240 DIS E A S E S A N D IN J U R IES OF BILO O DW E SSE L S.
is the chief danger. Wounds, even of the large cerebral sinuses, are not
of very grave prognosis, if the blood is given full opportunity to escape,
for moderate pressure arrests the hemorrhage in these venous channels of
slow current.
Wounds of small or moderate size veins require little special treatment.
Elevation of the part, removal of all constriction of clothing on the
cardiac side of the injury, and slight pressure by a compress and bandage
are sufficient. In three or four days cicatrization occurs. Large veins
require ligation. Styptics should never be employed. A catgut liga-
ture should be applied below and another above the wound, if the vein
is not completely divided; or the wound may be closed by fine catgut
sutures. Either of these is perhaps a better safeguard against secondary
hemorrhage than lateral ligation. By lateral ligation is meant tying the
portion of the wall of the vein immediately surrounding the wound. This
is readily done in large veins by grasping the flaccid coats of the vessel
with forceps and tenaculum and tying the ligature around the tissue so
seized. Such a ligature is possibly liable to slip off; hence suture may in
Some instances, at least, be better. Lateral ligature and suture do not
entirely destroy the continuity of the vessel as does circular ligation
above and below the wound. Aseptic ligation of veins is not apt to pro-
duce diffuse phlebitis and pyaemia, as was formerly taught. The method
of repair after ligation of veins is similar to that which obtains in arte-
rial ligation. The ligature does not, however, cut the internal and
middle coats of the vein, but merely corrugates them ; or, at most,
divides only the inner layer of the middle tunic. Coagulation then
occurs at the distal side of the ligature, and inflammatory changes ensue
which permanently seal the vessel. In some cases the bleeding may be
satisfactorily controlled by seizing the wounded portion with hemostatic
forceps, so placed as to close the opening and leaving them hanging in
position for twenty-four or forty-eight hours.
Septicaemia may follow venous wounds, if the open vein or sinus is
surrounded by unhealthy pus; hence absence of putrefaction and provi-
sion for drainage are important features in treating wounds in which
large veins are opened. Ligation by closing the open orifices tends to
prevent such septic infection, and is, therefore, at times advisable in major
operations, when sepsis cannot be prevented, even when there is no lia-
bility to venous hemorrhage.
When the large veins of the extremities, such as the femoral or axillary,
are wounded, ligation of the accompanying artery also may, according
to some authorities, be proper and judicious after ligation of the vein. The
flow of blood to the limb is thus diminished ; venous congestion of the
tissues is thereby prevented, because the equilibrium in the capillaries is
less disturbed; and the possibility of gangrene is probably less. Further
evidence of the advisability of such simultaneous ligation of veins and
arteries is desirable. I very much doubt its propriety in the upper ex-
tremity, though willing to admit its probable value in wounds of the
femoral vein.
Trephining may be required after wounds of the sinuses of the dura
mater to allow the removal of clots causing compression of the brain.
Moderate pressure upon the injured venous channel with antiseptic
cotton will control hemorrhage. Hemostatic preparations of iron or
other styptics should not be employed.
If from any cause the wound in a vein is kept widely open during
violent inspiratory efforts, air may be sucked into the venous circulation
W O U N D S OF VE IN S. 241
and be carried to the right heart. This dangerous accident is especially
liable to occur during operations in the vicinity of the internal jugular,
subclavian, innominate, and axillary veins; though it has been stated that
it may happen in veins of smaller calibre and in those situated further
from the heart. The manner in which wounded veins ordinarily become
collapsed during inspiration usually prevents the entrance of air; hence it
is only when some cause holds the lips of the wound apart that sucking
air into the veins is possible. This may be due to inflammatory thick-
ening of the walls converting the vein into a tube, the so-called canaliza-
tion of the veins; to the vessel being imbedded in hardened tissue or in
the substance of tumors, which prevents collapse; or to the efforts of the
surgeon who, in attempting to enucleate a tumor or foreign body, pulls
the walls of the vein apart at the time of a deep inspiration. The acci-
dent is less common since the introduction of anaesthesia, because there are
less struggling and gasping on the part of the patient, and more delibera- .
tion exercised by the surgeon. It is possible, however, that some of the
deaths attributed to anaesthesia may be cases of air in the veins. :
The symptoms of entrance of air into the veins are marked. During
the progress of an operation a sudden sucking sound is heard; frothy
blood is, perhaps, observed in the wound, the pulse fails, the heart beats
irregularly and feebly, respiration is oppressed, and syncope or, perhaps,
convulsions occur. If the amount of air drawn in is small, recovery
gradually takes place; if the quantity is considerable, coma and death
supervene. The fatal issue may be immediate, but usually is postponed
for a period varying from a few minutes to an hour. In cases that
recover transitory paresis has been observed. Secondary pneumonia has
proved fatal in others.
Occasionally a sound similar to that produced by air entering the veins
occurs when the deep fascia of the neck is incised, I was once startled
by this phenomenon when performing tracheotomy for great dyspnoea in
diphtheria.
The pathology of the symptoms induced by air in the veins is not
understood. It is probable that the air, causing a frothy condition of the
blood in the right auricle and ventricle, prevents proper action of the
valves and interferes with the blood transfer in the pulmonary circula-
tion. Anaemia of the brain and other nerve centres is thus induced."
This serious complication of operative surgery, which must be quite
rare, is to be prevented by securing regular and quiet respiration during
anaesthesia, by tearing the tissues in the vicinity of large veins apart with
fingers and dull instruments, instead of using the knife, and by avoiding
any posture of traction that tends to keep venous wounds gaping. When
it becomes necessary to divide a large vein the surgeon should make pres-
sure with the fingers upon the vessel at the cardiac side of the proposed
Yound. This should be done also when firmly attached tumors are being
forcibly enucleated. It has been proposed to bandage the chest as a pre-
liminary measure before operating in the region made dangerous by the
situation of the large venous trunks. Thus unexpected deep inspiration
is prevented.
When air has actually been sucked into the veins, prompt treatment is
demanded. The vein should immediately be compressed at the cardiac
side of the wound, and ligatures should then be applied on both sides of
* See N. Lewis's paper, Amer. Surg. Assn., 1885.
16
242 DIS E A SES AND IN J U R IES OF BLOOD WESS ELS.
the orifice. The patient's head should be lowered, stimulants should be
given, and artificial respiration instituted.
Galvanism of the chest and cardiac region, transfusion of blood or of
warm water, tracheotomy, venesection, and pumping the air from the
veins or even from the heart by the aspirator, have been proposed. The
injection of warm water directly into the heart-cavity has been suggested.
If the symptoms depend upon failure of the valve action because of
absence of fluid in the heart, this may perhaps be a rational therapeutic
IleaSUll’é.
It is probable that the dangers of air in the veins and heart have been
overestimated.
DISEASES OF THE WEINs.
Inflammation of Weins, or Phlebitis.
VARIETIES.—Inflammation of veins may be plastic or suppurative.
Idiopathic phlebitis is quite rare, but occasionally occurs in the course
of fevers, or as the consequence of syphilis, gout, varicose veins, and pos-
sibly of exposure to cold. This form of venous inflammation is more apt
to be located in the veins of the lower extremity than elsewhere, and
does not often assume the dangerous characteristics that quite frequently
belong to traumatic phlebitis, because traumatic phlebitis is often septic.
Traumatic inflammation follows contusion, rupture, or incision of the
venous walls, and may also be due to violent muscular contraction and
pressure, Uterine phlebitis after parturition is a phlebitis possibly due
to the cause last mentioned, but probably a result of microbic infection.
Inflammation of the tissues around a vein may cause phlebitis, which
should then be considered a form of traumatic phlebitis secondary to
peri-phlebitis. Traumatic inflammation of veins in healthy subjects is
usually a localized affection of slight gravity. If, however, Septic changes
occur in the wound, especially it would seem when the orifices of the
divided veins remain open, a diffuse or suppurative phlebitis, allied to
pyaemia, and of a most dangerous character may arise. Operation wounds
of veins are usually of slight gravity, because the consequent phlebitis is
an uncomplicated and localized adhesive inflammation.
PATHOLOGY..—Coagulation of blood in the living veins, technically
called thrombosis, is always an accompaniment of phlebitis. This clotting
may be the cause of the inflammation. Such is the case at times in the
phlebitis secondary to varicose veins. Here the overstretched venous
walls, with imperfectly-acting valves, allow retardation of blood-current,
and the consequent thrombosis sets up inflammation of the vascular tunics.
On the other hand, thrombosis may be the result of inflammation, as is
probably the case in traumatic phlebitis.
The pathological changes of phlebitis occur principally in the outer
and middle coats, which in veins, indeed, are scarcely to be considered as
two distinct tunics. Hyperaemia of these coats and infiltration of the
spaces between their vessels with cells and serum are observed. These
changes necessarily induce swelling, thickening and loss of flexibility of
the walls, which may remain patulous when divided. The internal coat
becomes cloudy, fissured and shreddy, and may be separated from its
neighboring tunic by the disintegrating influences of inflammation. At
the seat of inflammation coagulation takes place within the vein at an
early stage of the phlebitis. If the clot is aseptic and remains so, the
IN FLA M M ATION OF VE INS, OR P H L E BITIS. 243
inflammatory process is localized. The vein may then be converted into
an impervous fibrocellular cord, as occurs after arterial ligation. If the
coagulum adheres to only one side of the vein, however, partial circula-
tion may finally be established through the vessel; or, if complete
removal of the clot by absorption occurs, the calibre of the vein may be
perfectly restored. $
The occurrence of suppurative and gangrenous inflammation of veins
leads to disintegration or yellow softening of the clot, and the dangerous
septic elements are admitted into the general circulation.
As a result, portions of the coagulum are worked loose and carried to
the right heart and thence into distant arteries. Such plugs or emboli
produce infarctions and abscesses; and because of an infective nature
lead to pyaemic symptoms and death. It is for this reason that phlebitis
in broken-down subjects or in those suffering from infected wounds, is
regarded as a disease of grave prognosis.
SYMPTOMS.–Inflammation of a subcutaneous vein gives rise in the
course of the vessel to a hard painful cord, which is accompanied by
some swelling and a distinct dusky-red or copper color line upon the
overlying skin. The cord often has a knotted appearance indicating the
situation of the valves of the diseased vein. Coagulation in the vessel
impedes venous return from the distal part of the limb and causes oedema,
which may be further increased by actual inflammation of the general
connective tissue of the extremity. In the latter event, there is more in-
duration than in simple oadema from circulatory obstruction. Stiffness of
the limb affected with phlebitis and pain, often of a character resembling
neuralgia, are present. Phlebitis, when not localized, usully extends in
the direction of the heart.
When the deep veins only are inflamed the vessels are not mapped out
by the subcutaneous rigid cords that serve to distinguish superficial
phlebitis, neither are the copperish lines seen ; but the painful stiffness
and Oedema are perhaps the only indications of inflammation. The
diagnosis, consequently, is sometimes difficult.
The constitutional symptoms are slight in localized venous inflamma-
tion; but when the disease is more extensive, febrile movement is present.
In the event of septic infection occurring in the manner explained in the
paragraph on the Pathology of Phlebitis, chills, sweats, high temperature,
a rapid thready pulse, and delirium are to be expected. Under such
circumstances embolic abscesses and death from pyaemic symptoms may
readily supervene. Embolic abscess of the liver may thus occur in portal
phlebitis. A close connection exists between rapidly-spreading phlebitis,
with its ulceration and gangrene of venous walls, and diffuse cellulitis
and erysipelas. They all tend to destroy life by the induction of septi-
Gaemic processes; and are due to mycotic infection. Non-septic phlebitis
is, even when extensive, of favorable prognosis. Septic phlebitis is a very
fatal disease.
Phlebitis is to be distinguished from inflammation of the lymphatic
Vessels, or angeioleucitis, by the absence of glandular involvement and
by the darker red of the cutaneous line indicating the course of the
affected vessels. Neuralgia and neuritis are unaccompanied by the oedema
which almost invariably attends phlebitis.
TREATMENT-Phlebitis is to be treated by absolute rest of the part
affected, and by the avoidance of all causes that might favor the separa-
tion or disintegration of the intravascular coagulum. Pyogenic and
Putrefactive infection must be rigidly averted. Slight elevation of the
244 DIS E A SES A N D IN J U R I ES OF BILO O D W E S S E L S.
limbs to favor the return circulation is judicious and lessens pain.
Leeching, lead-water and laudanum, mercurial ointment, evaporating
lotions, fomentations of various kinds, and tincture of iodine have been
found useful as local measures. Quinine, iron, and rest in bed are essen-
tial in cases of even moderate severity. Cardiac depressants are to be
avoided because of the possibility that septicaemia may arise from unex-
pected infection.
When inflammation is spreading rapidly up the vein, Mr. Lee suggests
compressing the vein at two points—above the seat of inflammation by
acupressure pins, and subcutaneously dividing the vessel between them.
If suppuration, great oedema, and diffuse cellular inflammation arise,
free incisions, parallel to the veins, should be made.
This procedure should be followed by thorough antiseptic irrigation and
drainage.
To remove the swelling and hastem the absorption of inflammatory
deposits, due to phlebitis of a chronic type, elevation, friction, massage,
and pressure by the elastic bandage should be employed.
Bypertrophy and Varicosity of Weins.
DEFINITION.—When an abnormal quantity of blood is constantly
carried by a vein, the vessel becomes enlarged in calibre and thickened
in its coats. This constitutes hypertrophy of veins; and is seen, for ex-
ample, when obstruction of a vena cava causes enlargement of the
external epigastric vein and the veins of the anterior walls of the chest,
and in other instances of unusual development of the collateral venous
circulation. No treatment is required, for the condition is a compensa-
tory one. When the amount of blood in a vein is diminished, as happens
after amputations, venous atrophy results.
Varicose veins are veins which, on account of disease of the walls, have
become enlarged and more or less irregularly dilated and thinned, and in
which the blood current is abnormally retarded. Varix, or varicose vein,
is, therefore a condition that should be distinguished from hypertrophy
of veins. *
PATHOLOGY..—Varicosity is most frequently met with in the veins of
the leg, spermatic cord and rectum ; though the condition may arise in
any location, even, it is stated, in the veins of Osseous tissue. The long
saphenous vein is very frequently affected. The condition is probably
due to a paresis of the muscular tissue of the vessel wall depending upon
degeneration of muscular fibre or imperfect innervation. Any impedi-
ment of the blood current acts as a predisposing cause of varicose veins
by increasing the intravenous hydrostatic pressure. Hence gravity has
long been regarded as a prominent factor in the production of varix. I
doubt whether such causes are capable of giving rise to varicosity, when
collateral venous circulation is possible, unless at the same time there be
Some degenerative process going on in the venous walls. I should as soon
expect to see aneurismal dilatation of an artery produced by simple inter-
ference with the blood current without previous disease of the arterial
tunics. If the flow of blood is arrested in an artery the anastomosing
arteries become hypertrophied; so is it in the case of veins. If the blood
current is impeded in one vein, the collateral circulation is established
and the adjacent veins become hypertrophic.
Heredity, debility, continued standing, the wearing of tight garters, and
H Y P E R T R O PHY AND WA RIC OSITY OF VE IN S. 245
many other factors have been accused as causes of varicose veins; but
there must be some as yet unknown influence that determines the occur-
rence of this pathological venous lesion.
The pathological changes found in varix are dilatation, increased length
and tortuosity, hyperplasia of connective and other tissues, causing irregu-
lar thickening of the venous walls, incompetent valves due to partial
destruction of the leaflets, or to the impossibility of contact resulting from
the increased calibre of the vessel, and sacculation similar in appearance
to the pouched condition of the colon. The irregular dilatations, causing
sacculation, are especially prominent at points where two veins unite.
The wall in such pouches is exceedingly attenuated. Chronic inflam-
matory changes are apt to arise in the tissues surrounding varicose veins,
causing oedema, obstinate ulcers and even a condition resembling Arabian
elephantiasis.
Coagulation may occur within varicose veins, and thus induce inflam-
mation or occlusion and partial cure. Suppuration may occur from
infection with pus germs. Calcareous -
degeneration of the clot sometimes FIG. 95.
takes place, and concretions, called
vein-stones, or phleboliths, remain. Tº
These may be either free or adherent º
to the wall of the vein. They are sº
also, however, found in veins not vari-
cose, and are especially liable to occur
in the veins of the pelvis. It is be- Varicose vein. (BRY ANT.)
lieved that these pelvic phleboliths
may also be formed outside of the vessel and subsequently penetrate the
venous walls.
SYMPTOMS.–The symptoms of varix are, dull pain, a sensation of
weight or fulness, numbness, and perhaps some impairment of power.
Inspection shows a characteristic, bluish, knotted, soft tumor, in which the
dilated and tortuous veins can readily be recognized. CEdema, indura-
tion, eczema, and chronic ulceration of the skin are frequently present in
varix of the leg of long standing. It is probable that the deep veins are
affected about as frequently as the subcutaneous, but when the affection
pertains only to the former the diagnosis is difficult. Gay thinks muscu-
lar cramps indicative of deep varix. Slight local varicosities of the
cutaneous capillary veins are quite common in women, giving rise to an
arborescent appearance of the skin without swelling or other symptom.
. Profuse bleeding may supervene from perforation of a varix by ulcera-
tion. It is improper to say that the varicose vein bursts, since the ulcera-
tive process begins externally. The copious hemorrhage probably comes
from the cardiac portion of the vein, which is distended with blood and
furnished with diseased valves incompetent to resist the backward cur-
rent. Moderate pressure with a finger or compress will control the bleed-
ing, which, if not arrested, may prove fatal.
Phlebitis, with its characteristic thrombosis, may be developed in vari-
Cose veins without any specially assignable cause.
TREATMENT.-The distress produced by the existence of varicose veins
gan be greatly palliated by such artificial support as is obtained by cover-
ing the Jimb with elastic webbing, or a rubber bandage, applied smoothly
and with very moderate pressure. To prevent cutaneous irritation from
retention of secretion it may be necessary to cover the skin with a soft
piece of cotton or linen cloth, before applying the rubber bandage. If
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246 DISE A SES A N D IN J U RIES OF B L O O D W E S S E L S.
ulceration exists, ointments or solutions can be thus applied before the
bandage is adjusted. A silicate of sodium case, such as is used in treat-
ing partially united fractures, makes a convenient support for varicose
veins of the leg. These appliances for pressure should be removed at
night only after the patient has assumed the recumbent posture.
Elevation of the leg while keeping the patient in bed and pressure of
this sort will greatly hasten the cure of eczema and ulcers complicating
varicose veins of the lower limbs.
The radical treatment of varicose veins depends upon occlusion of the
calibre of the vessel; or, in other words, upon obliterating the vein at the
point operated upon, and thus compelling anastomosing veins to carry on
the circulation. The symptoms of varix are removed at the points of
operation, and much relief may thus be afforded the patient; but the
condition persists, or is soon developed in the adjacent veins, either super-
ficial or deep. There is a risk, though an exceedingly slight one, of
inducing dangerous phlebitis by these operations, for the so-called radical
treatment of varix. Such measures are to be recommended when incon-
venience, pain, intractable ulceration, or the danger of hemorrhage from
perforation renders the patient uncomfortable. Antiseptic surgery renders
these operations trivial.
The most approved methods are the subcutaneous ligature and acu-
pressure. Subcutaneous ligation is effected by carrying a catgut ligature
beneath the dilated vein by means of a straight needle, which is then
reëntered at the point of exit and thrust in front of the vein until it
emerges at the first puncture. Withdrawal of the needle through this
original opening causes the vein to be subcutaneously encircled by a loop
of catgut.
FIG. 96.
º
--~~~~
…tº' - * * - 2%
* ...-- &A
_º” ºx-º
2* ~~ s
2. 2’
skſ N 32°
Diagram of subcutaneous ligation of varicose veins.
The ligature is then drawn tightly around the vein and the ends tied.
The coats of the vein are thus brought into apposition and internal coagu-
lation, with consequent local plastic inflammation and occlusion, results at
as many points as the surgeon has ligated. The catgut ligatures become
absorbed and need no attention. The veins should be ligated at numer-
ous points, and care must be taken to avoid transfixing the vessel with
the needle. It is well to insert the ligature nearest the heart first and to
have the limb dependent, so that the vein may be distended to its fullest
capacity. º
Acupressure acts in a similar manner. Harelip pins are thrust behind



W O U N I) S OF L Y M P H A TIC S. 247
the varicose veins at various points about one inch apart, and the com-
pression obtained by a figure-of-eight or elliptical ligature applied as in
making the twisted suture. The uppermost pins should be inserted first.
The pressure may be increased by laying small pieces of rubber upon
the skin at right angles to the pins and tying the ligatures over these.
FIG, 97.
3%
Žº *>< 2.
rº-2 %%22-3.
- Zº º
: º %2 %
.a. *… ... : * % º %
º-" 3% %. AM, % % º
% * % %%
Varicose veins treated by acupressure. (ERICHSEN.)
The pins should be withdrawn after the lapse of eight or ten days. A
modification of this method is to compress the vein with pins and then
subcutaneously divide the vessel by means of a tenotome. The pins are
removed in about four days. Obliteration of the vein is thus insured, and
there is little danger of septic phlebitis. It is a good method. Excision
of about two inches of the vein through an ordinary cutaneous incision is
a successful method. It must be done aseptically. After any of these
methods of operating a bandage should be applied to the limb and the
patient kept in bed. Elastic stockings or rubber bandages should be
worn after the patient assumes the erect posture.
Intravenous injection of coagulating fluids, such as the iron salts, tan-
nin and chloral, peri-vascular injections of ergotine, the application of
caustic issues over the varix, and excision of portions of the dilated vein
have been advocated. I reject them as probably more dangerous than
subcutaneous ligation or acupressure.
Patients with varicose veins, if debilitated, should be treated with
tonics and made to refrain from occupations that require standing or
other positions favoring venous stasis.
Fluid extract of hamamelis has recently been recommended as an inter-
mal remedy to be administered in fluidrachm doses several times daily.
Its value, if it has any, is due to its astringent action. If hemorrhage
occurs from varix, elevation and a moderate compress will stop it.
Varicocele and internal hemorrhoids are instances of varix in special
localities, which will be discussed in subsequent chapters.
DISEASES OF LYMPHATICS.
Wounds of Lymphatics.
The lymphatic vessels of the body, which in their universal distribution
exceed in number the blood vessels, are injured in all wounds. Lymph
















248 D IS E A S E S OF LY M P H A TICS,
escapes from the several vessels, but is mixed with blood, and demands
no especial notice. It is only when the thoracic duct, a large lymphatic
trunk, or a varicose lymphatic vessel is wounded that the escape of lymph
is dignified by the name lymphorrhagia. The fluid thus discharged is at
times transparent, at others milky in appearance, and may continue
indefinitely if a fistula becomes established at the seat of injury. When
a lymphatic vessel becomes occluded from pressure of a tumor or from
disease, collateral lymphatic circulation is established, just as happens in
veins. The lymphatic vessels and their valves much resemble veins as
well in function as in histology. Lymphorrhagia is to be treated by pres-
sure applied to the distal portion of the vessel, and lymphatic fistulas by
compression and cauterization. Incision of lymphatic glands is said to
have been followed by lymphatic fistulas.
Inflammation of Lymphatic Vessels or Lynnphamgitis.
PATHOLOGY..—Lymphangitis, or angeioleucitis, may be idiopathic, but
generally it is traumatic. It should be remembered that though trau-
matic in origin, it may first appear at a distance from the wound. It is
especially liable to follow injuries inoculated with septic or other micro
organisms. Simple lymphangitis is much less dangerous than the septic
form, which frequently has a fatal issue.
The pathological changes are similar to those found in phlebitis. The
lymph loses its transparency, becomes opaque, and forms thrombi or, clots
of a pinkish color in the vicinity of the valves. These clots, by adhering
to the vessel wall may cause occlusion, or they may break down into pus.
Thickening, opacity, and dilatation of the walls of the lymphatic vessels
occur and the internal tunic becomes uneven. If occlusion is produced
the ducts anastomosing with the obliterated vessel soon become distended
and carry on the circulation of lymph. The connective tissue about the
inflamed absorbents becomes infiltrated with lymph cells escaping from
the vessels and peripheral oedema is induced by obstruction of the lymph
current due to the internal thrombosis.
The infiltrated structures may be relieved of this inundation by absorp-
tive processes, may suppurate, or may become indurated and hypertro:
phied. It is probable that occlusion of lymphatic vessels from repeated
lymphangitis occurring in connection with cutaneous changes, is a factor
in the causation of certain cases of Arabian elephantiasis. Cellulitis and
arthritis may be secondary to lymphangitis, and even go on to suppura-
tion. *
SYMPTOMs.--Inflammation of the fine capillary absorbent vessels, which
form an anastomosing network, is called reticular lymphangitis, while
inflammation of the larger ducts is termed tubular lymphangitis. Reticu-
lar lymphangitis occurs in patches, and may or may not be associated
with inflammation of neighboring ducts of larger calibre. The adjacent
glands, however, are nearly always involved. The patches are hot, red,
painful, and surrounded by slight Cedema, and may go on to suppuration.
Slight wounds, such as needle pricks, at the end of the finger, especially
when infected with pathogenic bacteria and when in debilitated subjects;
and frequent contact with septic tissues, even without breach of surface,
may give rise to reticular absorbent inflammation, which may be mani-
fested by multiple spots of inflammation successively extending up the
limb. Certain forms of felon are instances of lymphangitis, and the skin
,”
I N F L A M M ATION OF L Y M P HAT I C W E S S E L S. 249
disease called erythema nodosum is believed by some authorities to be a
reticular lymphangitis, with lymphatic Oedema.
Tubular lymphangitis, when affecting the superficial vessels, is mani-
fested by the appearance of vivid red cutaneous lines running from the
primary lesion toward the heart. These lines mark the centre of the
inflamed ducts which, by palpation, can be felt as hard threads. There
may be only slight tenderness along these red streaks, which by coales-
cing make bands nearly an inch wide, but usually pain is marked and
swelling of the limb observable. The nearest lymphatic glands soon
become swollen and painful. Subsequently a second group of more dis-
tant glands may be similarly involved, though there need not be any
marked evidence of inflammation of the lymphatic vessels connecting the
two glandular swellings. Resolution may occur in a week or ten days,
though suppurative inflammation of the glands or of the vessels is not
unusual. Glandular implication is almost never absent in lymphan-
gitis. It is stated, however, that in septic inflammation of the lym-
phatics such involvement may at times be wanting even when the syno-
vial lymphatic structures show suppurative processes of great severity.
The glandular inflammation or lymphadenitis results from the arrest of
the causative bacteria in the sieve-like structure of the glands.
When the deep lymphatics alone are inflamed the cutaneous redness is
absent and the symptoms are obscure. Glandular implication is the only
symptom which enables a diagnosis from cellulitis to be made.
In lymphangitis the constitutional symptoms are rigors, high tempera-
ture and other febrile manifestations, which in septic cases especially are
accompanied by great prostration, delirium, and typical asthenic symptoms.
Violent lymphangitis is often, probably always, due to the introduc-
tion of putrefactive or other pathogenic bacteria into the lymph current,
and is most liable to occur when open lymphatic capillaries are bathed in
or subjected to the influence of septic fluids. It is developed not infre-
quently in connection with dissection wounds, snake-bites, erysipelas,
diphtheria, typhus and typhoid fevers, and the puerperal condition.
Uterine lymphangitis of a septic character, which may follow labor even
When no injury to mucous membrane has been inflicted, is very prone to
cause diffuse peritonitis, and is usually fatal. Septic lymphangitis may
arise, it would appear, without traumatism by an endosmosis of the poison
through the skin.
Patients in enfeebled health are more prone to septic lymphatic inflam-
mation than those of greater resistive power. This form of lymphangitis
may run an acute or a chronic course, and is the forerunner of general
Septicæmic symptoms.
Lymphangitis is to be diagnosticated from phlebitis by the higher febrile
temperature of the former, the more vivid red of the cutaneous lines, and
the associated glandular inflammation. In erysipelas the discoloration of
skin is more diffused than in inflammation of the absorbent vessels.
TREATMENT:-The treatment of lymphangitis is very similar to that
*dapted to phlebitis. Septic infection is to be prevented by cleaning and
thºroughly disinfecting wounds at the time of their reception. If the
9xistence of poisonous inoculation is suspected at the time, as is the case
in, dissection wounds, suction and cauterization should be employed.
Absolute cleanliness and antiseptics should be enforced on the part of
those examining and attending puerperal cases, since septic uterime lymph-
*gitis, is almost uniformly fatal. Local applications may be made
along the course of the inflamed absorbent vessels when superficial. Moist
250 D IS E A SES OF L Y M P H A TI C S .
antiseptic dressings, equal parts of extract of belladonna and glycerin,
formentations containing morphia or other narcotics, and mercurial oint-
ment have been recommended as topical measures. Pencilling with nitrate
of silver and wrapping in dry cotton have advocates. The limb should
be kept elevated and at rest. Free incisions to evacuate pus must be
promptly made. Constitutional remedies of a supportive kind are always
judicious. Quinine, iron and morphia, and often alcohol, are the drugs
to be used. OEdema remaining after subsidence of the acute symptoms
is to be treated by pressure with the elastic bandage, massage and passive
motion of the joints.
Lymphademitis.
PATHOLOGY..—Inflammation of a lymphatic gland, called lymphade-
mitis or simply adenitis, may occur without the existence of lymphangitis;
but lymphangitis, as previously stated, rarely occurs without an accom-
panying lymphademitis. The retentive or sieve-like function of the lymph-
atic glands is the cause of their frequent implication secondary to
inflammation of the lymph vessels. All material conveyed along any of
these ducts is compelled to pass through the reticular or net-like structure
of the corresponding glands. Here pigments from tattooing, septic par-
ticles, whether bacteria or emboli, poison from syphilitic or other inocu-
lated wounds, cells from malignant growths, pus and abnormal lymph
cells are filtered out of the retarded lymph current and remain to choke
up the network of small spaces and channels of which the glands are in
large part formed. When these filtered-out particles cause stasis of the
current, coagulation of lymph and inflammation of the gland structure,
then lymphadenitis, with its characteristic swelling, hardness, and tender-
mess, exists. *
CAUSES.—Lymphadenitis then may be caused by direct irritation or
injury to the gland or by any peripheral lesion or absorption that sends
irritating substances to the gland. The lymph vessels between the
periphery and the gland may be free from involvement, even though they
have carried the irritative cause in the lymph current flowing through
them. Lymphadenitis may be acute or chronic, and is due to infection
by the tubercle bacillus, pyogenic organisms, and other bacteria, as well
as to direct injury. The character of the inflammation depends on the
cause and the constitution of the patient.
SYMPTOMs.-The symptoms of acute suppurative lymphadenitis are
swelling and tenderness of the gland, lancinating pain increased by
motion, and fever. The connective tissue around the gland becomes
implicated in the inflammatory process, the overlying skin assumes a red
and glazed appearance, and suppuration begins in the centre of the gland
or in the surrounding cellular tissue. Spontaneous evacuation of pus
finally occurs through an irregular orifice surrounded by thin purplish
skin, which after a prolonged period of cicatrization heals, leaving an
ugly, puckered cicatrix adherent to the deep tissues. Cure by resolution
without suppuration takes place in some instances of acute lymphadenitis,
but it is so usually due to pus infection that the formation of pus is very
common. Sometimes the tissues around the gland suppurate and on
evacuation leave the inflamed gland exposed in the wound as a reddish-
gray mass. Tubercular lymphadenitis, with burrowing of puriform fluid
and the formation of sinuses, is not very infrequent. In some cases
tubercular adenitis assumes a very chronic course, being accompanied by
W A RIC O S E L Y M P HAT I C W E S S E L S. 251
*
glandular swelling, induration, and hypertrophy without pain or fever or
tendency to degenerative softening. In some regions of the body the
lymphatic glands are scarcely perceptible by palpation through the
skin until they become enlarged by inflammation, when the nodulation
produced by them is sufficient evidence of adenitis. The inguinal bubo
occurring after syphiliticinoculation affords a good example of the behavior
of adenitis. If a whole group of glands is inflamed, the obstruction to
lymphatic circulation causes oedema of the peripheral regions. This may
become established if the adenitis is chronic.
Septic lymphadenitis differs from simple acute lymphadenitis in its
higher febrile movement and much greater danger to life.
TREATMENT.-Acute lymphadenitis requires absolute rest of the part
and antiseptic fomentations; blisters, or tincture of iodine painted around
the inflamed gland may be serviceable. Pus should be evacuated by free
incision, and the diseased gland and tissues removed by curetting. Car-
bolized oxide of zinc ointment, iodoform, and similar applications will
facilitate cicatrization of the resulting ulcer, which may become chronic
and intractable. All sinuses should be laid open and scraped. Chronic
adenitis with its characteristic hypertrophy is best treated by blisters,
tincture of iodine, and firm pressure; the last agent may be applied by
means of a specially adapted truss. Interstitial injections of alcohol by
means of a hypodermic syringe will often cause absorption and diminution
of large glandular masses. Caseous tubercular lymphatic glands should
be enucleated, to prevent general infection of the patient; as should
single groups of indurated glands producing deformity, such as occurs so
frequently in the neck, if internal and local treatment does not dissipate
the swelling.
Chronic adenitis demands internal remedies, such as cod-liver oil and
iodine. Syrup of the iodide of iron in full doses (mxxx-xl), quinine,
iron, nutritious diet, and sea air are very beneficial, particularly in
Strumous cases.
Syphilis and malignant and other tumors may affect the lymphatic
glands, but these topics demand no special consideration here. The pecu-
liar disease variously called lymphadenoma, Hodgkin's disease, adeno-
lympho-sarcoma, and malignant lymphoma, which is attended by enlarge-
ment of many groups of glands and profound anaemia, is a medical rather
than a surgical affection.
Varicose Lymphatic Vessels.
Varicosity, or dilatation of the lymphatic networks gives rise to small
transparent vesicles, like boiled sago grains, which are more frequently
seen upon the inside of the thigh, and upon the genitals and the abdomen
than elsewhere. When the superficial lymphatic trunks are the subject
of this infrequent condition, the dilated portions give rise to larger and
more elongated swellings.
. There is usually odema of the peripheral parts. Lymphatic varicosi-
ties can readily be emptied of their fluid contents by pressure.
Arabian elephantiasis is at times complicated with lymphatic varicosity.
Systic dilatation of the lymphatic ducts occurs at times in the tongue,
lips, and neck.
. A tumor formed of a congeries of dilated lymphatic vessels and similar
in structure to the arterial and venous vascular tumor, or angioma, is
occasionally developed. It is appropriately called a lymphangioma.
252 IN J U R I E S A N ID DIS E A S E S OF A R T E R I E.S.
Rupture or wound of a dilated lymphatic vessel is liable to be followed
by lymphorrhagia, or a prolonged discharge of lymph. If a fistula result,
cauterization and pressure are proper.
Lymphatic dilatation usually needs no treatment. The methods adopted
in corresponding venous changes would be applicable.
INJURIES AND DISEASES OF ARTERIES.
Wounds of Arteries.
PATHOLOGY..—After contusion of arterial coats there is a liability to
ulceration and secondary hemorrhage, which occurrence will, in open
wounds, demand prompt ligation at both sides of the bleeding orifice. If
the contusion has occurred subcutaneously, the ulcerative action will
allow extravasation into the muscular and cellular tissues, which, if ex-
tensive, may call for incision into the tissues and ligation of the vessel at
both sides of the wound, for ligation above the seat of injury, or for
amputation of the limb. ,”
By the advent of inflammation or thrombosis, a bruised artery at times
becomes obliterated at the seat of contusion, and this occlusion may give
rise to gangrene or visceral degeneration. Aneurism also may be de-
veloped after contusion of an artery.
Slight contusions of arteries may occur without marked pathological
consequences. The elasticity of the vessels, and their relations to sur-
rounding parts often protect them from such violence.
Arteries may be torn completely asunder subcutaneously by violent
manipulation, as in reducing old dislocations, or by accidental injuries.
The extravasation which follows may be absorbed as the torn ends of the
artery become sealed by obliterative inflammation, or it may become sur-
rounded by a capsule or sac, consisting of cellular tissue thickened and
condensed by pressure and inflammation. The extensive character of
the subcutaneous bleeding may cause violent inflammation, and its inter-
ference with the peripheral circulation may, because of pressure, lead to
gangrene. Amputation is at times demanded for such sequences of
arterial rupture.
Subcutaneous extravasation of blood, from spontaneous or traumatic
rupture or direct wound of an artery, is sometimes termed “aneurism.”
The term, even though qualified by the words false or traumatic, should
be rejected, as it is misleading as well as unscientific. When the effused
blood becomes encapsulated and the communication with the artery per-
sists, the resemblance to aneurism is, however, great. Then the term is
not altogether inapplicable, though the condition is not strictly an aneurism
but an arterial haematoma.
Complete laceration, or tearing asunder, of an artery in an open wound
may be unattended by hemorrhage because of the twisting and tearing
of the coats at the time of injury. It is well, however, to ligate such
vessels before the first dressing is applied if they are seen pulsating in the
wound. The two inner coats of an artery are sometimes torn in subcu-
taneous injuries, while the external tunic by reason of its elasticity re-
mains intact. This partial rupture may subsequently become complete
by the giving way of the outer coat, and be followed by fatal extravasa-
tion. On the other hand, the torn coats may curl up, cause coagulation
within the vessel, and thus lead to permanent occlusion, or to arrest of
W O U N DS OF A R T E R IF. S. 253
circulation and consequent gangrene. Gangrene may arise also from the
torn shreds acting as a valve and at once shutting off the blood-flow to
the parts beyond. Sometimes the injured region remains as a weak spot
or cicatrix which finally becomes the seat of aneurism due to a traumatic
Call Se.
FIG. 98.
º §§ º: ºffſ
f
t
lºſſº
; sº
§§§ {...}}
r , , ºf {{*."
§º
ºš
§ Ti, | il º
§§ ſºft
º º * {{ º
Laceration and turning backward of inner coats of an artery, due to injury.
(BRY ANT.)
Wounds of arteries, inflicted by sharp instruments or spiculas of bone,
may, under rare circumstances, involve only the outer and part of the
thickness of the middle coats. Such non-penetrating wounds give rise to
no primary bleeding, but almost invariably are followed in a few days by
secondary hemorrhage. Hence, partial penetration of arterial walls,
when recognized, should be treated by exposure of the vessel, ligation on
both sides of the wound, and complete section of the artery between the
ligatures. Penetrating arterial wounds, unless inflicted by very fine
needles, are followed by hemorrhage, either at once or secondarily from
ulceration.
The amount of primary bleeding from incisions into arteries depends
on the direction as well as the size of the wound. Transverse wounds
allow more gaping and, therefore, more bleeding than longitudinal inci-
sions. Oblique cuts hold an intermediate position. Complete section of
an artery is less dangerous in this respect than an incision involving only
a portion of the circumference, for the former, by allowing contraction
and retraction of the coats, affords an opportunity for spontaneous arrest
of bleeding. This is the reason that when cessation of bleeding is desired
after arteriotomy of the temporal artery for therapeutic objects, the
surgeon completely divides the vessel. Bleeding may at once cease after
the division, though pressure is often needed in addition. If this section,
moreover, was not done, secondary hemorrhage or traumatic aneurism
might occur.
Arterial wounds may be followed by death from external or internal
hemorrhage, or may cause suppuration or gangrene secondary to burrow-
ing of the extravasated blood in the cellular tissue. The tissues may
cicatrize and traumatic aneurism may be developed as a result of arterial
injury. If the corresponding vein is wounded arterio-venous fistula may
develop.
TREATMENT.-The treatment of arterial wounds in the limbs should
begin by resort to temporary compression by means of a rubber bandage
tightly applied above the wound. The arrest of bleeding thus obtained
allows opportunity for enlarging the wound in the superjacent structures,
which should be followed by ligation of the vessel on both sides of the
Wound, and by complete division of the artery at the point of injury.
Two ligations are necessary in all such cases, because establishment of the

254 IN J U RIES A N D DIS E A SES OF A R T E R IE S.
collateral circulation will render secondary hemorrhage from the distal
part of the artery almost certain. Gunshot wounds of arteries require
similar treatment.
When the arterial lesion is subcutaneous, or the communication with
the air valvular, or when the superficial tissues have healed before the
partially divided vessel has given way, large extravasation and burrowing
of blood may occur. The symptoms are: Sudden prostration and syncope
from the anaemia, and the development of a soft, somewhat elastic and
fluctuating tumor, with, perhaps, an impulse, thrill, and bruit similar to
what is found in an aneurism. Pulsation in the peripheral vessels may
become absent and the limb oadematous and of low temperature. Pulsa-
tion will probably not appear in the tumor until the formation of a cir-
cumscribing cyst wall has begun. This diffuse extravasation may con-
tinue increasing until death results or gangrene occurs. Death may
supervene by rupture and a discharge of blood and clots into some cavity,
or from the skin giving way, through suppuration and ulceration, and
allowing secondary hemorrhage. The treatment of such cases of arterial
injury consists in applying pressure to the artery above the wound and
over the swelling, keeping the patient in bed and the limb at absolute rest
by bandages and splints. The rubber bandage of Esmarch may be used
temporarily to occlude the artery. Ligation of the trunk at some distance
above the swelling so as to be above the first branch will generally succeed
if these measures be inefficient. When it is impossible to obtain absolute
rest, or when ligation above the first collateral branch is inapplicable or
inefficient, pressure by a rubber bandage above the wound must be made
or artificial anaemia by the Esmarch method obtained, the tumor laid
open, the clots turned out, the artery completely divided, and both ends
secured by catgut ligatures. The easiest way to isolate the artery is to
insert a probe into the opening and then dissect the vessel free. The
ligature can then be readily passed around it by means of a curved needle
with an eye near the point, or by Horner's curved awl, which has a
shoulder to carry a loop of string through the tissues and around the
vessel. If the circulation cannot be controlled above by the Esmarch
IIorner’s awl.
apparatus, the surgeon must make a small opening in the skin and intro-
duce one or two fingers of the left hand into the cavity of the tumor.
Thus he prevents profuse external bleeding by having the cutaneous
wound plugged with the fingers with which he feels for and compresses
the arterial wound. After getting the opening in the artery closed by
digital pressure, he uses the right hand to enlarge the skin wound and
then proceeds to turn out clots and ligate. In military surgery and in
special cases amputation may be preferable to these procedures.
When the extravasation is comparatively small and has become circum-
scribed by an adventitious sac of condensed and thickened connective
tissue, laying open the cyst wall and tying both ends of the artery will
often be quite easily performed, and, being the radical operation, is prob-

T R A U M ATIC A.N E U R IS M . 255
ably more judicious than ligation of the artery above the tumor. In the
diffuse and profuse extravasations just discussed, ligation above the first
branch is probably more judicious than searching for the arterial wound
among the structures inundated with partially coagulated blood, and is
certainly better than ligation immediately above the injured part of the
artery. This position of the ligature is usually allowable only in the
small extravasations, where there is little danger of secondary hemorrhage
from the distal part of the vessel when the collateral circulation is
established.
Surgical interference should not be adopted too hastily in small arterial
extravasations, especially when they are subcutaneous or due to fractured
bones injuring the artery.
Spontaneous cure may be accompanied by the contraction of the con-
densed cellular tissue and coagulation of the blood. The encysting pro-
cess, which causes the development of an adventitious sac, is the first step
in such cases. Hence, the surgeon should, when possible, wait until he
has decided that nature's efforts at cure are ineffectual.
Traumatic Aneurism.
VARIETIES.–Traumatic aneurism is a secondary result that occasionally
follows arterial injuries. This term has often been improperly applied.
It should be restricted to the following conditions:
1. Dilatation of the cicatricial tissue and adjacent arterial wall after a
healed penetrating wound of an artery.
2. Dilatation and hermial protrusion of the uninjured inner coats
through a wound of the outer tissue alone.
3. Dilatation of the outer tunic after an injury producing rupture of
the inner coats alone. Such ruptures are, as a rule, produced only in
vessels whose inner coats have been weakened by degenerative changes,
such as atheroma. Hence, such cases have an origin which often makes
the terms spontaneous aneurism and traumatic aneurism equally inappro-
priate, since two causative elements are present. In many of these cases
it is impossible to arrive at the exact cause, from either the clinical history
or symptoms. Fortunately, these are the very instances in which treat-
ment is very little influenced by the character of the cause.
A limited extravasation of blood from puncture of one of the smaller
arteries may become surrounded by an adventitious sac, formed by inflam-
matory condensation and thickening of the normal areolar tissue. This
differs somewhat from the diffuse and burrowing extravasation spoken of
on a previous page under wounds of arteries, and has more right to the
title “traumatic aneurism.” Still it is not strictly an aneurism, though
it is a blood tumor which pulsates and has a thrill and bruit. It is nothing
but an encysted extravasation of blood; or, in other words, an arterial
haematoma.
An aneurism is a circumscribed dilatation of one or more of the arterial
coats, induced by the distending influence of the blood current upon
abnormal vascular walls. The condition being discussed having no such
pathological nature, should not be called an aneurism. To call it a
“false ’’ aneurism would be illogical, since what is a false aneurism is
evidently no aneurism.
TREATMENT.-The proper treatment of traumatic aneurism is compres-
sion of the artery as near as possible to the sac ; or, in the event of this
procedure failing, ligation in the same situation.
256 A R T E RIO – W E N O U S W O U N ID S A N D FIST U L E S.
Small or superficial traumatic aneurisms may be treated by incision of
the sac and ligation of the artery on both sides of it. Dissection of the
tissues so as to expose the sac and the artery, followed by ligation on both
sides without opening the sac, is a good modification of the same method.
The different methods of ligation, described in the section on the treat-
ment of spontaneous aneurism as Hunter's, Wardrop's, and Brasdor's
methods may sometimes, on account of the location of the tumor, be
preferable to ligation immediately above the sac.
ARTERIO-VENOUs Woun DS AND FISTULEs.
DEFINITION AND PATHOLOGY..—Puncture or gunshot wounds simul-
taneously penetrating an artery and an adjacent vein are liable to be
followed by a persistent orifice of communication between the two blood-
vessels. Such fistulous communications which may form slowly have
been improperly called arterio-venous aneurisms.
When the lips of the arterial wound remain in contact with and become
closely adherent to those of the adjacent vein, a direct fistulous opening is
established between the calibre of the artery and that of the vein. When
the wall of the vein is pushed away from the wall of the artery and the
extravasated blood burrows between them, a pouch or sac is developed,
which communicates on one side with the artery and on the other side
with the vein. The former condition has been termed aneurismal varix;
the latter varicose aneurism. Neither of them is an aneurism, for they
FIG. 100. FIG, 101.
First form of arterio-venous fistule. Second form of arterio-venous fistule.
(WYETH.) (WYETH.)
are not circumscribed dilatations of one or more of the arterial coats
induced by the distending influence of the blood current upon abnormal
vascular walls, Hence, to class them together under the general heading
arterio-venous aneurism is obviously improper. The first form is exhibited
as a varicose vein or varix, with pulsation; and, therefore, may, per-
haps with some degree of propriety, be called an aneurismal, or better, an
aneurismoid varix. The second form is in the development of its adven-
titious sac identical with the encysted extravasation of arterial hematoma
described on page 252, which I there said was improperly termed a trau-
matic aneurism. Hence, it has somewhat more right to be classed with
aneurisms than the first form. I prefer to use the terms simple arterio-
venous fistule, and sacculated arterio-venous fistule to describe the two
forms of preternatural arterio-venous communication.
Arterio-venous fistules of both kinds very occasionally arise without
traumatism. Ulceration or an abscess may open a contiguous artery and
vein and permit the establishment of a direct or indirect orifice of com-
munication. Again, a true aneurism may cause thinning and perfora-
tion of a vein upon which its sac presses. In this case, however, the

SI M P L E A R T E R I O - W E N O U S FIST U L E . 257
condition is a sequence and complication of aneurism, not a new disease
deserving a special name.
Simple Arterio-venous Fistule or Aneurismoid Varia.
SYMPTOMs.-Aneurismoid varix is a dilated condition of a vein due to
a direct fistulous aperture between it and an artery. It appears as a
small, soft, bluish tumor, readily disappearing on pressure, which is the
seat of a peculiar tremulous jarring or vibratory pulsation, and a charac-
teristic continuous but remittent purring murmur. The vibration and
murmur are due to the injection of a small stream of arterial blood into
the vein through a narrow orifice at each pulsation of the artery. This
forcible blood current, by greatly increasing the intravenous pressure
opposite the orifice of communication and by antagonizing the upward
flow of venous blood, causes marked distention of the vein at the site of
the fistule, and leads to varicosity of other veins in the vicinity.
The vibration and murmur may be transmitted along the veins to a
considerable distance from the opening; especially is this the case in an
upward direction. The swelling, vibration, and murmur are lessened by
elevation of the limb, increased by its being placed in a dependent posi-
tion. Digital compression of the vein at the cardiac side of the tumor
increases these phenomena, but similar compression on the distal side
exerts no influence whatever. Compression of the artery above the
swelling causes immediate arrest of vibration and murmur, which are at
once reëstablished upon removal of pressure. Pressure upon the artery
below may be expected to increase the size of the swelling.
The arterial trunk above the seat of disease may after a time become
enlarged and pulsate more vigorously than the corresponding vessel of
the opposite limb; but below the aneurismoid varix the artery and its
branches become smaller and show diminution of the normal pulsation.
The limb below the disease is usually weak and of lower temperature
than normal. It may exhibit a hypertrophic condition of the skin, mails,
and hair, and become the seat of Oedema, ulceration, hemorrhage, and
perhaps gangrene. These secondary changes are due to interference with
the normal circulation.
Aneurismoid varix of the scalp is sometimes followed by such a gen-
eral hypertrophy of the venous and arterial branches that a mass of con-
Voluted and pulsating vessels is formed which cannot be distinguished
from arterial varix, the so called cirsoid aneurism.
, Simple arterio-venous fistule or aneurismoid varix is usually an affec-
tion of slow progress. If it does not increase nor annoy by reason of its
bulk or murmur, it requires no treatment.
After arterio-venous punctures, which by the way have not infrequently
been received during venesection at the elbow, the possible occurrence of
fistule should be remembered and an attempt to prevent such a sequence
should be made by applying pressure to the wound and also to the artery
above the injury.
TREATMENT—If curative treatment is deemed necessary, continuous
digital pressure upon the tumor directly over the orifice should be made.
The use of the rubber bandage may be advantageous if so applied as
to stop the circulation through the limb, and yet leave the tumor filled
With, blood. Coagulation and consequent occlusion of the orifice may
Possibly be thus effected. Many cases will resist both of these plans of
17
258 A R T E R I O – W E N O U S W O U NI) S A N D FIST U L E S.
treatment. Then resort to ligation is justifiable in severe cases of the
disease. The artery should be tied above and below the opening with
catgut. The vein should be carefully separated from the artery at the
point of ligation and left unmolested, since its ligation or destruction
greatly increases the risk of gangrene of the already poorly nourished
limb. In such a locality as the thigh, where the integrity of the femoral
vein is so essential, it is better to omit placing the lower ligature on the
artery and trust to elevation of the limb rather than to endanger the
vein by rudely endeavoring to separate it from the artery. It sometimes
requires great care during the operation to distinguish the thickened and
pulsating veins from the artery.
Sacculated Arterio-venous Fistule.
The so-called varicose aneurism is not an aneurism, but is a sacculated
arterio-venous fistule, differing from the aneurismoid varix or simple
arterio-venous fistule in having a sac or pouch between the artery and
vein, from which there is one opening into the artery and another into
the vein. In this sac, which is due to inflammatory condensation and
thickening of the normal connective tissue, the arterial and venous blood
currents meet and intermingle.
FIG. I.02.
Sacculated arterio-venous fistule. (ERICHSEN.)
SYMPTOMs.-Theclinical history differs from that of simple arterio-venous
fistule or aneurismoid varix in having certain additional symptoms. The
same venous varicosity exists and the same vibratory or jarring motion, and
purring murmur are present in the veins, though less marked than in
aneurismoid varix, because the arterial stream is not forced directly into
the vein. A tumor more or less solid can often be perceived lying between
the two vessels. This is felt to be the seat of a pulsation synchronous with
the arterial pulsation and distinct from the tremulous jarring of the dis-
tended vein. Auscultation reveals a blowing murmur, like that of a true
aneurism which is additional to the purring murmur, due to the blood
entering the vein. CEdema, cutaneous hypertrophy, ulceration, and other
nutritive changes may occur, as in aneurismoid varix. The sacculated
arterio-venous fistule differs from the simple in its greater tendency to be
progressive; and, by the distention and enlargement of the sac, to lead
to sloughing of the skin and fatal hemorrhage. The sac, as a rule, grad-
ually becomes somewhat hard from internal fibrous deposition, and, indeed,
this process occasionally causes spontaneous closure of the venous open-
ings and simplifies the treatment of the disease. The progressive char-
acter of the condition is such that treatment is nearly always demanded.
TREATMENT.-Means to obliterate the sac should usually be under-

IN F L A M M A TO R Y C H A N G E S IN A R T E R IF. S. 259
taken if the diagnosis from aneurismoid varix has been established. This
differential diagnosis at times may be difficult. Digital or instrumental
compression of the artery above the disease, combined with pressure di-
rectly upon the opening into the vein, should be the first resort. A similar
method is to apply the rubber bandage tightly from the fingers or toes
up to the tumor, to carry it with only moderate pressure over the tumor
and finally to constrict the limb tightly above the seat of the disease.
Thus the sac is left full of blood which, by the arrest of circulatory
movement, is given an opportunity to coagulate and thus induce oblitera-
tion of the sac and closure of the fistulous apertures. Pressure, if it does
not cause a radical cure, may at least close the venous opening and thus
reduce the lesion to a more simple and manageable condition.
When pressure fails, ligation of the artery immediately above and below
the sac is the proper procedure. The coats are usually healthy, since the
condition is due in nearly every instance to a wound. Hence, the ligatures
can be applied near the seat of disease. The neck of the sac also, if
accessible, may be tied close to the artery. When the shrunken lower
part of the artery cannot be found, it may become necessary to lay open
the sac. A probe can then usually be passed down the vessel through
the aperture connecting the sac with the calibre of the artery. In such
operations it must be remembered that if the vein is first laid open, the
surgeon sees only the venous opening into the sac. A second incision is
then required to open the Sac and disclose the arterial orifice. Care should
be exercised to avoid tying or tearing the main veins of the limb. Such
a complication adds to the risk of gangrene. When such venous inter-
ference is unavoidable in old and feeble patients, amputation will prob-
ably be preferable to the double ligation. In all these operations the
rubber bandage should be applied as a preparatory step.
Coagulating injections into the Sac after immobilizing the blood by an
elastic bandage have been suggested. The method by ligation is prob-
ably less dangerous, and at the same time more radical in principle.
ARTERITIS AND DEGENERATIVE CHANGES IN ARTERIES.
PATHOLOGY..—Inflammation of arterial walls, if acute, usually involves,
Sooner or later, the three coats; but the pathological changes may begin
or become more marked in any one of the tunics. Hence, we have the
terms endarteritis, mesarteritis, and periarteritis expressing inflammation
of the imper, middle, and outer coats respectively. Chronic arteritis
affects principally the inner coat. Arteritis is caused by external or in-
ternal violence, such as wounds or lodgement of emboli; by extension of
inflammation from surrounding tissues, as in phagedena; and by the con-
stitutional states that induce impaired nutrition, such as syphilis, rheum-
atism, gout, alcoholism, and renal disease. The results that may follow
arteritis are fatty degeneration, atheroma, and calcification of the tunics;
occlusion or aneurismal dilatation of the calibre of the vessel; and sup-
puration, ulceration, or perforation of the vascular wall. The organs
and structures supplied by the inflamed artery may suffer by loss of func-
tion and become the seat of gangrene secondarily to these sequences of
arteritis.
The pathological changes found in traumatic arteritis are similar in
character, whether they begin externally or internally. The inflammatory
process commences in the tunic injured, but, as a rule, soon spreads to the
26() I N F L A M M ATION OF A R T E R IE S.
other coats. Internal violence, such as is produced by the impinging of
the blood-current or by the impact of an embolus, is more apt to induce
an inflammation limited to one tunic than is external violence, which
usually injures all coats simultaneously.
Traumatic arteritis from external causes must necessarily be accom-
panied by contusion, laceration, or some such complicating lesion of the
periarterial structures. * *
The pathological, alterations seen in arteritis are very like those which
have been detailed as occurring in phlebitis. The external tunic of the
artery becomes unusually vascular, and is swollen from infiltration by
serum and white corpuscles that have migrated out of the vasa vasorum.
These changes cause thickening and softening. The middle and internal
coats also are thickened and softened and the site of cell proliferation.
The internal tunic loses its smooth, glistening appearance, is elevated in
patches which are sometimes the seat of erosions, and usually becomes
pinkish in color. The calibre, or lumen, of the vessel is lessened by the
swelling of the coats, the projection inward of the inner tunic, and prob-
ably also by spasm of the inner coat. When there is rupture of the in-
ternal tunic, as happens in ligations and other injuries, there will be more
encroachment and even occlusion of the lumen, for the roughened and
projecting margins will cause fibrinous deposition. The formation of a
coagulum consisting of white corpuscles and fibrin occurs in arteritis as
in phlebitis, though less often, even without previous rupture of the inner
coat. It is much more unusual in acute than in chronic arteritis. In
syphilitic arteritis it is not infrequent. As in phlebitis the thrombosis is
at times the cause, at others the result, of arteritis.
When complete occlusion of the artery and arrest of the blood-current
are produced by the pushing inward of the internal coat and by the depo-
sition of cells and fibrin, permanent obliteration of the vessel may take
place from organization of the cells of the coagulum as was formerly
believed, or from organization of the newly-formed tissue springing from
the normal cells of the internal coat. There occurs thus a species of
cicatricial contraction which converts the former arterial tube into an
impervious, fibrous cord. Sometimes, however, the clot, on the other
hand undergoing fatty degeneration, is washed away as minute particles
of fat which do no harm, and the artery regains its normal patulous con-
dition. Sometimes fragments of the clot are detached, and as emboli are
carried onward until they plug some distant artery of smaller calibre.
There they may be absorbed or may produce local anaemia and infarction.
At other times disintegration of the primary coagulum occurs, due to
septic or pyogenic bacteria, and septicaemia or multiple infective embolism
and pyaemia may result.
When suppuration and ulceration occur, as happens at times in Septic
traumatic arteritis, there is great liability of perforation and hemorrhage
unless the previous occlusion of the artery by a coagulum has been com-
plete. Suppuration in the outer coat is generally diffuse, but in the
middle tissue it may be localized as distinct abscesses. Pyaemic infarction
is readily induced if septic material from suppuration of the vascular
walls or of the surrounding structures gains entrance to the blood current.
The hyperplasia of connective tissue, which may take place in the middle
coat as a sequence of arteritis, causes atrophy of the muscular and elastic
fibres, and renders the vessel less able to resist the distending influence of
blood pressure; hence, subsequent aneurismal dilatation may occur at the
seat of the former arterial inflammation. Infective emboli, causing acute
D E G E N E H A TI W E C H A N G E S IN A R T E RIE S. 261
inflammation and softening, are believed to be a frequent cause of
aneurism when occurring in the young.
Idiopathic arteritis is usually associated with and a result of inflammation
of the structures surrounding the vessel, unless it be due to syphilis, gout, or
some similar dyscrasia. Many cases denominated idiopathic arteritis are
really instances of traumatic inflammation, caused by the impact of the
blood current, or of emboli from cardiac vegetations against the internal
arterial coat. Such are the cases of endarteritis and resulting fatty degen-
eration not infrequently found at the great sinus, the transverse arch and
the bifurcation of the aorta, and in the innominate artery. Idiopathic
arteritis presents pathological changes similar to those seen in traumatic
C2SéS.
Syphilitic arteritis is a chronic inflammation, and occurs especially in
the smaller arteries. The vessels of the brain are particularly liable to it,
and on account of the resulting circulatory interference the disease is a
serious one in this locality. Aneurism may be due to syphilitic arteritis
of the aorta and larger vessels. The pathological changes arise chiefly in
the internal tunic, which by reason of the inflammatory proliferation of
cells projects into the lumen or calibre of the vessel, and causes great nar-
rowing or complete occlusion of the blood channel. Death from cerebral
anaemia thus induced is not very infrequent. It is often impossible dur-
ing life to diagnosticate syphilitic arteritis from atheroma. In fact, both
diseases may exist at the same time. Atheroma is more common in the
old than the young, and causes arterial weakening and dilatation rather
than occlusion. Atheroma is not so apt to attack the smaller vessels as
is syphilis. After death microscopic examination shows that atheroma
has a greater tendency to involve all the coats than syphilis, which is
usually more or less limited to the internal coat.
Rheumatic arteritis is said to be rare. That it has not been studied as
carefully as the other forms may be the reason for this supposition.
Rheumatic inflammation of the lining membrane of the heart, which is
similar to the lining coat of arteries, is certainly common. Mechanical
strain put upon the coats of the vessel by reason of increased or unusual
intravascular pressure is a cause of chronic arteritis. These chronic
forms of arteritis are all allied to degenerative processes, and have few well-
marked symptoms.
SYMPTOMS.—The symptoms of arteritis, when more or less acute, and
the accompanying thrombosis are severe pain, tenderness and hyper-
*sthesia in the course of the vessel and in the parts supplied by it, and
impairment of muscular power. This pain may resemble rheumatism.
The surface temperature is lowered, and the skin perhaps mottled. When
the vessel is superficial, a hard, pulseless cord may be felt or seen through
the skin ; if only partial occlusion has taken place, a jerky pulse may be
berceptible. Secondary gangrene, with its characteristic symptoms, may
arise from the interruption of circulation, especially in the old and feeble.
TREATMENT.-The treatment of arteritis consists in rest, wrapping up
the limb in cotton to maintain heat, administering opium to relieve pain,
and using tonics, stimulants, and good food to prevent depression. As
gangrene is a not unusual sequence, the husbanding of vital resources is
required. This precludes the use of depressants in the early stages, unless
the patient is unusually vigorous and the disease so situated as to render
subsequent gangrene limited. Measures to obviate gangrene and to
avert fatal hemorrhage from ulcerative perforation are to receive careful
consideration. Syphilitic, rheumatic, gouty, and other forms of arteritis
262 I) IS E A SES OF T H E A R T E R [E S.
should be treated with mercury, iodide of potassium, alkalies, salicylic
acid, colchicum, etc., with a view both of preventing further progress and
of perhaps effecting cure. Microbic invasion of wounds must be pre-
vented by rigid asepsis and antisepsis, since it has been shown that septic
discharges are the chief cause of ulcerative and suppurative arteritis.
ATHEROMATOUS DEGENERATION AND CALCIFICATION OF ARTERIES.
Any form of chronic arteritis may terminate in atheromatous degenera-
tion of the vascular walls. This condition is due to malnutrition of the
arterial tunics, and is a fatty degeneration of their cellular elements. It
occurs as a secondary lesion following chronic inflammation of arteries,
and is frequently found in syphilitic and senile subjects. It differs from
the primary and localized fatty change belonging to the pathology of
endarteritis in being a secondary lesion, which affects the arteries gen-
erally, and which is liable to give rise to thrombosis, embolism, and
hemorrhage. The destructive process, moreover, causes infiltration not
only of the inner coat, but also of the muscular and elastic coats, trans-
forming the normal elements into granular material. Atheromatous
degeneration is seen, on examination of the inner surface of the vessel
wall, as numerous definitely-outlined, soft, pulpy patches, which are scat-
tered throughout the arterial system. The pulpy material found in the
centre of these softened spots gives the name atheroma to this peculiar
molecular destruction, and under the microscope is found to consist of
fatty and granular matter, mingled with cholesterin crystals and shreds
of fibrous tissue. The middle coat soon becomes infiltrated with fatty
particles, and the outer one also undergoes degeneration.
The weakening of the vascular wall may allow the blood pressure to
cause aneurismal dilatation or rupture. The softening of the deep layers
of the internal coat may give rise to the so-called atheromatous abscess;
if the Superficial layer is destroyed the atheromatous ulcer remains.
At times calcereous degeneration of the tunics occurs as a secondary
and conservative process, as if nature was endeavoring to counteract the
effect of the softening influences of atheroma. Calcification is more fre-
quent when the atheromatous change is slowly progressing, and the two
processes may be going on together at the same time in the same locality.
The chalky change begins in the inner and middle coats, but the entire
vessel wall may be converted into a calcareous cylinder, though isolated
plates of calcification are much more common. By the washing away of
the pulpy or atheromatous material on the inner surface the calcareous
plates may be uncovered; and sometimes the blood current gains entrance
beneath the chalky portion of the wall, and by a species of dissection
separates the tunics, or their different layers, and thus creates the so-called
aneurism by dissection.
The atheromatous and calcific degeneration causes arteries to become
brittle and inelastic and roughened on the interior and exterior, and thus
predisposes to loss of function and rupture, by which hemorrhage, occlu-
sion, and gangrene may arise. It is a common senile change, and is par-
ticularly liable to occur in the arteries of the brain and in the main
arteries of the trunk and limbs. It is not uncommon as a ring about the
root of a large branch. Ligation of such diseased vessels is apt to be
followed by secondary hemorrhage from the ligature cutting through the
brittle walls. A broad, flat ligature to produce mere apposition of the
A N E U R IS M . 263
arterial walls is proper under such circumstances. The weakening of the
middle coat induced by atheroma is a frequent precursor of spontaneous
aneurism.
Some writers believe that the calcareous degeneration of arteries in the
aged is not secondary to atheroma, but is a primary change, and occurs
in the middle coat first ; while that secondary to atheroma begins in the
internal coat.
True ossification of arteries seldom, if ever, occurs. Cases so denomi-
nated are probably instances of calcification. These degenerative changes
cannot be arrested by any special line of treatment. The indications are
to keep up nutrition, to avoid severe exercise, which causes increased
blood pressure in the brittle arteries, and to perform none but necessary
operations, because of the imperfect circulatory supply and the tendency
to secondary hemorrhage.
ANEURISM.
DEFINITION.—An aneurism, strictly defined, is a circumscribed dilata-
tion of one or more of the arterial coats, induced by the distending in-
fluence of the blood current upon abnormal vascular walls.
This definition properly excludes:
1. General dilatation with elongation of an artery (often called cirsoid
aneurism, varicose artery, arterial varix).
2. General dilatation of small arteries and of capillaries (often called
aneurism by amastomosis).
3. Arterial venous fistule (usually called arterio-venous aneurism).
4. Separation of the arterial tunics by the blood current (usually called
dissecting aneurism).
5. Extravasation of arterial blood due to spontaneous rupture (one of
the forms of so-called false aneurism).
6. Extravasation of arterial blood due to wounds and injuries (called
by some writers a form of traumatic aneurism).
These widely different pathological conditions often receive, though
improperly, the name aneurism because they are tumors containing blood
or blood-clots. They are not aneurisms according to the definition that I
have given, and as they present symptoms and require treatment different
º aneurism I have discussed them in their appropriate places else-
Where.
VARIETIES.–If the conditions mentioned above be excepted, there are
only two forms of aneurism—the tubular or fusiform and the sacculated
Or Sacciform.
Separation of arterial coats, which occurs at times as a result of arter-
itis by the blood insinuating itself between the layers of the middle tunic
or between the inner tunic and the middle, is, under the name “dissect-
ing” aneurism accepted by most writers as a form of aneurism. I
prefer, however, to reject it, since it differs from aneurism in every essen-
tial feature. It occurs chiefly in the aorta, which may show the separation
through nearly its entire length. The blood current may separate the
Coats for a long distance or form a circumscribed sac within the thick-
ness of the arterial wall. The blood may finally burst through the outer
surface of the wall, and cause hemorrhage into the cellular tissue, or into
the pericardial, pleural, or abdominal cavity. Sometimes the diverted
Current re-enters the calibre of the vessel through an opening, due, as
Was the opening of exit, to a patch of atheromatous softening. This tun-
264 D IS E A SES OF T H E A R T E R IES.
nel-like channel, with the consequent thickening of the vessel wall, may
cause the artery to present the appearance of being double. It would be
possible for the separated coats to bulge into the calibre of the artery, and
by occlusion cause gangrene of the parts
FIG. 103. below. It is readily seen that this separa-
tion of arterial coats is very different from
aneurism, and only corresponds to the defi-
nition of aneurism when a distinct circum-
scribed sac is formed within the thickness
of the vessel wall. This is of exceedingly
rare occurrence. It is, therefore, better to
limit the term aneurism to the two forms,
tubular and sacciform, and dismiss the term
dissecting aneurism entirely, using instead
the words separation of arterial coats.
A fusiform or spindle-shaped aneurism is
a dilatation or expansion of the entire cir-
- cumference, and usually of all the coats of
º W an artery, while a sacciform aneurism is a
º Yº sac or pouch consisting of one or more of
à º the coats developed upon one side of the
artery, and communicating with the interior
of the vessel by a narrow opening.
Fusiform aneurism is much less common
than the sacciform variety, and is chiefly
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Diagram showing separation at the middle of the tumor and diminished
of arterial coats, often called dis toward each extremity until the normal
secting aneurism. calibre of the artery is regained. This gives
* the aneurism, which necessarily has an
opening of entrance and one of exit, a spindle shape. The walls of the
tumor consist of degenerated and thickened arterial coats with a rough-
ened inner surface. There is some increase in the length of the artery
at the dilated and hypertrophied spot. This form of aneurism, unlike
the sacciform variety, does not, as a rule, enclose laminated fibrine.
Chronic arteritis with its consequent atheromatous degeneration of the
arterial walls is the chief factor in the causation of such aneurisms.
Traumatic fusiform aneurism seems to me to be almost an impossibility.
Occasionally several fusiform aneurisms are developed in connection with
the same artery, which is of normal calibre between the dilated regions.
The lateral blood pressure in fusiform aneurisms is comparatively mod-
erate in amount; hence they grow slowly and do not readily burst; but
it is not unusual for a sacciform aneurism to be developed upon the sur-
face of a fusiform dilatation and to cause death by rupture. In cases
of very large fusiform aneurism of the aorta death may also occur from
syncope, because the heart is unable to give sufficient forward motion to
the mass of blood contained in the large tumor. Hence the circulatory
movement in the more distant vessels is impaired and fatal syncope may
supervene.
The sacciform aneurism is the most common variety of the disease, and
is that which is meant when the simple term “aneurism " is used. Fusi-
form aneurisms are so infrequent, and in comparison with the sacciform









































A N E U R IS M . 265
variety so unimportant surgically, that I shall scarcely refer to them
again. My subsequent remarks, therefore, will refer to sacciform dilata-
tion of arteries.
A sacciform aneurism is a sac or pouch developed upon one side of
an artery by localized dilatation of the arterial wall and communicating
with the interior of the vessel by a narrow orifice or mouth. The cavity
of the sac has a much greater diameter than its orifice of communication
with the artery, and it is, therefore, usual to speak of the body, neck, and
mouth of the aneurism. The walls of the sac may, if the tumor is small,
consist of all three arterial tunics; but usually it is only the outer tunic,
and perhaps part of the thickness of the middle tunic that form the sac.
As internal pressure causes further distention, the tunics become blended
and finally may disappear at places and be substituted by an adventitious
wall of condensed and newly-formed cellular tissue.
Sacciform aneurism may be developed upon the sur- FIG. I ()4.
face of a fusiform aneurism, which is, as has been Seen,
little more than a diseased and greatly enlarged ar-
tery.
CAUSES.—Any agency that lessens the power of
the arterial wall to resist the stretching influence of
the blood impelled by the cardiac impulse, and any
circumstance that diminishes that normal elasticity by
which the artery contracts as soon as this stretching
influence is relaxed must predispose to aneurismal
dilatation. Hence the degenerative fatty change
known as atheroma, which occurs in the arterial
tunics as a result of arteritis, is the chief factor caus-
ing a predisposition to aneurism. Anything that in- sº
duces the atheromatous change, such as advancing Sacciform aneurism
age and alcoholic intemperance, may be an indirect from injury. The ar-
cause of aneurism. Unusual muscular exertion, by tery laid open to show
inducing violent heart action and preventing rapid opening into sac.
admission of blood into the capillaries, causes in- (BRYANT.)
creased intravascular pressure, and thus may be the
immediate cause of an aneurismal dilatation If the artery is previously
atheromatous the sudden strain causes the inner coat to give way at a
point where an atheromatous patch is situated; the fatty pulp, lying
under the inner layer of the inner tunic, is evacuated, and thus in the
integrity of the wall a breach is made which allows distention to occur
under the force of the blood stream. Continuously laborious occupation
is not so dangerous in this regard, for the vessels seem to acquire strength
by the gradual accession of great intravascular tension. It is a sudden
Strain, in vessels unused to such a degree of tension, and which are pre-
viously degenerated, that tends to cause such damage.
External violence without a wound, such as blows and concussions, may
loosen the membrane covering an atheromatous spot and induce aneurism
in much the same way. Internal strain upon the arterial walls is in-
creased by postures which cause flexures of the vessel; by over-tight
clothing, especially around the neck; and by the anatomical division of
the artery into two branches of nearly equal calibre. The blood-flow is
retarded by these conditions, and consequently the lateral pressure is in-
Cºased. Hence, aneurism is more liable to occur when sudden muscular
effort is made or any unusual strain is thrown upon the walls of an artery
under such disadvantageous circumstances. Sometimes a “ giving way”

266 D IS E A S E S OF T H E A R T E R I E S.
sensation is felt at the time of the violent exertion. This is probably
caused by a rupture of the middle coat, and may, perhaps, occur in a
healthy artery.
There appears to be an imperfectly understood connection between heart
disease and the occurrence of aneurism. Embolism is believed by some
authors to cause the development of aneurismal dilatation. This is espe-
cially so in infective embolism from ulcerative endocarditis and other
septic processes. As the aneurism occurs at and not above the point of
lodgement of the embolus, the lesion is supposed to be due to a local
arteritis resulting from the septic character of the embolus. This is the
explanation of the well-known non-occurrence of aneurism in cases of
non-infective embolism.
Syphilis has been regarded by some writers as a cause of aneurism.
This is doubtful, since syphilitic arteritis seldom attacks the larger
arteries, and it is here that aneurism is more commonly met. It is pre-
eminently a disease of small vessels. I am, of course, speaking now of
surgical aneurism, not of aneurism of arteries of the brain. Finally,
wounds of arteries may be followed by aneurism. The subject of trau-
matic aneurism has, however, been discussed in a previous section, and
requires no further mention here.
When an atheromatous spot has given way, as described above, and the
pressure does not cause complete perforation of the wall and hemorrhage,
it is usually a sacciform aneurism that is developed. When, however,
there is an absence of normal and of inflammatory adhesion between the
tunics and their component layers, separation of the arterial coats may
be induced by the blood current insinuating itself between them. Thus
may be caused on rare occasion separation of the arterial coats, the so-
called dissecting aneurism.
PATHOLOGY..—Dissection of a sacculated aneurism shows on the out-
side an investment or covering of cellular tissue, resulting partly from
inflammatory condensation, partly from atrophy of the muscles and other
structures that have been subjected to pressure by the increasing tumor.
Within this more or less imperfect investment is found the true aneurismal
sac, consisting of one or more of the arterial tunics which have become
so thickened, blended, and changed by interstitial growth that it is usually
impossible to determine their exact identity. The inner and middle coats
can sometimes be recognized by the patches of atheromatous degeneration
visible in their structure. In large aneurisms the two inner coats have
usually disappeared ; indeed, the outer one may be absent in places and
its place be supplied by the external investment above mentioned and the
laminated fibrine contained in the sac. The true sac is of varying thick-
ness in different regions of the tumor.
It is evident that in all aneurisms, except in the very smallest, there
must be a natural growth of the sac wall after the pouch has first been
formed, for the area of tissue that constituted the arterial wall at the site
of disease could not possibly be stretched so as to form a sac of such
dimensions. The irregular thickening and thinning of the Sac depend
upon the force of the blood current in the aneurism. Where the blood
impinges with the greatest force, there will the sac be thinnest. Inside
the true sac there will nearly always be found numerous concentric layers
of more or less completely decolorized fibrine. The layers of fibrine
nearest the sac wall are tougher and more yellow than those nearer the
centre of the aneurism, which are softer and somewhat reddish. This
laminated fibrine is found especially in those irregular pockets or pouches
A N E U R IS M . 267
of the sac which are away from the rapid current circulating in the
aneurism. This deposition of fibrine is encouraged by any agency,
whether within the aneurism or entirely foreign to it, that diminishes the
force of the current within the tumor. When fibrine has once begun to
form upon the inner wall of the sac it has a tendency to increase by
further deposition of the blood. Thus, layer after layer is formed. The
outer layers, being the oldest, naturally become more decolorized and
tougher. The laminated fibrine is a beneficial provision of nature for,
by reason of its tough, fibrous nature, it strengthens the sac wall and acts
as a pad to lessen the force of the pulsating blood current, which is tend-
ing to distend and rupture the sac. Moreover, it lessens the capacity of
the sac, and by its continual deposition tends to fill up and obliterate the
cavity of the aneurism. Fusiform aneurisms usually contain little or no
laminated fibrine. At the centre of the aneurism, within the concentric
layers of fibrine, there will be found a mass of soft, black or reddish-
black clot, or a mixture of such clot and fluid blood. This soft clot may
be an ante-mortem or a post-mortem formation.
The secondary changes produced by an aneurismal tumor are numerous
and are due especially to the pressure exerted by its growth. Thus,
oºdema, varicose veins, and venous occlusion may occur from pressure on
the veins; and neuralgia, paralysis, anaesthesia, obscure pains, and
“tired "sensations may result from nervous compression. Aphonia may
follow if the function of the recurrent laryngeal nerve is interrupted.
Organs are displaced, bones and cartilages eroded and perforated, synovial
sacs opened, gangrene of distal parts determined, and many other de-
structive processes inaugurated before death or cure occurs. Gangrene
may be due to pressure causing interference with circulation to the parts
below, or to a portion of laminated fibrine or soft clot becoming detached
and being washed into one of the distal branches and plugging it.
SYMPTOMS.—The symptoms of aneurism are usually of gradual develop-
ment, but occasionally it happens that the patient experiences a sensation
of something giving way, which is accompanied by a sudden, sharp pain,
and is followed by the appearance of a tumor. An aneurismal tumor is
usually rounded or oval in outline, and is covered by healthy skin, unless
suppuration or ulceration is taking place. These events occur only in
the last stages of the disease.
An aneurism gives rise, as does any other tumor of similar size and
location, to certain pressure effects. These symptoms are in no way charac-
teristic, and do not aid in establishing a differential diagnosis. In addi-
tion there are symptoms depending upon the relation of the aneurismal
tumor to the circulation. These are peculiar, and, when found in combi-
nation, are pathognomonic of aneurism.
The pressure of an aneurism may give rise to a pain, numbness, muscu-
lar weakness, or paralysis, venous congestion, cedema and varicosities,
gangrene, obstruction to breathing and swallowing, and many other symp-
toms due to interference with the function of special organs. Hoarseness,
Spasmodic dyspnoea, cough or uncontrollable eructation may be produced
by pressure upon the laryngeal or other branches of the pneumogastric
nerve; facial distortion, deafness, ptosis, or strabismus from similar involve-
ment of cranial nerves; boring pain or even synovitis from erosion and
perforation of bones and cartilages, and nutritive changes from involve-
ment of lymphatic vessels or thoracic duct. The pressure effects of an
aneurism are apparently more rapidly developed than those of an ordi-
268 D IS E A SES OF THE ARTE RIES.
nary tumor of similar size. This is probably due to the pulsating charac-
ter of the former.
The symptoms due to the circulatory relations of the aneurism may be
called intrinsic symptoms, and are five in number, namely, location,
change in tension, pulsation, thrill, murmur. An aneurism is necessarily
located in the course of an arterial trunk, and cannot be displaced from
its connection with the artery. If occluding digital pressure is made upon
the vessel below the aneurism, the tumor becomes more tense and less
compressible; and if the sac contains but little laminated fibrine and has
thin walls, the tumor may even become larger than usual by the stretch-
ing influence of the unusual amount of blood dammed up in it. If the
entrance of blood into the sac is prevented by pressure upon the artery
above the aneurism, the tension is diminished and the tumor becomes com-
paratively flaccid and compressible. The elastic bandage when tightly
applied to the limb, as in bloodless operating, often causes a marked dimi-
nution in the size of the tumor. It may do harm, however, by displacing
portions of fibrine and causing embolism.
The compressibility or non-compressibility of individual aneurismal
tumors is chiefly determined by the absence or presence in them of a large
amount of laminated fibrine. The variation in compressibility or ten-
sion, observed when the exit or entrance of blood is checked, is due to the
degree of distention of the sac by its circulating blood contents. When
the sac contains much fibrine, or has a thick wall, this symptom is not
well marked.
The pulsation of an aneurism is a peculiar expansive beat, which not
only lifts the fingers or hand laid upon the top of the tumor, but drives
apart the fingers or hands when the tumor is grasped laterally. This
lateral pulsation is due to the fluid contents of the aneurism transmitting
the shock of the heart-beat equally in all directions. When the sac is
largely filled with fibrine, and, therefore, has little blood contents, this
lateral pulsation is less marked, and only a dead thud is perceived.
Another peculiarity of aneurismal pulsation is the wave-like movement.
The pulsation does not seem to affect all parts of the tumor simultane-
ously, but swells up somewhat gradually as if propagated from one point,
and then in a similar way subsides. Pressure upon the artery above the
tumor arrests pulsation ; pressure below it and elevation of the limb have
a tendency to make it more marked. Aneurisms with large orifices, and
which contain little fibrine, present the most characteristic pulsation. In
partially solidified aneurisms the pulsation may be absent or obscure, or
may resemble the simple rise and fall of a solid tumor lying upon an
artery. Pulsation may also be absent because of rupture of the anuerism,
because of inflammatory infiltration between the sac and the surface,
because loose clots have plugged the orifice of communication, or because
the disease has just been spontaneously cured, and the tumor has not yet
entirely disappeared. When the artery is compressed above the seat of
disease, so that no blood enters the sac, the tumor, as previously stated,
becomes pulseless and flaccid. If the tumor is now grasped laterally,
and the pressure upon the vessels suddenly removed, the expanding
pulsation by which the sac is instantly refilled, is readily felt and even
seen. When the sac has a large mouth, one pulsation distends it fully;
if the orifice is small, the sac fills more slowly, but the first pulsations
are strong beats.
The arterial pulse below the aneurism is much less marked than on the
opposite side of the body. This may be due to pressure of the tumor on
A N E U R IS M . 269
the artery, to arteritis causing occlusion, or to the rigidity of calcification.
It is possible that it may also be caused by the large amount of blood in
the sac distributing the pulsation and lessening that in the current below.
This variation in the two radial arteries is of aid at times in diagnosticat-
ing aneurism of the thoracic aorta. Just after the heaving pulsation of
an aneurism, the hand of the examiner can often perceive a peculiar
tremulous or vibratory movement called the thrill. The thrill is due to
the rebound of the blood column, and is said to be more distinct when the
artery lies between the sac and the surface upon which the hand is placed.
The last of the five intrinsic symptoms of aneurism is the murmur or
bruit. This is an intermittent blowing, rasping, or purring sound due to
the blood rushing through the narrow mouth into the dilated cavity of
the sac. It is heard by applying the ear either with or without a stetho-
scope to the surface of the tumor. The tone varies greatly, depending
on the size, shape, and location of the orifice, its relation to the sac, and
perhaps upon the character of the surrounding tissues. It is most dis-
tinct in fusiform aneurisms and sacciform aneurisms with large mouths.
It is synchronous with the aneurismal pulsation, and is stopped by pres-
sure on the artery above the sac, but returns as soon as the pressure is
removed and the blood allowed to flow into the sac. If the tension of
the sac is lessened by elevating the limb or by compression of the artery
above the tumor, the murmur may sometimes be heard in cases in which
it was previously absent. Increasing the tension by pressing upon the
artery below would, on the other hand, have a tendency to diminish the
murmur. If the orifice is very small or the sac nearly filled with fibrine
there may be no murmur generated. The aneurismal murmur is not in-
frequently absent, and, indeed, may be present at one time and afterward
disappear. A double murmur indicates, according to Erichsen, a sacci-
form aneurism. -
These intrinsic symptoms may not all be present in a given aneurism,
but the association of two or more of them usually renders the diagnosis
quite clear.
When an aneurism ruptures, permitting the blood and clots to become
diffused, the tumor loses its definite outline and becomes rapidly larger.
Pulsation, thrill, and murmur become obscure or absent; pain increases,
and coldness, lividity, and oedema of the extremity are apt to occur. The
subcutaneous hemorrhage may cause syncope. Coagulation of the blood
and inflammatory condensation of the cellular tissue may in very occa-
sional instances limit diffusion after the rupture and lead to spontaneous
cure of the aneurism. Usually, however, the swelling increases, and the
case terminates in gangrene or suppuration, accompanied most likely with
hemorrhage.
DIAGNOSIS.—The differential diagnosis of aneurism from other tumors
should always receive careful and systematic attention. No swelling near
an artery should ever be laid open until the possibility of aneurism has
been eliminated by accurate examination.
The pain caused by internal aneurism may, when the tumor is not
easily discoverable, be mistaken for rheumatism or neuralgia. Such an
error is hardly probable in the external aneurisms that come under the
observation of surgeons. There are two circumstances that at times
render the differential diagnosis of aneurism troublesome, First, there
are pulsating tumors that are not aneurisms; and secondly, there are
aneurisms that do not pulsate.
Any solid or cystic tumor or abscess situated over a large artery may
270 D IS E A SES OF T H E A R T E R II. S.
show transmitted pulsation. The pulsation in such cases is not so expan-
sive as in aneurism, but is rather a simple rise and fall which may be
diminished or stopped when the tumor is pushed or lifted away from the
artery. Flexing the limb so as to relax the deep fascia will probably
lessen the pulsation, which, moreover, is sometimes felt only in the line
of the artery and not over the entire tumor. There is no murmur, or if
any, it is only a dull beating such as is heard when an artery is com-
pressed with a stethoscope. The tension and size of such tumors are not
affected by occluding pressure upon the artery above or below the swell-
ing. The suddenness with which aneurisms regain their usual size when
arterial pressure on the cardiac side of the tumor is removed is very
characteristic, and is not present in tumors with a mere transmitted pul-
sation.
Cysts or abscesses communicating with a joint, or with the abdominal
or any other cavity, may be partially emptied by pressure; but they refill
afterward without reference to the arterial circulation. An abscess sit-
uated above or surrounding an aneurism will appear as a tumor having
pulsation, and some of the other symptoms of aneurism. Such cases are
fortunately rare. The aspirator would be available for establishing the
diagnosis. If the suppuration is due to rupture of the aneurism the
opening between the sac and the pus collection will permit hemorrhage
to follow the opening of the abscess. Pulsation is usually feeble or absent
in such conditions, and unless the previous history is obtained the surgeon
may be misled into laying open the tumor. The fatal bleeding may not
occur until some hours after the incision, because the laminated fibrine
may for a time act as a barrier. A murmur should be carefully sought
in such cases, since it is less likely to be absent than other aneurismal
phenomena. w
Some vascular tumors or angeiomas resemble aneurisms very much.
They are apt, however, to have a more spongy feel, and are not so dis-
tinctly circumscribed as aneurisms. If the blood is pressed out of such a
tumor it returns somewhat tardily and irregularly, causing the tumor to
dilate slowly and unevenly, and not with the sudden bound that is seen
in aneurisms. Pressure upon the artery below causes no marked increase
in size of tumor. The pulsation is not as forcible or as distinct as an
aneurism, and it lacks the expansive and wave-like character of the pul-
sation found in the latter disease. The murmur is more confused and less
well defined. The introduction of a hollow needle will probably give
exit to blood, but the blood will scarcely spurt as in the event of puncture
of an aneurismal sac, nor will the needle be likely to give to the surgeon's
hand the sensation of having its end in a cavity.
Malignant tumors, especially sarcomas of the bones, may, when very
vascular, assume pulsation. If in localities where aneurism is common
the diagnosis becomes at times almost impossible. The history of such
growths generally shows that pulsation was not present when the tumor
first appeared, and that the growth has recently become of softer consist-
ence than formerly. Careful examination shows that the pulsation is not
very distinct, that the murmur is soft and subdued, and that little varia-
tion in size is produced by pressure on the artery between the tumor and
the heart. The pulsation and murmur after having once appeared do
not, as in aneurism, become more conspicuous as the bulk of the growth
is augmented; often these phenomena are perceptible only over certain
parts of the tumor. Involvement of the adjacent lymphatic glands sug-
gests malignant disease, which, moreover, is apt to be more or less irreg-
A N E U R IS M, 271
ular in outline. In very obscure cases an attempt might be made to
remove a small portion of the interior of the tumor for microscopic ex-
amination by inserting an instrument such as is used for cutting out
pieces of muscle in cases of suspected trichinosis.
Aneurisms that are devoid of pulsation may be mistaken for deep
abscesses and for granular, fibroid, and other tumors. The pulsation
ceases in an aneurism when spontaneous consolidation has occurred, or
when rupture or diffusion of the blood contents has taken place.
An aneurism, when spontaneously cured by consolidation, continues for
a long time as a hard mass, which finally shrinks and disappears. Such
a mass cannot easily be distinguished from other hard tumors except by
the history. A tumor located near an artery, especially if it shows a
tendency to decrease, should, therefore, be well scrutinized before any
operative treatment for extirpation is attempted. When a small rupture
of the sac occurs, the effused blood conceals pulsation, changes the ordi-
nary globular shape of the aneurism, and, by gravitating away from the
seat of disease, may make the tumor appear to have a site distant from
the line of the artery. Moreover, the superficial veins may become
unusually marked, because the circulation in the deep veins is interfered
with by reason of the pressure. This circumstance gives the tumor the
appearance of malignant disease. Aneurisms, which are the seat of small
ruptures, are, therefore, at times diagnosticated from solid tumors with
difficulty. The diagnosis is easily made when the rupture is large, for
the interruption of circulation in the limb below, the swelling, pain,
ecchymosis, and rapidly occurring suppuration and gangrene are quite
distinctive. If suppuration occurs around an aneurism, from inflamma-
tion due to pressure or to rupture, pulsation may be absent. The careless
surgeon may plunge a bistoury into such a swelling and cause fatal
bleeding. This has been spoken of above.
Finally, abnormal pulsation of an artery is at times noticeable in con-
ditions of debility and in nervous subjects, and may be mistaken for
aneurism. The absence of lateral or expansive pulsation and of a tumor
serves to dispel the illusion.
COURSE AND TERMINATION.—Untreated aneurism generally continues
to increase in size until death occurs from : (1) Pressure interfering with
important organs, such as the trachea, pneumogastric nerve, or heart; (2)
syncope, from weakness of cerebral circulation beyond the large sac ;
(3) embolism of the cerebral arteries from fragments washed from the
laminated clots; (4) rupture and hemorrhage; (5) gangrene, from pres-
sure on the vessels of the limb. When an aneurism bursts upon a serous
surface the hemorrhage is usually rapid, and occurs through a slit or
star-like tear; but when the rupture is upon a mucous surface, the bleeding
is apt at first to be intermittent and so slight as scarcely to attract atten-
tion as it oozes through a small fissure. Subsequently, on the occasion of
Some increase in blood pressure from emotion or exertion, a small slough
gives way and a sudden gushing hemorrhage supervenes through a small
circular apeture. Rupture upon the cutaneous surface takes place, as a
rule, by the processes of ulceration or suppuration and pointing as in
abscesses. Rupture of the sac may, of course, occur without external
Communication. In such cases the blood is effused among the muscles
and fascias, and commonly leads very promptly to suppurative or
gangrenous inflammation.
Occasionally, but rarely, an aneurism is cured spontaneously. Any
*gency that lessens the blood-current and thereby encourages the deposi-
272 D IS E A SES OF T H E A R T E R I ES.
tion of laminated fibrine and the coagulation of blood in the sac, may be
a factor in this fortunate issue. , Absolute quiet of mind and body and
maladies that depress the general circulation or draw the mass of the blood
to a region distant from the seat of aneurism, have this tendency. The
ameurism itself or some other tumor may compress the artery above the
seat of disease, and thus diminish the current through the sac. Sponta-
neous cure may also occur from occlusion of the vessel above or below
the disease by an embolic plug swept from vegetations in the heart, or
from the fibrine in the aneurismal sac ; from inflammation of the sac
wall, causing within the aneurism the formation of soft clot; from sup-
puration; from rupture; and from gangrene. Any of these processes
may at times fortunately cause sealing of the vessel and obliteration or
destruction of the sac ; but they are dangerous complications not often
attended by such a gratifying result.
TREATMENT.-The medical or constitutional treatment of aneurism is
important, even in those instances that require additional surgical inter-
ference. Absolute rest of body and mind must be enforced by keeping
the patient in bed in the recumbent position, and free from the excitement
of talking. He should be cautioned to avoid rapid or frequent move-
ments of the limbs, and not to rise in bed unless aided by attendants.
He should not get out of bed on any pretence. The food should be limited
in quantity, and free from stimulating or indigestible ingredients. Very
little water or fluid diet should be given. The design of these precau-
tions is to diminish the bulk, and retard the circulatory force of the
blood in order that deposition of laminated fibrine in the sac may be
encouraged. These objects may be further obtained if the patient is
robust and plethoric by a moderate bleeding from the arm, and the
administration of aconite and veratrum viride in comparatively small
doses. Bromide of potassium, hydrate of chloral, and the other narco-
tics may be employed here, and also in a debilitated subject to induce
circulatory repose. Iodide of potassium has been strongly recommended
in the treatment of aneurism. It should be given in doses of 20 to 30
grains two or three times daily.
The medical treatment just delineated is the only treatment applicable
to the majority of internal aneurisms, as aneurisms within the cavities of
the trunk are called. It should also be employed as an adjuvant to
surgical measures in cases of external aneurism. Though cure of any
form of aneurism by medical means is rather unusual, amelioration of
symptoms and retardation of progressive enlargement are their common
sequences. Fusiform aneurisms cannot, but sacciform aneurisms may, be
cured by such measures.
Many surgical expedients have been devised for dealing with aneurism.
There are but three that possess sufficient value to be discussed in this
treatise.
These are:
1. Excision of the tumor, which is applicable to very small aneurisms
only, such as occur in the fingers.
2. Compression of the artery above the tumor by instruments, the
fingers, flexion of the joint, or the Esmarch apparatus.
3. Arterial ligation. -
Galvano-puncture, acupuncture, the introduction into the sac of foreign
bodies, such as horsehair or wire, injections of coagulating liquids, such
as the iron compounds, manipulation which aims to detach fragments of
fibrine and plug the distal orifice of the sac, and the other proposed
A N E U RIS M. 273
methods are either far inferior to, or much more dangerous than the pro-
cedures mentioned above. Still it may be justifiable to resort to one of
these methods when those recommended are impracticable.
Amputation may be demanded as a last resort in order to save life in
aneurisms of the extremities that threaten immediate death from hemor-
rhage or gangrene.
Excision of the aneurismal sac is applicable only to small aneurisms
such as occur in the hands and feet. In these situations excision is some-
times to be employed because the intimate anastomosis of vessels renders
solidification of the aneurism by either compression or ligation of the
main vessels of the limb difficult. The method is simple. After the
application of the Esmarch apparatus the tumor is dissected out as any
other growth would be and the vessel tied above and below the seat of
dilatation. The wound is then brought together with sutures. A some-
what similar method, which may be called the incision method, is at times
justifiable in large aneurisms, though it is seldom employed except in
cases of rupture or accidental puncture of an aneurism. After the circu-
lation has been controlled by compression or the Esmarch apparatus, the
sac is incised so that the clots can be turned out and the orifice in the
artery discovered. Into this aperture a probe is passed to enable the
operator to detect the position of the vessel, which is then ligated above
and below the opening. The wound is afterward brought together by
sutures or packed with some antiseptic dressing and allowed to granulate.
Compression, as a method of treating aneurism, may be applied directly
to the tumor, or to the artery, either above or near the seat of disease.
Pressure applied directly to the tumor or to the artery on the distal side
of the aneurism is seldom effective and needs no further description.
Proximal arterial compression is the form adopted in all cases; for even
in those in which flexion is employed it is the compression exerted on the
artery above the sac that is the chief element of value. Compression of
the artery above the aneurism acts by diminishing or completely arresting
the flow of blood through the sac. This, in the one case, encourages
gradual deposit of laminated fibrine which finally fills the pouch and
leads to solidification; and in the other, causes the sac to become filled
With soft clot, after which, under the influence of absorptive and con-
tractile influences, the aneurism shrinks and becomes obliterated.
It is probable that here, as in ligation, the more certain and safe treat-
ment is that in which the pressure is so regulated that a small amount of
blood is allowed to enter the aneurismal pouch during the application of
the compressing force. Thus, a slow, laminated deposit of fibrine occurs
and the sac becomes hard and solid. When sufficient pressure is made
upon the artery to close its calibre entirely, the anastomosing arteries, if
the pressure is continuous, will soon carry a small blood-stream through
the tumor, provided a branch leaves the main trunk between the seat of
Compression and the sac. The conditions are thus identical with those
obtaining after Hunter's method of ligation; providing the occluding
pressure is maintained without interruption for a sufficient number of
hours and is not changed to a point below the origin of the branch
through which the small reversed current is to enter the main trunk.
When the compression is only sufficient partially to close the arterial
calibre, a small amount of blood necessarily enters the pouch by the
Qrdinary route, and the therapeutic conditions are similar to those just
described. When the complete compression is made so near the sac that
no intervening branch exists all access of blood to the sac is stopped and
18
274. D IS E A S E S OF T H E A R T E RI E S.
it becomes filled with soft clot. Cure must then result as in Anel's method
of ligating, and with the same liability to failure from inflammatory reac-
tion due to the pressure of the soft coagulum.
*...* ºr ==E=- v.--> gº º
*** º: *...* > ...,' ... < §§§tº
!Cº. §:#:*** -- .. ź.
wº- $ºlº.º. ººr. Fºr ºxº~ 3 - Nº.:*:::=º:
º sºrº: Tº sºrº, º ºvºº
## §§ º #:#:::::=== º:
3.
&
§ §:
Diagram showing small amount of blood entering sac because pad of compressor does
not entirely occlude the calibre of the artery.
It takes longer to fill the sac with deposits of laminated fibrine than
with soft, homogeneous coagulum; but reasoning from what is seen after
ligation I am inclined to recommend it as the surer and safer method.
Therefore, that complete compression, as a rule, should not be employed
unless the pressure can be applied far enough above the aneurism to in-
sure the existence of an intervening branch which will carry a gentle
current of blood through the sac, partial compression may be employed
even near the aneurism because it allows a portion of the current to pass
through the vessel at the seat of pressure and thus enter the sac.
By complete compression is not meant such a degree of force as will
cause inflammation of the tunics and permanent occlusion of the artery;
merely such pressure as will bring the opposite walls of the vessel in con-
tact and prevent the passage of the blood current during the continuance
of the pressure. This sort of compression should be continued for from
four to ten hours, and usually requires anaesthesia during the whole period,
for the prevention of discomfort and actual pain. When the aneurismal
tumor appears to have become consolidated, which may occur in a short
time, the pressure may be somewhat relaxed ; but partial compression at
least should be maintained for several hours longer. If this is not done,
the sudden rush of blood may displace the fibrinous deposits in the sac ;
or, if the coagulum is merely soft, may cause its disintegration and thus
destroy the prospects of cure.
Partial compression, which allows some blood to flow through the
artery at the point of pressure, is more tolerable to the patient than com-
plete compression, and, therefore, does not require anaesthesia. Narcotics
may be demanded, however, to relieve distress occasioned by the restraint.
This method of treatment must be continued for days, and perhaps for
two or three weeks, because the blood current, though greatly diminished
in volume, is sufficient to prevent rapid solidification in the Sac.
Either form of compression may be employed continuously or inter-
ruptedly. Continuous compression is probably better than interrupted
compression, whether complete or partial, because cure is more rapidly
attained. It quite frequently happens, however, that treatment by either
complete or partial compression requires so many hours or becomes so
irksome to the patient, that it is necessary to suspend its employment from
time to time. The intervals of non-treatment should be generally at














A N E U R IS M . 275
night, so that the patient may have every opportunity for obtaining rest
and sleep. In the case of complete compression an intermission of Several
days is at times advisable. During the intermissions the patient should
be kept perfectly quiet in bed. The Sac is finally filled, if cure be effected,
by successive layers of fibrine deposited during the periods of pressure.
The best method of compression probably is continuous complete com-
pression applied far enough above the aneurism to insure the existence of
an intervening branch to carry a little blood into the sac. If this form
of treatment is not adaptable resort may be had to continuous partial
compression.
After an aneurism has been cured by compression there is usually no
obliteration of the artery found at the point of pressure. In the Sacciform
variety there is in some instances no obliteration even at the seat of the
tumor, but the circulation goes on through a groove or channel in the
solidified aneurism. Fusiform aneurisms are not very amenable to treat-
ment by pressure.
Before compression is begun the patient should be confined to bed for
three or four days, that he may become accustomed to the restraint and
to urinating and defecating in the supine posture.
The limb should be shaved and washed, and the skin at the seat of pro-
posed pressure sprinkled with chalk, oxide of zinc, Soapstone, or other
unirritating powder. The bed should have a firm mattress upon it. The
intelligent coöperation of the patient should be obtained, for much depends
upon the continuous perfect adjustment of the compressing force whether
it be digital or instrumental.
Bromide of potassium, chloral and morphia are often valuable agents
for keeping the patient comfortable. When about to apply the compress-
ing force the surgeon should, by momentary pressure on the distal portion
of the artery, cause the sac to become well distended with blood. The
finger or pad is then adjusted to the artery above the aneurism before the
distal pressure is relaxed. Gentle compression of the tumor by an ordi-
nary bandage applied up the limb during the time of treatment possibly
conduces to hastening contraction of the sac. Inflammation of the skin
or cellular tissue at the point of compression calls for temporary cessation
of treatment.
. The best compressing force is that exerted by the human finger. This
is called digital compression, as opposed to instrumental compression,
Which is obtained by tourniquets, suspended weights, or similar appara-
tus. Digital compression necessitates relays of physicians or trained
assistants, since one person cannot exert effective digital pressure continu-
ously for more than ten or fifteen minutes. Two persons should be with
the patient constantly. The first makes pressure on the artery with his
thumbs placed one upon the other, while the second keeps his hand on the
surface of the aneurism to see that absolute cessation of pulsation is main-
tºined. When the first becomes tired of pressing, the second places his
thumbs upon the vessel just above or just below the point compressed by
his companion and controls the circulation before the latter relaxes his
Pressure. He that was the compressor now watches the tumor to see that
Pulsation does not return from inefficient arterial occlusion. Instead of
using the muscular power of the second hand to reinforce the thumb placed
ºver the artery, the compressor may have a bag of shot or a tourniquet
* adjusted as to press upon the back of his thumb. This renders the
9Pºrºſion less wearisome. Intelligent assistants are required for carrying
* digital compression, since the pressure must be made in that direction
276 DIS E A SES OF T H E A R T E RIES.
which will press the artery against the bone; and must not be made upon
the vein if is possible to avoid it.
The femoral artery should be controlled by pressure below the groin
directed backward against the head of the femur. The brachial artery
at its upper part is compressed by pressure outward and backward against
the shaft of the humerus. The amount of force should be no greater
than that which stops pulsation in the tumor. It is for these reasons that
the finger-tip of an intelligent person is far better than any pad that can
be devised by instrument-makers. Complete occlusion can, therefore,
generally be maintained without anaesthesia. Another, though indirect
advantage of digital compression, is the constant presence of the assist-
ants, which serves to interest and encourage the patient.
When trained assistants are not obtainable,
FIG. 106. digital has to be substituted by instrumental
* , w pressure. Sometimes one method may be
used as an adjuvant to the other.
Various tourniquets and compressors have
been devised for making pressure on the ar-
tery. The essential point is that the venous
circulation shall be interfered with as little
as possible; hence a small pad controlled by
a screw or spring and a larger pad to make
counter-pressure on the opposite side of the
limb are characteristics of nearly all these
instruments. Sometimes there are a series of
small pads so that pressure can be applied
alternately to different parts of the artery,
and thus relieve the integument from inju-
rious pressure. The same object can be ob-
tained by using two single pad tourniquets
placed a few inches apart, one of which can
be relaxed while the other is screwed down
upon the vessel.
gº These methods are objectionable when the
Watson's weight compressor. varying points of pressure cause different
The dotted line indicates the anastomosing branches to carry on the collat-
position of the limb. eral circulation, for too much blood may reach
the sac in case ligation is required after failure
to cure by compression. A single pad is probably preferable, supple-
mented, if necessary, by digital compression applied near the same spot.
A conical weight or a bag of shot may be suspended or other means
arranged so as to make arterial compression.
When the aneurism is of the brachial artery at the elbow, or of the
popliteal artery, compression by flexion may be employed as a method of
treatment. This mode consists in keeping the elbow or knee firmly flexed
so as to bend the artery and at the same time exercise pressure on the
tumor itself. The circulation through the sac is thus greatly lessened.
The flexed posture can be maintained by applying a collar around the
limb above the joint and another below it, and preventing extension by
a short chain attached to both. A more simple means is an ordinary
roller bandage applied by figure-eight turns. The forced flexion should
be sufficient to check pulsation completely in the sac, but the joint should
not be flexed to such an acute angle as will make too violent pressure on
the aneurism or injure the articulation. It is not satisfactory in large

A N E U R IS M. 277
aneurisms, nor in those tending to inflammation. Rupture or suppura-
tion may be induced by it in such cases. In small aneurisms and as an
adjuvant to digital or instrumental compression, flexion has a value.
FIG. : 07.
º-
*
wº-
sº
ſº
|*:::C-
2-Hº- === Sº
Briddon’s compressor.
Cure of aneurism at the elbow or knee has occasionally been obtained by
voluntary maintenance of the flexed position. So, indeed, has digital
compression, of the interrupted kind exerted by the patient’s own fingers,
effected a cure of aneurism.
FIG. 108.
Signorini’s tourniquet.
The last method of employing pressure is what may be called general
*Pression, and is accomplished by the Esmarch apparatus. A rubber
bandage is applied, as in preparing for amputation, from the distal ex-





278 D IS E A SES OF T H E A R T E R IF. S.
tremity of the limb to the lower end of the aneurism. The surface of
the aneurism is then left uncovered and another elastic bandage firmly
applied above it, or the first bandage is carried loosely around the loca-
tion of the tumor and applied tightly to the limb above. Near the trunk
the application of the bandage is discontinued and the limb is encircled
by the thick elastic band, which plays the part of a tourniquet. The access
of blood to the limb is thus cut off and the other bandage or bandages are
removed. The tumor, however, is left distended with fluid blood in a
state of rest, which soon coagulates. It is perhaps well to delay a mo-
ment when the elastic bandage has been applied as far as the lower end
of the aneurism, so that the current from above may fully distend the
sac before the vessel is compressed on the proximal side of the tumor.
The circulation should be kept out of the limb for about an hour, unless
there is some contra-indication. Before the constricting cord is removed
complete digital or instrumental pressure should be made upon the artery
above it, lest the sudden current wash away or break up the soft, black
clot in the sac. This, or moderate compression at least, should be kept
up for a few hours afterward to allow the clot to become firmer. Anaes-
thesia will be required when the Esmarch apparatus is used,
FIG. I 09. * ~~
Tuſhell’s truss-like compressor applied. (ERICIISEN.)
If the aneurism does not show absence of pulsation after this treatment,
the patient should be let alone for a week before a second trial is made.
In the meantime efforts to increase the coagulability of the blood may be
carried on. These have been described under the medical treatment of
aneurism. General compression seems to be most applicable to recent
aneurisms of moderate size with walls that are not very thin. It is to be
avoided or only applied with extreme caution and for short periods in
patients whose vessels are markedly atheromatous. Danger of inducing
gangrene is, under such circumstances, very great.

A N E U R IS M . 279
When ligation becomes necessary, after failure in curing by the Es-
march apparatus, the surgeon should not attempt to apply the ligature at
the point where the constricting band encircled the limb. The peri-arte-
rial structures are liable to be infiltrated or inflamed at this point. A
higher or lower point should be selected. . This rule should be followed
in ligating after any form of compression has been previously employed.
The comparative advantages and disadvantages of compression in the
treatment of aneurism claim attention. Though not without risk of in-
ducing erysipelas, inflammation, and suppuration of the sac, thrombosis
and gangrene, compression is safer than ligation. This is probably true,
notwithstanding the fact that the use of catgut and similar aseptic liga-
tures has reduced very greatly the risks formerly associated with ligation.
Partial compression has, however, the disadvantage of being a more tedi-
ous method than ligation, and is not available when the patient is fretful
or the disease rapidly increasing. Neither form of compression is to be
attempted when the limb is inflamed or oadematous. It is probable that
the development of the collateral circulation due to the compression acts
at times as a source of failure when subsequent ligation is demanded by
inefficacy of compression as a means of cure. On the other hand, the
same effect may be a preventative of gangrene after ligation, especially
in the old, whose arteries are not well fitted to carry on the collateral cir-
culation after ligation, unless previous gradual enlargement has been
effected by compression.
Compression is not serviceable, as a rule, in the cure of fusiform
8,IlellTISIOl. º
The rules for employing compression then may be formulated as fol-
lows: Use it:
1. In aneurisms of recent development and when the success of subse-
quent ligation is not much imperilled by its use.
2. When ligation is especially dangerous, as it is in the aged, during
epidemics of erysipelas, and in certain locations of the body.
3. Experimentally for five to seven days in nearly all cases.
If nothing is gained by compression in the course of a week, it is usually
proper to resort to ligation.
Arterial ligation for the cure of aneurism has been practised in four
ways, of which two are practically valueless. Of the two remaining
methods one is always preferred, except when the proximity of the
aneurism to the heart renders its performance exceedingly dangerous.
This method is called the Hunterian method. . It consists in applying a
ligature to the artery between the aneurism and the heart, and at such a
distance from the former as will insure the existence of a small branch
leaving the artery between the ligature and the seat of disease. The
ligature on being tied arrests at once the current in the main artery and
Would entirely stop the blood flow through the aneurismal sac, if the small
branch mentioned did not exist. This small branch, which has an anasto-
mosis with branches given off from the main vessel above the site of liga-
tion, Soon, by dilatation and reversal of current, carries a small amount
of blood into the main vessel below its origin, and thence through the
aneurismal sac. Thus, it is seen that the Hunterian method of ligation
does not entirely arrest the current through the sac, but merely diminishes
it very greatly, Deposition of laminated fibrine, which is the method of
Spontaneous cure which is most desirable, is thus determined, whereas
entire arrest of the current would have caused the formation of soft clot
280 D IS E A S E S OF T H E A R T E R I E S.
in the sac, which may, it is true, cause final solidification, but which is
apt to be followed by inflammation of the sac.
EIG. 110.
}| __ Anastomosis around ligature, giv-
l ing feeble current through sac.
|| ||
lºs
/~
.S.
Anastomosis around Sac, giving
feeble current.
Strong current from neighboring
large trunk.
Diagram of anastomosis after Hunterian method of treating aneurism.
Of the three other methods of ligation one is a proximal ligation, that
is, on the side of the disease nearer the heart, and two are distal liga-
tions, that is, on the side away from the heart.
Table of the four methods of ligation in treating aneurism.
Proacimal Ligations.
Anel's.-Ligature applied close above aneurism with no intervening
branch.
Objections: 1. Difficult, because artery is overlapped or displaced by
Sà,C.
2. Causes total arrest of blood current, hence soft clot
and tendency to inflammation of sac.
3. Artery probably atheromatous, hence tendency to
secondary hemorrhage.
Hunter's.-Ligature applied at some distance above aneurism, so as to
have an intervening branch.
Advantages: 1. Easy of performance.
2. Causes partial arrest of blood current, hence firm
fibrinous deposit.
3. Artery much more likely to be healthy.


A N E U R IS M . 281
Distal Ligations.
Brasdor's.—Ligature applied just below aneurism.
Objections: Same as in Anel's.
Wardrop's.-Ligature applied to trunk a little below first branch or
to first branch a little below its origin from the
trunk.
Advantages: Same in kind as those of Hunter's method, but it is less
successful in causing solidification because current
is not arrested sufficiently. Never used except in
aneurism of innominate or of root of common
carotid artery and then it is adopted because the
Hunterian method is impossible.
FIG. III.
Diagrams showing Anel, Hunter, Brasdor and Wardrop methods.
The Hunterian method of ligation must be considered more fully, since
it is the one to be adopted when compression is deemed impracticable.
The method of exposing the various arteries and ligating them in con-
tinuity is described in a subsequent section.
When the catgut cord has been placed under the vessel and before the
knot is tied the artery should be compressed between the cord and a
finger inserted into the wound, in order to prove by absolute arrest of
pulsation in the tumor that the supplying artery has been exposed. Just
before the ligature is drawn tight, it is well to make pressure for half a
minute upon the artery on the distal side of the aneurism in order that
the sac may be fully distended with blood before the circulation is
arrested. A good size catgut or flat silk ligature is to be preferred. With
ligation of the vessel, pulsation, thrill and murmur in the tumor imme-
diately cease and the limb below shows some elevation of temperature,
which usually, however, soon subsides.
Loss of muscular power, pain and hyperaesthesia are frequently ob-
served in the parts below the site of operation. The tumor at first feels
softer than usual, but in a few hours becomes harder and more elastic.
This process of solidification continues and in a few days is completed by
the transformatson of the sac into a hard ball. Contraction then begins
and in the course of several weeks or months, mothing at all, or nothing

282 D IS E A SES OF T H E A R T E R I E S.
but a slight thickening, is perceptible to the touch. In rare instances
Some enlargement of the tumor without return of pulsation may occur
after ligation from influx of blood from the distal part of the artery.
This is apt to lead to the suspicion that a malignant muscular growth has
been mistaken for an aneurism. A subsequent solidification of the sac
clears up the doubt. A similar condition may follow compression.
After the operation the limb should be enveloped in cotton-wool held
in position by a bandage loosely applied, and the patient should be
directed to avoid attempting to move the extremity. Quiet should be
obtained by anodynes, if necessary. The cotton tends to preserve an
even temperature, and protects from injurious influences the parts which
have now a diminished circulatory supply. For a long time, even after
consolidation of the tumor, all violent exercise of the extremities should
be avoided. Impairment of muscular power, liability to suffer from ex-
posure to cold, and other nutritive defects often remain permanently after
arterial ligation for any cause.
The Hunterian method of ligation is usually followed by the develop-
ment of two collateral circulatory arches: one between the branches
above the ligature and those given off between it and the aneurism, and
another between the branches below the aneurism and those above it.
The lower anastomosis—namely, that around the aneurism, is generally
established more rapidly than that around the ligature, because the col-
lateral branches in the former region have previously been enlarged by
the circulatory interference occasioned by the pressure of the aneurismal
tumor. This double anastomosis is due to the fact, that the artery
usually becomes obliterated at the seat of aneurism as well as at the seat
of ligation, but is pervious between those points. If the sac solidifies and
leaves the vessel pervious opposite the seat of aneurism, or if the vessel
becomes entirely occluded by clot or obliterated from the ligature to a
point below the aneurism, only one collateral arch is developed.
Ligation is indicated for the treatment of aneurism :
1. When compression has been tried unsuccessfully and when com-
pression cannot be applied ; provided that the disease is advancing and so
located that the application of the ligature is not attended with unusual
risk.
2. When the aneurism has ruptured and caused hemorrhage into an
articulation or into the intermuscular spaces; provided that the condi-
tion does not demand amputation. -
3. When rupture into one of the cavities of the body or upon the
surface, or the possibility of an early occurrence of such rupture threatens
to destroy life by hemorrhage,
Ligation is contra-indicated :
1. When the locality of the aneurism is such that compression can be
applied.
2. When the operation is peculiarly dangerous on account of the loca-
tion of the aneurism, the existence in the patient of extensive arterial or
cardiac disease, or the prevalence of erysipelas or pyaemia.
3. When, on account of the proximity of large anastomosing branches
or from any other circumstances, the operation would probably be unsuc-
cessful. Under such circumstances ligation is justified only by impending
rupture.
The complications likely to arise after ligation, which may interfere
with the successful solidification of the aneurism or tend to destroy the
patient's life, are: recurrent pulsation in the tumor, secondary hemor-
A N E U R IS M . 283
rhage at the site of operation, suppurative and gangrenous inflammation
of the sac, gangrene of the extremity, pyaemia, and in special locations,
secondary disease of the brain or thoracic viscera.
Recurrent pulsation is due to the anastomotic arch around the ligature
allowing too free a blood-current to enter the artery between the ligature
and the aneurism. An anomalous distribution of the branches or abnor-
mally large size of the usual branches, is the cause of this undesirable
freedom of the collateral current. The employment of the compression
treatment for a considerable period previous to resort to ligation, is at
times an agent in developing unusually free anastomosis. Recurrent
pulsation develops within twenty-four hours, and, if slight, is not likely
to interfere with progressive consolidation of the tumor. If it increases
in force in the succeeding few days and the tumor remains soft and with-
out diminution in size or shows evidence of enlargement, the operation is
proved to have been unsuccessful, and other means of cure must soon be
adopted. Recurrence of pulsation after the lapse of several months is
almost certainly due to the development of a new aneurism, near the site
of the cured aneurism.
Recurrent pulsation should be treated by elevation of the limb and
moderate compression of the tumor and of the artery above the site
of ligation, success will probably follow ; if not, continued progress of
the disease will demand Anel's method of ligation, incision of the sac
and double ligature, or amputation.
Secondary hemorrhage may, after the lapse of one or two weeks, occur
from the wound made at the time of ligation. This is due sometimes to
an atheromatous condition of the artery preventing proper healing of the
vascular coats divided by the ligature. At other times, it is caused by a
large branch being given off so near the site of ligation that the collateral
current coming through it into the main trunk exerts too much pressure
for successful resistance by the short internal clot.
Secondary hemorrhage is more frequent in the upper than in the lower
extremity, because the anastomosis is more free. As rapidity of union
of the wound is a barrier to secondary hemorrhage, strict asepsis and
antisepsis have made secondary hemorrhage very uncommon after ligation
for aneurism. The flat ligature of animal nerve or tendon, which merely
approximates the arterial walls without dividing the internal and middle
coats, will probably be found by future experiment to be the safest means
of ligating atheromatous vessels.
When secondary hemorrhage occurs, it should be treated by pressure
made upon and in the wound by compression with plugs of sponge, or fine
shot. If this fails the Esmarch apparatus should be applied, the wound
opened freely and the artery ligated above and below the former ligature.
In the event of the bleeding still continuing ligation of the artery in con-
tinuity at a higher point is good practice in the upper extremity, but is
Very likely to be followed by gangrene if done in the lower extremity,
Where the establishment of sufficient collateral circulation is unusual.
Amputation is, therefore, usually preferable in persistent secondary hemor-
rhage occurring after ligation for aneurism of the leg or thigh. If the
Second ligation in continuity is done in either extremity, such a point
must be selected as will permit subsequent amputation if this becomes
necessary. Occasionally it is possible to control secondary hemorrhage
by ligating in continuity the branch through which the blood finds its way
into the distal portion of the trunk originally tied.
Suppurative or gangrenous inflammation of the sac may result from
284 D IS E A SES OF T H E A R T E R IES.
recurrent pulsation, from incomplete anastomosis around the aneurism,
from complete arrest of circulation in the sac and consequent formation of
soft clot, from the great size and thinned walls of the sac, and from exter-
nal violence, such as may be sustained by rough handling or kneading of
the tumor either before or after ligation. The symptoms of inflammation
of the sac are those characteristic of a similar process elsewhere. Suppu-
ration is exhibited by the ordinary signs of abscess. When an opening
has occurred spontaneously or by incision, hemorrhage becomes a promi-
ment symptom. If recurrent pulsation has existed, the bleeding will be
immediate and profuse; under other circumstances the escape of blood
may not occur for several days, and at first will probably seem insignifi-
cant. Suppuration or sloughing occurring even so late as six or eight
weeks after ligation may, especially if accompanied by recurrent pulsation,
be followed by fatal hemorrhage.
Suppuration of the sac is to be treated by at once applying a provisional
tourniquet to the artery above the seat of ligation and laying open the
abscess. If bleeding occurs the surgeon should proceed to turn out the
clot, securing dangerous points by ligature or the actual cautery, make the
wound antiseptic, pack it, and wait for it to heal by granulation. Sponge
grafting would probably hasten cicatrization by causing granulations to
fill the cavity more promptly. The patient must be constantly watched by
competent surgical attendants, so that on the first sign of bleeding the
artery can be controlled by digital compression, or by screwing down the
pad of the tourniquet, which is kept loosely applied. If hemorrhage per-
sists, amputation should not be long delayed by experiments with tem-
porizing measures.
Gangrene of the limb is a formidable complication of ligation. Its
occurrence may be due to rigidity of the arterial branches preventing
sufficient enlargement for the establishment of collateral circulation, to
pressure of the tumor upon the anastomosing branches, to injury of the
main venous trunk at the time of ligating the artery, and to exposure of
the limb to heat, cold, or undue pressure soon after the operation. This
complication arises within the first week or ten days, and is more frequent
in the lower than in the upper extremity. The form is generally that of
moist gangrene because venous obstruction is usually one of the factors in
its etiology. Wrapping the limb in cotton to keep the temperature equable
and to avoid injury, and slightly elevating it to encourage venous return
are measures calculated to lessen the probability of gangrene. Gentle
friction of the limb toward the body may sometimes be used to accelerate
the venous blood current. When gangrene has begun after arterial liga-
tion, but little can be done except promptly to amputate the limb high
up. In the upper extremity removal at the shoulder-joint, in the lower
removal at the junction of the middle and upper thirds of the thigh will
probably be necessary. Occasionally laying open the sac and turning
out all clots will relieve venous obstruction and restrain the progress of
gangrene.
Gangrene of a similar character may follow the employment of com-
pression for the cure of aneurism.
Pyaemia may follow ligation, and is more frequent in patients who have
previously suffered from hemorrhage or other depressing influences.
Finally ligations of vessels near the body may be complicated with
pleurisy, peritionitis, and other unfortunate sequences, due to injury at the
time of operation, or to spreading of inflammation. The fatal issue after
LIG ATION OF A R T E R I. A. L T R U N K. S. . 285
ligation of the common carotid artery may be due to cerebral anaemia or
thrombosis.
Suppuration and septicamic or sapraemic processes occurring in connec-
tion with aneurism are, of course, due to the same vegetable parasites as
cause these conditions in other surgical wounds or diseases. The bacteria
either gain access by the wound made, or while circulating in the blood
or lymph streams, are arrested and find a place of least resistance in the
tissues where the aneurism exists.
LIGATION OF ARTERIAL TRUNKS IN CONTINUITY.
Arteries are tied in their continuity to lessen the circulation through
aneurismal tumors and to arrest secondary hemorrhage, which pressure
or ligation in the wound has failed to control. The special instruments
required for the operation are a bistoury or scalpel, dissecting forceps, a
grooved director, two metallic retractors with which to hold the margins
of the incision apart, an aneurism needle, and a strong antiseptic ligature
of catgut, ox-tendon, or nerve.
FIG 112.
*-
sesssssssssssssssssss-
Grooved director.
FIG. I.13.
|
-------.
Aneurism needle.
FIG. 114.
Blunt and sharp-pointed retractors.
The surgeon must first of all determine the exact course of the artery
by the well-known landmarks of clinical anatomy and the linear guides
Which are based upon these relations. If the artery is a superficial one
its pulsation will aid in this determination. If a superficial tendon or
muscle is one of the guides, it can be made to stand out prominently by
getting the patient, before etherization, to use it voluntarily. The line of
the tendon or artery can then be marked on the skin with a moistened
aniline pencil. In operating on the dead body such tendons are made
Prominent by moving the joints in such a manner as to bring tension on









286 L) I SE A SES OF T H E A R T E R I E S.
the muscular fibres. For example, if a flexor is the guide ask the patient
to flew the joint, and the muscle will on contraction become prominent;
but in the surgical laboratory the same muscle in the cadaver can only
be rendered prominent by forcibly eatending the joint.
The second step is to decide upon the point of ligation. In secondary
hemorrhage it is the best, if practicable, to expose and tie the vessel near
the wound and on both sides of it. In the case of aneurism the Hun-
terian method is usually the best. This places the ligature sufficiently
far from the aneurism to insure at least one small branch being given off
by the trunk between the site of ligation and the aneurism. The ligature
should always be applied at least one-half or three-quarters of an inch
below the origin of any large branch or bifurcation of the artery. When
this is anatomically impossible it is often wise to secure the branch also
with a ligature to prevent secondary hemorrhage, which otherwise may
result from the forcible collateral current developed in the branch or bi-
furcation.
The incision in most instances should be made slightly oblique to the
course of the artery and with its centre over the point chosen for ligation.
Such an obliquity of ten degrees makes it much more easy to search for
the muscular interspaces and other deep guides leading to the vessel.
The skin should be steadied, but not displaced, by the thumb and fingers
of the left hand while the point of the knife is inserted perpendicularly
through the skin and an incision varying from two to five inches in
length is made with one sweep. The scalpel should be brought out per-
pendicularly in order that the wound may be of one depth throughout
its entire length. The incision should always be sufficiently long to afford
free access to the tissues beneath. When the artery is deeply located,
whether from its anatomical relations or the obesity of the patient, a long
incision is demanded. The superficial fascia may be divided at the same
time as the skin, if the vessel lies below the deep fascia. Large super-
ficial veins should be drawn aside, if convenient, though their division is
of little importance since the bleeding is easily arrested by hemostatic
forceps or ligatures if it does not cease spontaneously. The deep fascia
is to be incised in a similar manner as the skin, or it may be punctured
and a grooved director slipped under it, after which manoeuvre it is
divided by carrying the inverted knife along the groove. The original
length of the incision should be maintained until the sheath of the artery
is reached. If the deep fascia is so tense as to prevent satisfactory inves-
tigation of the parts beneath, a short incision may be made across the
middle of the longitudinal one.
Muscular interspaces are guides to some of the arteries. These, on
account of the fat deposited in them, are usually quite readily recognized
as yellow lines. Sometimes this yellow appearance is seen before the
deep fascia is divided. Another guide to them is furnished by the small
vessels which ramify in them and perforate the fascia covering them.
The proper muscular interspaces to gain access to the artery are next torn
open with the rounded end of the director; or the wound is deepened by
the careful use of the scalpel. As the situation of the artery is approached
the forceps and the back of the scalpel's point are the safest means of
separating the tissues. During this dissection the wound may be held
open by blunt hooks or retractors, and the bulging muscles relaxed by
bending the joints.
The larger arteries, with the accompanying vein or veins, are enclosed
in a distinct fibrous sheath. This sheath is to be opened by pinching up
LIG ATION OF A R T E R I. A. L T R U N KS 287
a fold with small toothed forceps and making in it with the knife a cut
about a quarter of an inch long. While the forceps holds the edge of
the opening the end of the grooved director or aneurism needle is intro-
duced into the sheath on one side of the artery and used to break up the
adhesions between the vessel and the sheath, or the adjacent contents of
the sheath. By a similar manoeuvre on the other side of the vessel com-
plete isolation of the same is accomplished. ... Isolation of smaller arteries
which have no distinct sheath can be readily performed by using two
pairs of forceps to pull away the small veins and cellular tissue. . The
use of the point of the knife is dangerous in cleaning the artery, lest a
puncture be inflicted upon the artery or vein. Care must be observed
with the blunt instruments that undue bruising is not done.
The Esmarch apparatus is sometimes applied to prevent obscuration of
the parts by hemorrhage during the operation. Usually it is unnecessary,
for only a few small branches are divided. These can be tied, if necessary.
It is well to remember the characteristics of an artery in the living
subject. It has a pinkish-white, smooth, shining surface, and is compres-
sible, feeling as it is rolled under the finger-tips as if two surfaces were
slipping upon each other. A nerve has not this smooth, shining surface,
but has longitudinal markings, due to its fibrous structure, and rolls
under the fingers as a Solid non-compressible cord. A vein is purplish,
soft, and flaccid, and from its distention with dark blood resembles a leech
in appearance. It becomes more distended if pressure is made on its car-
diac end. A small tendon is pearly white and glistening, and gives, when
seized, the impression of great density. Passive motion of the neighbor-
ing joint may prove its identity. The recognition of the artery is often
aided by its location between two satellite veins and by its pulsation.
Pulsation, however, may be absent, because exposure and manipulation
sometimes cause arteries to contract and become temporarily pulseless.
On the other hand, a deceptive pulsation may be transmitted to nervous
or fascial bands lying over an artery. When the operator fails to find
the artery he should not tear up the tissue in an aimless manner, but
should at once review all the steps of the operation and systematically
verify each landmark from the surface downward. In this way he will
discover the source of error.
After the artery has been recognized and isolated the end of the curved
aneurism needle, threaded with antiseptic catgut or silk is carefully passed
around it without disturbing its surroundings or pulling it from its bed.
Chromicized gut is better for large vessels than plain gut since it is not so
quickly absorbed. This is best done by grasping the tissues at one side
of the artery, but not the artery itself, with the forceps and insinuating
the aneurism needle with a curvilinear movement under the artery from
that side. A little lateral movement of the point of the needle will
render its passage more easy. As the point projects at the opposite side
of the vessel the tissue overlying it may be torn through with the finger-
nail or forceps, if it is seen not to be a vein or part of the arterial wall.
When the loop of ligature in the eye of the needle is visible it is drawn
out of the wound by the forceps while the needle is made to retrace its
Course under the vessel and is thus removed.
If the artery has a single vein alongside of it the needle should be in-
troduced at the venous side of the artery, since puncture of the thin-
Walled veins is thus less likely to occur than when the point of the needle
is carried beneath the vessel from the side opposite to the vein. If accom-
Panying veins exist on both sides of the artery this precaution loses its
288 D IS E A SES OF T H E A R T E R I E S.
value. If by accident such a large vein is punctured during the opera-
tion, it may be well to extend the incision and tie at a higher point of the
artery. Bleeding from the vein is to be controlled by lateral ligation or
suture of the vein, if any venous hemorrhage of importance occurs. Be-
fore tying the ligature the surgeon should hold the artery in the loop of
the string and compress it with a finger to be sure that pulsation below is
arrested by constriction of the structure encircled. This manoeuvre proves
FIG, 115.
§º
* j \º
|
Diagram of opening sheath of artery, passing ligature and tying ligature. (BRY ANT.)
or disproves the proper application of the ligature, which may be around
the wrong artery or perchance around a nerve or piece of fascia. The
ligature should be secured by a friction knot or a flat knot; and in the
latter case it is well to tie the ends a third time after completing the
ordinary double tie, for the catgut is apt to become loosened. During the
knotting the index fingers should be carried into the depth of the wound
in order not to raise the vessel from its bed. Sufficient tension should be
put upon the first tie to insure division of the inner and middle coats of
the artery. This is known by the sensation of cutting into the wall that
is felt by the operator as the noose is tightened. When mere approxima-
tion of the inner tissue is desired, this cutting is avoided by using flat liga-
tures of ox aorta or nerve. After ligation is accomplished the wound is
approximated with sutures, cotton is applied around the limb to maintain
an equable temperature, and the extremity is slightly raised to encourage
venous return. The wound must be kept bacteria-free so that septic and
purulent infection may be with certainty avoided.
LIGATIONS OF SPECIAL ARTERIES.
Certain of the arteries are ligated in continuity with comparative fre-
quency. The most eligible site for such ligations must be mentioned and
the successive steps described. The unusual operations will be omitted.

H. R. A. C. H. I. A. L. A R T E R Y . 289
RADIAL AND ULNAR ARTERIES.—These vessels are seldom tied, except
at the wrist. If deligation at a higher point of either artery is demanded,
the surgeon usually prefers to secure the brachial. The radial artery
above the wrist lies between the tendons of the radial flexor of the
carpus and the long supinator, immediately below the deep fascia, and
upon the square pronator. Its direction and site are indicated by a
line drawn from the middle of the bend of the elbow to the inner side
of the styloid process of the radius. An incision one and a half to two
inches in length midway between and parallel to the radial flexor and the
long supinator will expose the vessel with its satellite veins. The deep
fascia must be divided with care or the artery may be wounded. The
pulsation of the artery is readily felt before the skin is incised.
, FIG. 116.
Deehſascia
\ –
-
º
>
• * :--
Ligation of radial and ulnar artery. (BRYANT.)
The ulnar artery at the wrist lies under the radial border of the tendon
of the ulnar flexor of the carpus and between it and the superficial flexor
of the fingers. The vessel lies under a layer of fascia situated below the
tendon; hence, it is necessary to divide two layers of deep fascia before
reaching it. The ulnar nerve is situated at the ulnar side of the artery
and close to it. The course of the lower portion of this artery is indi-
cated by a line drawn from the inner condyle of the humerus to the radial
side of the pisiform bone. The surgeon may depend upon this line for
determining his incision, or may recognize the position of the tendon
of the ulnar flexor of the carpus by its insertion into the pisiform bone,
and make an incision of one and a half or two inches along its radial
margin. The glistening tendon, uncovered after dividing the deep fascia,
should be drawn from the middle line of the arm, when the second pro-
cess of deep fascia will be exposed. This must be opened before the artery
is reached unless it has an anomalous course above the fascia. It is usual
to pass the aneurism needle first between the artery and the nerve.
BRACHIAL ARTERY.—The brachial artery in the middle of the arm
lies along the inner border of the biceps; and upon the coraco-brachial,
the anterior-brachial muscles, and the inner head of the triceps. The
median nerve passes over it, though occasionally under it, from without
inward. A satellite vein is to be seen on each side of the vessel, and the
large, basilic vein not far distant internally. A line, drawn from the
junction of the anterior and middle thirds of the axilla to the middle of
the bend of the elbow, indicates its course with accuracy. Its pulsation
is easily felt. An incision two and one-half or three inches in length is
to be made along the inner side of the biceps; when the deep fascia has
been divided, the muscular fibres of its margin will be fully exposed.
Alongside of or under the edge of this muscle will be seen the median





19
290 D IS E A SES OF THE A R T E RIES.
merve, which is then drawn aside to reveal the artery lying beneath it.
The nerve often shows marked transmitted pulsation. Sometimes the
artery is more superficial than the nerve. The arm should at this stage
be flexed at the elbow to relax the belly of the biceps. It is usually
better to have an assistant hold the arm than to allow it to lie upon the
table, because such pressure displaces the artery and pushes up the triceps,
which may be mistaken for the biceps. The edge of the biceps should
always be uncovered and identified; if it is not, the surgeon may work
too far inward and backward and become confused by mistaking the ulnar
nerve for the median, and the basilic vein for the artery. The vessel is
to be sought at or under the edge of the biceps in an outward rather than
an inward direction.
FIG. 117.
Bicyes Žtas cle
§§º)\\
* : *
*
i
l
& I
-Mºdiaz'zeroe
Tendinous Ahoneurosis
divided _`
f - / ſ ,”
Ligation of brachial artery. (BRY ANT.)
Since the brachial artery is not infrequently double or perhaps bifur-
cates into the radial and ulnar up near the axilla, it is important that the
surgeon remember this possible anomaly, and ascertain that he has secured
that vessel which will diminish the blood-supply as he desires.
AxILLARY ARTERY.—The third portion of this vessel can be reached
with safety and ease. If ligation at a higher point is demanded by the
exigencies of the disease, it is better perhaps to secure the third portion
of the subclavian than to attempt ligating the first or second portion of
the axillary. -
The last, or third portion of the axillary artery, beginning at the lower
edge of the lesser pectoral muscle, lies along the inner border of the
coraco-brachial muscle. The median and musculo-cutaneous nerves lie
on the outer side of the artery; the ulnar and internal cutaneous nerves
and the axillary vein on the inner side. Sometimes there is a satellite




S U B C L A VI A N A R T E R Y . 291
vein on each side of the artery instead of the single large axillary vein
on its inner side, which is replaced by the continuance upward of the
basilic vein.
A line drawn from the junction of the anterior and middle third of the
axillary fossa to the middle of the bend of the elbow, gives the course of
this portion of the axillary and the greater portion of the brachial
artery.
FIG. 118.
32 º
* * ... “..., 4 ºr a s
“ ”… .º. 2: 3:
7Mediczz meriz tº
. . . & 2&ºr;, re
. . . ...;;… ſº. 2.....
Ligation of axillary artery. (BRYANT.),
When the arm is placed at a right angle with the body the muscular
margins of the axillary pit are prominently shown. With the limb in
this position an incision three or three and one-half inches long should be
made parallel to the anterior boundary of the axilla, and about one third
the width of the axillary space behind this boundary; or, in other words,
directly over the head of the humerus and a little oblique to the line
given above. The edge of the coraco-brachial muscle will be exposed.
From this the operator searches in an inward direction, finding, first the
median and perhaps the musculo-cutaneous nerves, and then the artery,
with the axillary vein, the ulnar and internal cutaneous nerves on the
inner side.
The nerves, which wary somewhat in their relations, may be mistaken
for the artery. Occasionally a muscular slip from the broad dorsal muscle
crosses the artery. It is recognized by the transverse direction of its
fibres. The ligature must be passed from within outward, and should not
be applied near the origin of the subscapular artery.
SUBCLAVIAN ARTERY.—The third portion of this artery extends from
the outer margin of the anterior scalene muscle to the outer or lower
border of the first rib, and is the only part of the vessel that can be
ligated with comparative safety. It is situated in the triangle bounded
by the clavicle and the sterno-mastoid and omo-hyoid muscles; lying
against the first rib, the anterior scalene muscle and brachial plexus of
nerves. The subclavian vein is situated below and in front of the artery,
from which it is separated by the insertion of the anterior scalene muscle
intº the tubercle of the first rib.
To ligate the artery in its third position proceed as follows: Depress
the patient's shoulder, turn his head in the opposite direction, and draw
the skin of the supraclavicular fossa downward upon the clavicle with

292 D IS E A SES OF T H E A R T E R IE S.
the left hand and hold it there. Then make an incision, three or four
inches in length, upon the clavicle and following its curves, beginning a
half inch from the sterno-clavicular joint. The tissues should be divided
down to the periosteum. When the left hand has released its traction,
the skin will slide upward and the incision will be located about half an
inch above the clavicle. This manipulation of the skin preserves the
external jugular vein from division by the incision. The wound should
now be deepened by dividing the deep fascia and cutting the edges of the
sterno-mastoid and trapezius muscles, if they prevent the wound being
continued deeper with its original length. The fibres of the platysma
myoid muscle in the superficial fascia will be noticed during the dissec-
tion. If the external jugular vein cannot be held out of the way with a
hook, it is to be divided. A ligature should be placed also at the cardiac
side Óf the proposed section before the division is made, lest air be sucked
into the heart. As the wound is carefully deepened the surgeon's finger
seeks, at its inner corner, the edge of the anterior scalene muscle as it goes
down to its insertion into the first rib. The tubercle of insertion is often
poorly developed, but the direction of the fibres, and possibly the ex-
posure of the phrenic nerve running obliquely over the muscle, will serve
to differentiate it from other structures.
FIG. I 19.
% Ža.
º
A
º
t :: # .../
22-222.2%*g_
e-º sº- _Z37 a.
&zo-/32/22%-"
" A
f.
* t” ~~~
22* _`
Ligation of subclavian artery. (BRY ANT.)
º
lº:
º
3. -
* . .233
* : * > *
If the omo-hyoid muscle or brachial plexus is recognized before the
anterior scalene is seen, the search should be made in a direction down:
ward and inward from those landmarks. The artery is finally uncovered
beyond the outer border of the anterior scalene by opening with the foll-
ceps or director a layer of fascia extending over the vessel from this
muscle. The artery lies at a depth of from one to three inches from the
surface and runs in a downward and outward direction almost in the axis
of the arm. The aneurism needle should be passed from above down-
ward, because there is more danger of encircling the nearest cord of the
brachial plexus than of injuring the vein which lies at some distance from
the artery, though below it. This is an exception to the axiom which
















C O M M O N C A R O TI D A R T E R Y . 293
directs the needle to be passed, as a rule, first between the vein and the
artery about to be ligated.
The chief errors to be avoided in the operation are injury to the veins
and ligature of that portion of the brachial plexus. During the dissection
the suprascapular artery or the transverse artery of the neck, may be
divided and require ligation.
COMMON CAROTID ARTERY.—The direction of the common carotid
and its continuation, the internal carotid artery, corresponds with a line
drawn from the sterno-clavicular joint to the tragus of the ear. The com-
mon carotid artery extends only to the level of the top of the larynx,
where it bifurcates into the external and internal carotid arteries. The
left carotid has its origin lower than the sterno-clavicular articulation, but
in this intrathoracal portion of the artery surgeons have little interest.
This circumstance, however, renders ligation of the carotid below the omo-
hyoid muscle safer on the left than on the right side; because the ligature
is further from the blood stream in the parent vessel. The external
carotid at its origin lies from a quarter to a half inch nearer the middle
line of the neck than the line given for the internal carotid.
The common carotid artery lies beneath the anterior edge of the sterno-
mastoid muscle in a sheath, which also encloses the internal jugular vein
and the pneumogastric nerve. The vein lies on the outer side of the
artery, the nerve lies behind both and in the groove between them. The
descending branch of the hypoglossal nerve forms a loop with branches
from the cervical plexus usually upon the front of, but sometimes within,
the sheath. The artery becomes more and more superficial as it ascends.
Its sheath is crossed by the omo-hyoid muscle about midway between the
sterno-clavicular joint and the top of the larynx; or, in other words, at
the level of the cricoid cartilage.
For ligation of the common carotid the patient's head should be thrown
well back, with the chin turned toward the opposite side. A small pillow or
roll of cloth under the nape of the neck enables the surgeon to keep the
patient in this posture. An incision of two and a half or three inches
with its centre corresponding to the level of the cricoid cartilage should
be made along the anterior edge of the sterno-mastoid muscle. When the
fascia and the platysma-myoid muscles have been divided and the fibres
of the sterno-mastoid become visible by the dissection, the margin of the
latter muscle must be turned outward and the angle between it and the
9mo-hyoid muscle, with its obliquely ascending fibres, found. If the omo-
hyoid is pulled inward and the sterno-mastoid outward, the sheath of the
artery, with very possibly the descending branch of the hypoglossal nerve
upon it, will be seen. The sheath will also be recognized by its slipping
sideways between the finger and the vertebrae behind, and by the pulsating
Vessel within it. The external and anterior jugular veins should be drawn
aside, if in the line of the dissection. When this cannot be done, they may
be tied and divided. The sheath is then opened toward the tracheal side
Of the artery, which is isolated with care, and the needle passed from with-
ºut in Ward, in order to avoid injury to the internal jugular vein lying on
the outer side of the artery. This operation ties the common carotid
*y just above the omo-hyoid muscle, which is the better situation for
application of a ligature.
º: º below the omo-hyoid, make a three-inch long incision just in
e anterior margin of the lower third of the sterno-mastoid
muscle. Detach the inner portion of the muscle from the clavicle and
turn it outward. The Omo-hyoid and the sterno-hyoid muscles will thus
294 D IS E A SES OF T H E A R T E R IF. S.
be exposed. These are to be pulled apart by hooks, when between and
below them will be seen bulging upward the sterno-thyroid muscle. The
finger thrust down between the lower part of the omo-hyoid and the sterno-
thyroid, which is on a lower plane, will feel the artery beating in its
sheath.
FIG. I. 20.
%:
%.
g
gº ºf
#/.
%
|
. | % %
\º/ % % * 22escenden &
t %) º * % i\\?\ºš º ^s \ ºº::
% % * % % y - § % <---------sh; * * * * tº tº º ſº tº sº sº º tº sº sº sºº v-º-Ozzo- o/d
l!/ % 4% %” S.C.222//d
2.2% aróczy
% *% t
%
º; --- / !.
ºs-s------Intjugular
s *'' peºai,
2.
:
:
26.
2.*
*
i
Af
ºZ.
.2.*2%
ºz%
ź%
•e&
%&& *%
&%
Žg
*
:
ſ
%
|
%
ſº
ń.
sº
%
º-º º
&
Sº t
º,' ‘....Sººº... ºff.
§ % %. tº #} ***. s f <<
%. Aft/" '}; # , ,
%% 4% # * :::::::#"
g
• & (,, , , "," “.
777,
.re Aarºer ož’ AS/
./Musſočá. Žºrža
Ligation of the common carotid artery. (BRYANT.)
It may be necessary to incise the sterno-thyroid in order to expose fully
the sheath, which is then opened and the aneurism needle passed around
the artery from without inward. In both operations the branch of the
hypoglossal nerve should be protected from injury as much as possible.
INTERNAL AND ExTERNAL CAROTID ARTERIES.—The common caro-
tid artery should not be tied for a lesion of the external carotid or its
branches when there is room between the bifurcation of the common
trunk and the lesion to allow the safe application of a ligature to the
external carotid. Ligation of the internal carotid should be performed
in many conditions which formerly have been treated by tying the com-
mon carotid trunk."
For ligating the internal carotid an incision two and a half inches long
with its centre about half an inch above the upper border of the larynx,
should be made a little oblique to a line drawn from the sterno-clavicular
joint to the tragus of the ear. The vessel will be found along the edge of
the sterno-mastoid muscle. The hypoglossal nerve crosses the vessel about
an inch above its origin, and the descending branch of the same nerve
will probably be found running down the artery. The hypoglossal nerve
1 See Dr. John A. Wyeth’s Prize Essay on- this subject. Trans. American Med. Asso-
ciation, 1878. *



































POST E R I O R TIB [A L A R T E R Y . 295
and the digastric muscle, which also crosses the artery, should be drawn
upward and the ligature passed from without inward, avoiding constric-
tion of the internal jugular vein and the pneumogastric nerve on the outer
side, the external carotid on the inner side and the hypoglossal nerve
superficially.
The external carotid, which also is crossed by the hypoglossal nerve
and digastric muscle, may be tied by a similar incision, but it must be
remembered that this artery is placed a little nearer the middle line of
the neck than the internal carotid.
If a large branch is given off near the point of ligation, it also should
be tied.
ANTERIOR TIBIAL ARTERY.—A line drawn down the front of the
leg from the inner side of the head of the fibula to a point midway be-
tween the two malleolar prominences marks the direction of the anterior
tibial artery. The vessel, throughout its course, lies along the outer
margin of the anterior tibial muscle. It is deeply placed upon the front
of the interOsseous membrane, at its upper part; but it gradually becomes
superficial as it descends to the ankle, where it is found immediately under
the deep fascia. It can be quite readily tied in its middle third by an
incision, three inches long, made a little obliquely to the line given above.
The operator, before incising the deep fascia, can usually define the inter-
muscular space bounding the outer border of the anterior tibial muscle,
by a yellowish-white line of fat showing through the deep fascia. The
deep fascia should be divided just as the
skin and superficial fascia have been ; after FIG. 121.
which the space between the anterior tibial
muscle and the long extensor of the toes
should be torn open with the finger or end
of the grooved director. This procedure
will expose a third muscle, the extensor of
the great toe, lying between the two just
mentioned and at a lower level. Search in the
bottom of the fissure between this extensor
of the great toe and the anterior tibial
muscle will reveal the artery, with the an-
terior tibial nerve lying to the outer side or
a little in front. It is possible that the ex-
tensor of the great toe may have its origin Ligation of anterior tibial artery.
from the fibula lower than usual, then the (SMITH.)
Vessel will be found in the same manner,
but between the anterior tibial muscle and the long extensor of the toes.
The operator must remember to keep close to the outer margin of the
anterior tibial muscle. If he mistakes the proper intermuscular space he
Will fail to reach the vessel. Passive motion of the great toe, of the
smaller toes, and of the ankle joint will enable him to distinguish the
Various muscular bellies in the wound.
PošTERIOR TIBIAL ARTERY.—The course of this artery is indicated
by a line drawn from the middle of the popliteal space to a point midway.
between the tip of the inner malleolus and the anterior border of the
*ndon of Achilles. The vessel, when it gets behind the inner malleolus
9turves forward and goes to the sole of the foot. Behind the malleolus it
* Covered only by the skin and the superficial and deep fascias. The
deep fascia is very thick because of fibres prolonged from the lateral liga-
*nt of the ankle-joint. Ligation of the artery at this point is readily

296 L) IS E A S ES OF T H E A R T E R IB S.
effected by a crescentic incision of two inches in length, situated half an
inch behind the malleolus, with its concavity toward that bony projec-
tion. A single large nerve, the posterior tibial, is usually found on the
posterior or heel side of the artery; sometimes there are two small nerves,
one on each side. The tendons of the posterior tibial muscle and long
flexor of the toes lie in front of the artery—that is, nearer the malle-
olus; the tendon of the long flexor of the great toe behind it and deeper.
Occasionally the artery bifurcates into the two plantar arteries before
reaching the sole; in such a case the two vessels may be tied.
FIG. I. 22.
* * * *
§ º
; , , - *
4 * * 3. * w * *
... :- ‘ZZ . . . . . sº
*=~ * %, ,,,, , , :'' wº *...}
- | | | ||
Ligation of posterior tibial artery. (BRYANT.)
In the middle of the leg the posterio-tibial artery lies beneath the gas-
trocnemius and soleus muscles and upon the posterior tibial muscle and
the long flexor of the toes. It is separated from the soleus by a septum
of the deep fascia and has the posterior tibial nerve lying on the outer or
fibula side. The artery can be ligated from the side of the calf as fol-
lows: Lay the leg on its outer aspect with the knee flexed and the heel
raised to relax the calf muscles. Make an incision of four or five inches,
parallel to and half an inch behind the inner margin of the tibia. If the
gastrocnemius is seen, draw it away from the tibia and expose the soleus;
if it is not seen, the soleus will be exposed at once. The soleus is then
to be cut from its attachment to the tibia by carrying the knife, with its
edge directed against the bone, along the entire length of the cutaneous
incision. By drawing the cut muscle outward the surgeon will uncover
the septum of deep fascia that lies over the artery. The vessel can be
seen or felt beneath this fascia about an inch from the edge of the tibia
and is readily uncovered by incising the fascia, which may be thick, with
the knife.
The operator may mistake the gastrocnemius for the soleus because the
incision was made too far from the tibia, or he may cut too close to the
tibia and, therefore, fail to recognize the soleus and, as a result separate
not only it but the deeper muscles from the tibia and get down to the
interosseous membrane.
The knife should be held with its edge toward the bone in order not to
make an oblique section of the soleus. There is an intramuscular septum
in the middle of the soleus which is parallel to the septum of deep fascia
under which the artery lies. This may mislead the surgeon, who will


EXT E R N A L A N D C O M M ON I L I A C A R T E R IE S. 297
think he has cut entirely through the muscle when he has only gone half-
Wà.W.
Feworx, ARTERY.—The common femoral artery and the upper part
of its continuation, the superficial femoral, have their course indicated by
a line drawn from a point mid-
way between the anterior superior FIG. I 23.
spine of the ilium and the sym-
physis of the pubes, where the
pulsation can always be felt, to
the prominence of the internal . . . . .
condyle of the femur. This line " ,---- --
bisects Scarpa's triangle, running
from the centre of the base |º
through its apex. Scarpa's tri- , ...)—º
angle is bounded by Poupart's 6 - *NSY
ligament above, the Sartorius
muscle externally, and the long
adductor muscle internally. The t
apex of the triangle at the point Ligation of femoral artery. (SMITH).
of junction of these muscles is on
the inner side of the thigh. The vein corresponding with the arteries
lies upon their inner side except near the apex of Scarpa's triangle, where
it passes behind the artery, and finally gets to the outer side. The ante-
rior crural nerve is on the outside of the arteries, and at a distance,
except near the apex of the triangle, where one of its branches lies close
to the vessel. It is well to remember that in fat persons the fold of the
groin is a little below Poupart's ligament, and does not, as in lean
patients, correspond with the ligaments.
The superficial femoral artery is to be ligated where it is crossed by
the Sartorius muscle at the apex of Scarpa's triangle, which is about four
inches below Poupart's ligament. The thigh should be everted and an
incision three or four inches long made at this point, a little oblique to
the line of the artery, avoiding the internal saphenous vein. When the
inner border of the sartorius is recognized by its fibres passing obliquely
downward and inward, the proper landmark or guide has been found.
The edge of this muscle should be turned up and under it will be discov-
ered the sheath of the artery, running in the direction indicated by the
line already mentioned. The vein will probably be a little behind the
artery, though on its inner side. The ligature should be passed from
Within outward. The artery is so superficial that its pulsation can usually
be felt through the tissues before the first incision is made.
The common femoral artery is readily secured by making an incision
two inches long parallel to Poupart's ligament, and a half inch below its
Centre. . Some lymphatic glands may require pushing aside when the
Superficial fascia is being divided; after which incision of the deep fascia
Will disclose the sheath of the artery. The vein is on the inner side of
the artery, hence the ligature should be carried around from the inner side.
ExtERNAL AND CoMMON ILIAC ARTERIES.—The course of the com-
Ill Oll iliac artery and its direct continuation, the external iliac, is indicated
by a line drawn from the left side of the umbilicus, on a level with the
top of the iliac crest, to a point midway between the anterior superior
Špine of the ilium and the symphysis of the pubes. The upper third of
this line corresponds with the common, the lower two-thirds with the
°xternal iliac ; though this proportion often varies, because the bifurca-

298 D IS E A SES OF T H E A R T E R IB S.
tion of the common trunk into external and internal iliac varies in
location.
The common iliac has the peritoneum just in front of it and is crossed
at its lower end, near the point of bifurcation, by the ureter. The rectum
as it descends into the pelvis also crosses the left artery. The lower part
of the common and the entire length of the external iliac lie along the
inner border of the great psoas muscle. The common iliac vein on the
left side of the body lies at the inner side of the artery; on the right
side it is behind the artery at its lower part, and on the other side above.
This may be memorized by the fact that each common iliac vein lies on
the right side of the corresponding artery.
The external iliac arteries are covered by the peritoneum, and have the
veins lying internally and the genital branch of the genito-crural nerve
lying externally. Near Poupart's ligament the external iliac is crossed
by the was deferens and the spermatic vessels, and gives off two branches.
It must not be tied here.
The external iliac artery is reached for ligation by a crescentic inci-
sion of four or five inches in length, with its convexity downward, begin-
ning an inch above and an inch outside of the middle of Poupart's
ligament, and ending at a point an inch above the anterior superior iliac
spine. This will probably cut the superficial epigastric artery, which will
require tying. The tendon of the external oblique muscle, which is ex-
posed, must be divided to the same extent as the skin, either with the
knife's edge held perpendicular to its surface, or upon a director.
FIG. 124.
Lines of incision for (A) common iliac, (B) external iliac, (C) femoral arteries.
(STIMson.)
The fibres of the internal oblique and transversalis muscles must be
divided in the same way. If it is preferred, the last may be divided on
a grooved director. The transverse fascia is now exposed. It may be
thick and white or thin and transparent. It should be carefully torn

EXT E R N A. L. A. N. D. C.O M M O N II, I A C A R T E R IES . 299
through with the forceps and fingers, when the bluish, though rough
looking, outer surface of the peritoneum will be seen crossing the bowels.
The operator with his finger loosens this serous membrane from the
front of the iliac fossa and vessels; beginning at the external end of the
wound, where the attachment is least strong.
FIG. 125.
*... • * *
* *
Zee/fascća.
* *
w g
* º:
* ** , ,
SSÉ
Saráortºs zuscſº-sº
* *...*.
**
gº
A .* ...'."
2’ %.
2 ozz 25'aft/en a º
..º.
22*7°22&
A.
Ligation of external iliac and femoral arteries. (BRY ANT.)
The assistant, who, during the incision was pressing on the belly wall
to make the muscles tense, now puts a broad spatula into the wound and
draws the peritoneum inward. -
. The artery and vein in a sheath of fascia will now be felt along the
inner border of the belly of the psoas. After the sheath has been
Opened, the aneurism needle is carried around from within outward.
The incision given should be carefully followed as to length and curve
through its entire depth. It should not go nearer the middle line lest it
cut into the external abdominal ring, nor lower, lest it open the inguinal
canal or cut the deep circumflex iliac artery. When the director is pushed
under the tissues it should be kept longitudinal, so as not to puncture
deeper layers unawares. It is wise not to incise all the way to its end,
lest the peritoneum be folded over the extremity and thereby be wounded.




300 D IS E A SES OF T H E A R T E R IB S.
The common iliac artery can be reached by an incision similar to that
used for the external iliac, but beginning an inch higher and extending
about two inches further upward toward the last rib. The muscles and
transversalis fascia are divided in the same manner as just described.
When the peritoneum is pushed inward the ureter and spermatic vessels
are carried with it, as they adhere to its outer surface. The artery can
then be felt near the promontory of the sacrum. The needle should be
carried from right to left on each side of the body, as the vein lies to the
right of the artery in each instance.
The ureter might be tied instead of the artery if the operator is not
careful, and in case of high bifurcation of the common iliac the ligature
might in error be applied to the external iliac artery.
INTERNAL ILIAC ARTERY.—This vessel extends from the bifurcation
of the common iliac at the Sacro-iliac junction to the top of the great
sacro-sciatic foramen with the ureter and peritoneum in front, its vein
and the sacral plexus of nerves behind. It is ligated by an incision sim-
ilar to that for tying the common iliac.
These methods of reaching the common and internal iliac arteries are
somewhat complicated and difficult because of the great depth of the
wound. It is a question whether a laparotomy in one of the semilunar
lines with ligation of the vessel through the peritoneum is not simpler,
and therefore easier and safer.
ARTERIAL VARIX OR VARICOSE ARTERIES.
Arteries may become dilated and elongated, presenting a condition
similar to varicose veins. The term arterial varix is generally applied
to such a pathological change if the
artery affected be a large vessel, such
as the temporal, facial, or iliac, while
to similar dilatation of the terminal
subcutaneous arterioles of a normal
diameter of about one-fiftieth of an
inch the term cirsoid aneurism has
been applied. I shall discard the
latter name, since the condition
has no pathological resemblance to
aneurism, and use the term arterial
varix, or varicose artery, for dilata-
tion and elongation of prečacisting ar-
teries of any size, provided their pre-
existence can be demonstrated clinic-
ally or microscopically. When there
is a development of new vessels with
arterial characteristics, it is proper
to call the mass or tumor an arterial
angeioma. It may at times be diffi-
- cult to determine clinically whether
Arterial varix of the palm and fingers. the pulsating growth is composed
(AGNEw.) principally of new vessels or prečx-
isting ones.
A varicose artery in addition to being generally dilated, may show
irregular pouches or sacculations. The middle tunic especially is thinned

A. R. T E R I A. L. W. A. R. I X O R. W. A. R. I. C. OS E A R T E R I E S. 301
until the artery looks like a vein ; hence the blood current may become
very sluggish. The cause of the change is probably some obscure vaso-
motor disturbance leading to loss of muscular tone in the middle coat.
Atheroma seems not to be a factor in the causation.
Arterial varix is exhibited as a pulsating tumor with an irregular,
nodulated surface, which usually shows the position beneath the skin of
the dilated arteries. When the hand is applied to the tumor a vi-
bratory thrill is felt that in some cases resembles the wriggling of a
mass of worms. Pulsation may be distinct and is more general than
the limited pulsation felt in aneurismal varix or arterio-venous fistula
between vein and artery. Auscultation reveals a blowing or cooing
murmur. Pressure upon the afferent artery stops all movement and
murmur. If there are several arteries, pressure on one merely dimin-
ishes these signs. When the disease affects a number of small arterioles
the tumor has a spongy feel, and the outline of the vessels is not traceable
through the skin. If an arterial varix shows no tendency to increase in
bulk, and is not threatening hemorrhage from inflammatory and ulcera-
tive processes, it should be let alone. If treatment is demanded, excision
or ligation should be done in the manner described in the section which
discusses angeiomas. This is better, and probably safer, than injection
with coagulating fluids.
C H A P T E R X W II.
DISEASES AND INJURIES OF BONES.
PERIOSTITIS.
CAUSES.—Periostitis, or inflammation of the fibrous membrane cover-
ing the exterior of bones, is caused by injuries, such as contusions, and by
certain constitutional conditions, such as rheumatism, gout, and especially
syphilis. Agnew believes that it may be due to violent traction of muscles
inserted into the periosteum. The vessels of the periosteum, of the bone,
and of the medulla are continuous through the ramifications of Haver-
sian canals and spaces. Hence, inflammation of one of these structures
is usually associated with inflammation of the other in the same locality.
As ostitis is really an inflammation of the medulla within the bone spaces,
it may be the cause of periostitis, and periostitis may similarly be the
cause of ostitis or of myelitis.
PATHOLOGY..—The pathological changes seen in periostitis are conges-
tion, thickening, and softening of the membrane due to rapid cell-prolifera-
tion and accumulation of the wandering blood cells. The deepest layer
of the membrane, which is that which causes bone growth, is especially
active in cell formation ; hence, the membrane is raised from the bone by
a subjacent exudate and becomes easily detachable. The bone imme-
diately beneath the inflamed area also becomes inflamed and softened to
a limited extent. If resolution occurs, this exudate is absorbed, and the
elevation, or node, caused by the cells and fluid beneath the periosteum
disappears. At other times, the inflammation does not subside so easily ;
this new material becomes organized into bone, and there is left a per-
manent change in the contour of the skeleton. The entire bone may be
enlarged if the periostitis is wide-spread. Flattened bony elevations or
modes are of frequent occurrence after syphilitic periostitis, and often aid
in establishing the constitutional causation of later obscure lesions in
other parts and tissues. In periostitis, if pyogenic bacteria be present,
suppuration may take place between the membrane and bone, giving rise
to subperiosteal abscess, also called cortical osteomyelitis, and secondarily
causing superficial necrosis of the bone in the vicinity. Periostitis of
syphilitic origin occurring in the later stages of this constitutional disease
is more prone to suppuration than when it occurs earlier. In diffuse Sup-
purative periostitis the membrane is separated from a large surface of
bone, and the vessels going to the bone are injured and stretched and be-
come the seat of thrombosis. The surface of the bone, therefore, becomes
necrotic. If there is concurrent suppurative inflammation of the marrow
in the medullary canal, which is not infrequently the case, the necrosis
will involve the entire thickness of the bone and not merely the Outer
surface. Death from pyaemia may occur in such conditions. Subperi:
osteal hemorrhages are sometimes found. This bleeding may be mechanical
and due to forcible and rapid dissection of the membrane from the bone
by the sudden inflammatory exudation. Acute infective periostitis is a
P E RIO STITIS. 303
variety of suppurative periostitis and is liable to be followed by septi-
caemia or pyaemia. It is usually associated with acute infective Osteo-
myelitis, and is, of course, due to bacteria, probably the bacteria of or-
dinary suppuration.
SYMPTOMS.–The symptoms of circumscribed periostitis, which is by
far the most common form, are pain, often worse at night, tenderness on
pressure, heat of the surface, circumscribed swelling and, perhaps, local
oedema. Persons whose occupations require them to work at night and
sleep in daytime may have more pain during the day than at night. The
deposition beneath the membrane may cause the parts to feel baggy or
puffy on strong pressure with the fingers. The swelling has not abrupt
edges, but gradually reaches the level of the surrounding surface. The
pain is often excruciatingly severe and of a throbbing character. Red-
ness of the surface occurs late and sometimes at no time during the pro-
gress of the inflammation. The tibia, clavicle, ulna, and cranial bones
are very frequently the subjects of syphilitic periostitis. Diffuse perios-
titis, which is probably usually infective, is very rapid in its course, while
the circumscribed variety is often a disease of slow development and
progress. The former attacks particularly the long bones of tuberculous
persons in early life, and is accompanied by violent constitutional dis-
turbance. In this violent periosteal lesion chills, high fever, and delirium
occur, and are accompanied by rapidly-spreading inflammation of the
limb, which is shown by great pain, swelling, Oedema, and enlarged veins
from obstruction to deep circulation. Ostitis, endositis, epiphysitis, and
even arthritis often follow in its train. Death from septicæmia or pyaemia
is not uncommon. Diffuse suppurative periostitis of the digital phalanges
is often called whitlow or felon.
The diagnosis of circumscribed periostitis is easy. It is usually syphil-
itic when not traumatic. The diffuse or suppurative form may be mis-
taken for diffuse cellulitis, but, as a rule, it does not extend beyond the
joints at the extremities of the bone affected. Suppurative cellulitis fre-
quently passes beyond joints. From rheumatism, periostitis is dis-
criminated by the swelling, which is not apt to be situated at the joints,
and by the evidences of suppuration in the purulent form of periostitis.
Acute infective periostitis is often mistaken for rheumatism, and must be
remembered as a possibility when such violent general symptoms, in
young persons, are associated with pain about the tibia and femur.
TREATMENT.-The treatment of acute periostitis of a sthenic type
should consist of cathartics and diaphoretics combined with anodynes.
The asthenic cases demand iron, quinine, and stimulants with concen-
trated food and anodynes. Locally, leeches, lead water and laudanum,
and moist antiseptic dressings should be employed in the acute form ;
tincture of iodine and blisters in the more chronic cases.
As syphilis is probably the commonest cause of non-traumatic periostitis
full doses of iodide of potassium should be administered. The dose
should not be less than 10 grains three times a day after meals, and may
be increased to 30 or 40 grains in a rebellious case. As this lesion is a
manifestation of the later stages of syphilis, the iodides are possibly more
efficacious than mercury. The two remedies may be combined. The
pain of syphilitic periostitis, often called syphilitic neuralgia, can fre-
Quently be promptly cured by these large doses of potassium iodide.
When the pain of periostitis of any origin does not promptly subside,
free incision of the tense fibrous periosteum is the proper surgical remedy.
The tension due to the subperiosteal exudation is thus removed, and as a
304 D IS E A SES A N D IN J U R IF S OF B O N E S.
consequence pain is relieved, resolution favored, and the danger of sec-
ondary necrosis lessened. In non-suppurative cases the incision is to be
done subcutaneously by passing a tenotome through the skin in one or
more places and incising the periosteum freely and deeply in every direc-
tion by pushing the knife as far under the tissues as the handle will allow.
In suppurative periostitis free incision must at once be made through the
skin and other tissues directly down to the bone. If the bone becomes
necrotic notwithstanding this line of treatment, it should be removed as
soon as the patient can bear the shock. Some reproduction of bone may
subsequently take place from the shreds of the periosteum not destroyed
by the violent inflammation and from the medullary tissue in the inter-
stices of the living bone. If great destruction occurs from involvement
of the medullary membrane and the joints amputation may be demanded.
OSTITIS OR OSTEOMYELITIS.
CAUSES.— Ostitis or osteomyelitis may arise from contusions of bone,
fractures, amputations, and other injuries, and from various constitutional
deteriorations and mycotic affections such as rheumatism, syphilis, tuber-
culosis, and low fevers.
PATHOLOGY..—Inflammation of bone is pathologically identical with
inflammation of the soft tissues, for it is the soft or animal tissue in the
Haversian spaces, canaliculi, and lacunae of the bone that undergoes the
morbid process. The earthy constituents cannot inflame; they only show
the impress of the alterations induced in the vascular and other living
tissues. When the inflammation affects the soft structures within the
spaces mentioned the term ostitis is used; when the marrow in the medul-
lary canal is the seat of these changes the term myelitis or endostitis is
used. As ostitis is usually, if not always, associated with myelitis, sur-
geons now use the word osteomyelitis almost exclusively, having dropped
to a great extent the word Ostitis, except when speaking of chronic in-
flammations, when ostitis is still used to some extent.
The increased vascularity of inflammation is followed by softening of
the bone, due to absorption of the earthy structures and the filling of the
vascular canals and spaces with embryonic cells and migrating blood
corpuscles. The coalescence of numerous canals and spaces by the ab-
sorptive process exerted on their walls, makes the bone much more porous,
while the increase in cellular elements gives it a soft and spongy charac-
ter. This process has been called “rarefying ostitis,” or “dry caries,”
because the bone is eaten away as if ulcerated, but without any pus for-
mation. Changes in shape of long bones or vertebrae, due to this process,
occur, hence the name “deforming ostitis.” This is the change that
occurs when aneurisms cause absorption of the bone, when sequestrae are
loosened, and when the ends of broken bones are rounded off. The inflam-
matory cellular infiltration or exudate may be absorbed and the ostitis
may thus be terminated by resolution without leaving permanent change.
This is possible only in the early stages, or in a very mild degree of in-
flammation.
More frequently the cells become converted into Osseous tissue, which,
though formed in the widened Haversian canals and medullary spaces,
encroaches upon the calibre of these channels so much that they become
smaller than they were originally. Thus the bone becomes harder, more
compact or ivory-like, and, as a consequence, heavier than it was previous
OSTITIS OR O S T E O MY E LITIS. 305
to the occurrence of ostitis. This is the pathological nature of most cases of
chronic ostitis. As enlargement takes place both in diameter and length
during the stage of softening and Swelling because of the coincident perios-
titis and epiphysitis, an inflamed bone which is thus sclerosed becomes of
greater bulk as well as harder than it was previously. This sclerosis or
* condensing ostitis” may be found accompanying “rarefying ostitis” in
the same specimen.
The osteomyelitic inflammation may terminate in softening and degen-
eration which will cause the so-called “cold * or “chronic abscess” of
bone. The puriform fluid contained in such cavities is not true pus. It
is well to remember that such abscesses are probably always due to the
tubercle bacillus. When they occur in syphilitic persons it is possible
that the syphilitic taint favors infection with the tubercle bacillus. Pus
from inflamed bone contains oil globules in considerable numbers and is
due to infection from pus bacteria. Septic osteomyelitis is then the con-
dition. This last process is acute. Ulceration of bone, termed caries,
and mortification of bone, called necrosis, may follow ostitis. The various
stages and results of ostitis may often be found in different parts of the
same bone. When repair takes place after deforming ostitis, tubercular
ostitis or traumatic ostitis after fractures, the process is one of Ossification
of granulation tissue which fills in the gap. It is simply a bony trans-
formation of scar tissue. This process is well shown in some cases of
curvature of the spine cured without the formation of puriform discharge.
Acute inflammation of the bone and marrow may be traumatic; or it
may occur without visible injury, and is then called spontaneous osteo-
myelitis. In the latter case it is usually diffuse; in the former case it
may be diffuse, but frequently is not so. In acute diffuse osteo-myelitis
the marrow is injected and swollen, purple or marked with red, yellow,
and purplish streaks, and protrudes in a fungous mass from the medullary
canal when the bone is sawed. Oil and pus escape from the canal when
it is opened. Abscesses and thrombosis of veins are found in the tissues
surrounding the diseased bone; bacteria are found in the marrow and
other structures, and pyaemic abscesses frequently arise secondarily. It
may occur in short or flat bones as well as in long bones, and is due to
mycotic infection. The microörganism or microörganisms are probably
those known as pyogenic. The periosteum is often involved in a similar
inflammation, but not necessarily so. The bones are in severe cases
stripped of periosteum and become necrotic from one epiphysis to the
other. Separation of the epiphysis from the shaft is common, and is
due to destruction of the intervening cartilage.
SYMPTOMS.–The symptoms of ostitis are with difficulty differentiated
from those of periostitis and myelitis, with which the former affection is so
frequently accompanied. In the early stages the symptoms are often very
indefinite. Dull aching or gnawing pain, especially severe at night and
Varying with the conditions of the weather, is a common symptom in
chronic ostitis, and the inflammatory signs spoken of in the discussion of
periostitis will probably be observable in the later stages.
Enlargement of the bone without much change in its outline was
formerly thought to be characteristic of ostitis, but it is due largely
to the concurrent periostitis. In ostitis, unaccompanied by much peri-
ºstitis, irregular flattened swellings on the surface of the skeleton change
the contour greatly. Some of the increase in size in these inflammations
is apparent, being due to the overlying soft tissues. A feeling of weak-
ness and heaviness in the limb is frequently described by the patient.
*
306 D IS E A S E S A. N. D. IN J U R I ES OF B O N E S.
Lücke has employed percussion with a small rubber-tipped hammer
to determine the existence and exact seat of Osseous inflammations.
Corresponding parts are struck and the existence of increased sensibility
determined; and then its superficial or deep location estimated by the
forcé required to develop tenderness. There is greater dulness on percus-
sion when the bone is compact, or infiltrated with inflammatory exudations,
than elsewhere.
- Left knee higher than right,
Superficial ulcer.
Internal malleolus on a level
|Malleoli on different levels. with external malleolus.
Š(ºj
Hypertrophy of tibia from syphilitic ostitis (inherited).
Acute inflammation of the bone and marrow, called acute Osteomye-
litis, or acute infective osteomyelitis, may be associated with a similar
periostitis, and when it occurs without a recognized injury is often mis:
taken for rheumatism. The sudden development of fever with chills and
delirium, accompanied by severe pain in the limb of a person So Young
that the epiphyses have not yet become united to the shafts, should be
carefully examined and watched. If redness and oedema occur, and espe:
cially if crepitation from inflammatory destruction of the epiphyseal
cartilage is developed, or if the joint is involved, the diagnosis of infective
osteomyelitis is confirmed. Abscess under the periosteum and muscles,
necrosis, septicæmia, and pygemia are later symptoms. Thickening of
the bone and early ossification of the epiphyseal cartilage will probably
occur in cases of only moderate severity. This disease is most frequently
found in the long bones of the lower limb; and occurs before ossification
of the epiphyseal cartilages, which is not completed in the tibia and femur
until about the twentieth year.
TREATMENT.—The treatment of ostitis is almost identical with that of
periostitis. If medical remedies fail a deep periosteal incision should be
made, which may be at once, or subsequently, followed by longitudinal
section of the bone with a Hey's saw or the circular saw of the surgical

N E C R O S IS OR M O R TIFICATION OF B O N E . 307
engine. This incision should be deep enough to go into the cancellated
structure or medullary canal of the bone. Cutting out one or more disks
with the trephine answers a similar purpose in relieving tension and pain,
and is often better, even if there is no abscess cavity in the bone to be
curetted.
Acute infective periostitis and Osteomyelitis must be met by early and
free incision of soft parts and periosteum, down to the bone, and thor-
ough disinfection of the diseased tissue with antiseptic solutions. Corro-
sive sublimate solution (1:1000 or 1: 2000) is probably the best ; but it
must be watched if repeated daily, so that it may not produce toxic effects.
Beta-naphthol solution may be used in its stead. Free drainage and anti-
septic washing of the cavity daily are essential. Separated epiphyses
should be kept in position by splints; dead portions of bone removed and
the patient kept alive by tonics, good food, and stimulants until the force
of the mycotic poison has been exhausted. When the infective inflam-
mation does not involve the periosteum to any extent, but is limited to
the bone and marrow, the general treatment is the same as in associated
periostitis and osteomyelitis.
The local treatment consists in boring into the bone with a trephine and
scraping out with a curette the inflamed suppurating marrow. If neces-
sary, more than one trephine opening may be made, or two or more such
holes may be connected by cutting away the intervening bone with a
chisel. Complete removal of the diseased tissue and disinfection of the
cavity are the indications.
Necrotic bone should be removed when it becomes loosened from the
living Osseous tissue. This is usually a secondary operation, unless trephin-
ing and curetting have been done in the early stages. The latter opera-
tions are indicated as soon as a probable diagnosis is made. It is better to
operate too early than too late. Amputation may be required to save life
in infective osteomyelitis and periostitis.
NECROSIS OR MoRTIFICATION OF BONE.
DEFINITION.—Necrosis is death of bone in masses or in bulk, in con-
tradistinction to caries, which is death in minute particles. It is pathologi-
cally identical with mortification or gangrene of soft tissue.
CAUSES.—Necrosis is caused by anything that at once destroys vitality
of bone, such as intense heat or cold, crushing pulpefying injuries; and
by whatever prevents the continuance of the blood circulation through
the Haversian canals and their ramifications, thereby interfering with the
bone's nutrition. Obstruction of these blood spaces by the exudate of
Ostitis, and detachment of the periosteum or inflammation of the marrow
by reason of suppurative inflammation of these structures, are the most
Common direct causes of necrosis. Osteo-myelitis, whether central (endos-
titis) or cortical (periostitis) is probably the most frequent cause. They
act by interfering with proper blood supply, which is arrested by stretch-
ing, compression and thrombosis of the vessels. Syphilis and tuberculosis
may, by inducing ostitis, act as remote causes. The depressed vitality of
old age and of eruptive fevers, division or embolism of the nutrient artery
of a long bone, and exposure to the fumes of phosphorus are occasionally
Causes of mortification of bone. If a piece of bone is torn loose from its
Periosteal attachments, as happens in compound fractures, necrosis is not
apt to occur, unless the wound is infected with putrefactive or pyogenic
308 D IS E A S E S A. N. D. IN J U R I ES OF B O N E S.
germs. This proves that it is the septic character of a given periostitis
that inclines it to cause necrosis.
PATHOLOGY..—The occurrence of necrosis more frequently in compact
than in cancellated osseous structure is due to the greater ease with which
the circulation is obstructed in the former unyielding structure. The
usually dry condition of the dead bone shows the dependence of this
necrosis on deprivation of blood supply. If death occurs in cancellated
tissue, which is normally more vascular than the compact, the necrotic
tissue, especially when the destruction is sudden, is moist instead of dry.
The moist form of necrosis is seldom seen except in military practice,
and then usually in the cancellated portions of bones. It is liable to
occur as a sequence of severe gunshot contusion of bone or compound
fractures, and is evidently the result of septic infection of some sort. The
dead bone has a dirty-gray or greenish-brown color, is moist and soft and
emits a very offensive odor. The periosteum is usually found in a slough-
ing condition, and shows little tendency to form new bone. Death from
pyaemia is a common result of moist necrosis.
In the ordinary variety of necrosis the devitalized bone is dry and hard,
and has a relatively large proportion of mineral constituents. When
struck with a probe it often gives a sonorous note, but is not sensitive to
touch, nor does it bleed. Its color is yellowish-white, unless it has become
blackened by contact with putrid pus or other agents. The necrotic
action may pertain to the surface of a bone (superficial necrosis) to a por-
tion some distance below the, perhaps healthy, bone surface (central
necrosis), or to the entire thickness of the bone (total necrosis).
FIG. 128.
Central necrosis, showing new bome and cloacae.
After osseous tissue has died, it is separated from the living bone by
the process of rarefying ostitis or ulceration, exactly as gangrenous parts
are separated from soft tissues. The adjacent bone becomes inflamed,
softened, and ulcerated, and soon a line of demarcation appears. It re-
quires a long time, varying from weeks to months, according to the extent
and situation of the necrosis, to effect complete detachment. Very often
pus infection occurs and suppuration takes place between the dead and
living bone. During the accomplishment of this process the overlying
periosteum becomes abnormally active in producing bony tissue, probably
because of the induction of a chronic periostitis, and deposits a layer of
new bone. This new bone may form a covering over the necrosed part,
or, if the latter is central, increase the thickness of the surrounding living
bone. In this manner the devitalized bone is usually, by a process of
invagination, enclosed in a bony sheath or involucrum of irregular shape,
which, however, conforms somewhat to the outline of the original bone.
If the periosteum has previously been entirely destroyed, no invagination
occurs. The dead portion of bone enclosed in the sheath is called the
sequestrum, while the leaf-like portions detached in cases of superficial

N E C F O S IS OR M O R TIFICATION OF B O N E . 309
necrosis are termed exfoliations. In cases of total necrosis the endosteum
may also furnish new bone, so that the dead structure lies between two
layers of newly-formed Osseous tissue. There is usually no invagination
in necrosis of the skull or of the cancellated bones.
Through the living bone, whether original or newly formed, which
covers the sequestrum, narrow channels or fistules, called cloacae, are es-
tablished by the discharge, formed at the line of demarcation, making its
way to the surface. These cloacae communicate with sinuses extending
through the overlying soft parts of the cutaneous surface, which sinuses
are the remains of collapsed abscesses that were developed soon after pus
formed in the bony structures.
The surfaces of a sequestrum or exfoliation are usually rough and
jagged, because the living bone has been eaten away from it by rarefying
or suppurative ostitis. The external surface of an exfoliation is some-
times quite smooth, since it may have been originally the normal surface
of the bone. The sequestrum may be dense or spongy, according as it
has been sclerosed or rarefied before death. After some amputations of
the thigh in which the nutrient artery has been divided, necrosis of the
area of bone nourished by this artery occurs, while the regions nourished
by other vessels coming from the periosteum and endosteum remain
healthy. As a result, a tubular or cylindrical sequestrum is formed and
may, when finally detached, be pulled out from the sawn end of the bone.
93 unches
Cylindrical sequestrum from femur.
SYMPTOMS.—The early symptoms of necrosis are those of ostitis fol-
lowed by inflammation, and often of suppuration of the overlying soft
parts. Through the openings or sinuses left after the evacuation of the
pus, a hard and more or less rough surface can usually be felt with the
probe if the necrosis is superficial. This is the dying or dead bone un-
Covered by periosteum. Bare bone, however, is not necessarily dead bone,
for after periostitis and ostitis of a simple kind we may have an ulcerated
surface of bone that is slow in healing. In cases of central necrosis the
probe must be passed through the sinuses in the soft parts and the cloacae
in the involucrum or sheath before the rough sequestrum can be felt.
Until sinuses and cloacae have been formed it is practically impossible to
diagnosticate necrosis from ostitis or tubercular caries and abscess. The
fever and other constitutional symptoms may be marked during this early
stage, but are apt to decrease in severity with the evacuation of any puru-
lent accumulation which may become thereafter the seat of putrefaction
from germ infection. From time to time, however, exacerbations of the
Symptoms may occur, and new abscesses may form. The symptoms during
this, the dying stage, are more chronic in progress when necrosis happens
in Spongy bone. When the osseus tissue is killed at once the symptoms
of this stage are absent.
The stage of separation, as the period occupied in detaching the dead
structure may be termed, has characteristic features.
Chronic discharge from the cloacae and overlying sinuses, increased

310 D IS E A S E S A N D IN J U R IES OF B O N E S.
thickness of the bone and gradual impairment of health, if the disease is
extensive, are the most prominent. Symptoms of waxy degeneration of
the liver or kidneys may arise. The time occupied in separation varies
from a few weeks to many months; being shorter in the upper limb than
in the lower and when the necrosis is superficial or circumscribed than
under opposite conditions. That separation has been accomplished is
known by the motion that can be communicated to the sequestrum by a
probe passed into the openings. This is sometimes better determined by
introducing two probes, one near each end of the sequestrum. Sometimes
the sequestrum is not movable, even when completely detached, because
it is imbedded in the granulations on the inner surface of the sheath." If
this condition is suspected a strong probe should be used to force the
sequestrum down upon the granulations until they are flattened and the
cavity enlarged. Motion can probably then be detected.
PROGNOSIS.—The prognosis in necrosis as to final restoration of the
usefulness of the part is generally good, except in acute septic cases. The
disease seldom extends beyond the epiphyseal cartilages, and, after re-
moval of the dead bone, the sinuses heal, leaving, however, some deformity
in contour. Death at times does occur in the early stages, as, for example,
in cases following acute Septic osteomyelitis or periostitis; so also exhaus-
tion from prolonged suppuration or pyaemia may lead to a fatal issue.
Again, death may result from secondary implication of other structures.
This is illustrated by brain disease following necrosis of the skull, arthritis
subsequent to disease of the patella and laceration of the femoral artery
by necrotic spicules from the femur. Pyaemia from moist necrosis is not
uncommon ; but fortunately this form of bone disease is quite rare.
TREATMENT.-The indications in the first stage are to moderate accom-
panying inflammation by treating thoroughly the causative Osteomyelitis
or periostitis, to open abscesses early, and to keep up the general health.
A blister will sometimes hasten suppuration and thus be beneficial. Early
incision of the periosteum is often valuable, since it relieves pain and tends
to prevent extensive destruction of this membrane and the bone by sup-
puration. So trephining the inflamed bone and scraping away the diseased
medullary tissue are valuable operative procedures. Disinfectant solu-
tions should be freely employed to allay fetor; and all cases should be
treated with rigid antiseptic measures. As soon as the dead bone is loose,
it should be removed by operation. An exfoliation can be lifted away
with a chisel after simple incision of the musculo-cutaneous coverings.
When the bone has been devitalized by caustics or burning, and the dead
area is easily determined, there is no objection to cutting it away with the
chisel even before detachment has taken place, for it hastens the cure. A
sequestrum should seldom be removed until it is entirely loose. To effect
its removal an opening should be cut in the encasement by means of
small sharp chisels and a hammer, or with a saw or trephine, until the
sequestrum can be seized with strong forceps and pulled out. Sometimes
the cloacae simply need enlargement; at other times the bridge of new
bone between two of them must be cut away. The surgical engine, by
which circular saws and burrs can be rotated with great rapidity, may be
very useful in these procedures.
After application of the Esmarch apparatus an incision should be
made in the line of the principal sinuses and cloacae, and the exposure of
the bone will then enable the surgeon to determine upon the proper
method of reaching the necrotic piece. The encasement should be freely
cut, but in such a manner as not to weaken the bone more than necessary,
N E C R O S IS O R. M. O. R. T.I. FIC ATION OF B O N E. 311
nor to fracture it transversely. Occasionally it will be found easier to get
the sequestrum out after it has been divided into portions by the bone-
cutting forceps. The cavity left is generally lined with granulation tissue,
but in tubercular subjects its walls may be carious. Such carious bone
should be scraped away with a gouge. In getting access to the seques-
trum, the surgeon should not feel compelled to follow the sinuses or cloacae;
any safe path of attack which gives best opportunity for thorough removal
is justifiable.
After the operation is completed the wound should be stuffed with dry
antiseptic gauze, the limb. enveloped in a similar dressing, and a roller
bandage firmly applied to the parts before the elastic band of the Esmarch
apparatus is removed.
Subsequently to this operation, called sequestrotomy, the encasement
contracts, new bone is formed in the cavity of the sheath, as well as under
the preserved periosteum, and the sinuses and cloacae become closed. The
medullary cavity, if destroyed, is, as a rule, not reëstablished.
There are some circumstances in which it is probably better to operate
before detachment of the sequestrum is complete, notwithstanding the
possibility of thus tearing away portions of the living bone. This is the
case in acute necrosis from sub-
periosteal abscess and septic osteo- FIG. 130.
myelitis and in moist necrosis; f/sºu.A
SKIN -Yº,
for more extensive destruction of
the periosteum and septicæmic
complications may perhaps be
obviated by early excision of the
dead structures by means of saws.
The periosteum should be peeled
off and preserved in these opera-
tions so that the flail-like limb,
often left, may have an oppor-
tunity of becoming solidified and
useful. An objection of some
force against waiting too long for
separation in ordinary chronic dry gangrene is the very great thickness
of the encasement that occurs. Three to six months is probably long
enough to wait in the majority of such cases.
Small pieces of healthy periosteum or of bone, taken from man or the
lower animals and kept aseptic, have been inserted in the gaps left by
extensive operations of this kind. Such bone chips act as centres of bone
formation, thus hastening and perfecting the regeneration of the removed
shaft. It is absolutely essential that the cavity from which the seques-
trum has been taken be made perfectly aseptic by the removal of every
particle of diseased bone, diseased granulations, and discharge. Herein
lie the difficulty and frequent failure of the method. These osteo-plastic
operations deserve further trial in cases in which the bone has been exten-
sively destroyed.
The methods of performing sequestrotomy, adopted before the advent
ºf modern antiseptic surgery, gave good results; though the healing of
the remaining wound was very prolonged. It was always the seat of pro-
tracted suppuration. Septic complications were, however, uncommon;
because the dense inflammatory infiltration of the surrounding osseous
and other tissues rendered septic absorption difficult, and the open wound
With rigid bony walls made drainage thorough and perfect.
Diagram of a transverse section, showing
relations of sequestrum, involucrum, fistula
and skin. (GERSTER.)


312 I) IS E A S E S A N D IN J U R I ES OF B O N E S.
Antiseptic surgery has much shortened the process of healing by
making possible the implantation of cellulo-cutaneous flaps and the
organization and ossification of aseptic blood-clots.
|FIG. 131.
Neuber's method. Top of involucrum removed, skin flaps turned into the bottom of the
bone cavity. (GERSTER.)
Implantation of cellulo-cutaneous flaps may be done in order to cover
the fresh surface of living bone, left after cutting away all diseased bony
structure, and thereby obtain primary
union between the bone and the turned-
in cutaneous flaps. This leaves little or
no bony surface to heal by granulation
and hastens cicatrization; though, of
course, a defect is left in the contour of
the part. This defect would also occur,
even if the process of implantation was
not adopted. The turned-in flaps are
held in position by sterilized mails driven
through the flap and into the bone, and
by sutures passed through the skin at the
edges of the cavity and carried across
the gap; or by sutures carried through
the edges of the flaps and then brought
out and tied upon the opposite side of
the limb. These different methods are
shown in the cuts from Gerster. The
nail and sutures are removed at the end
Implantation of cutaneous edges of three or four weeks; which, if the
into the defect by transfixing catgut wound has been made and kept aseptic,
suture. (GERSTER.) will probably be the date of first
change of dressing.
The utilization of the blood-clot to aid in rapid cicatrization is accom-
plished by allowing the cavity to fill with blood, which clots and protects
the wounded bone and other cut surfaces from septic irritation. The
clot must, however, be kept aseptic and moist. This is done by covering
the cavity with its contained clot with a piece of aseptic or antiseptic
rubber-tissue, just large enough to overlap the borders of the wound.
This is in turn covered with a voluminous dressing of dry sublimate
gauze. The rubber tissue keeps the blood-clot moist, the dry antiseptic
dressing absorbs all leakage of blood and serum.
FIG. I32.


CARIES, or TU BERCULAR U LG ERATION OF BONE. 313
This method of Schede is only possible when the entire mass or all the
masses of necrotic bone are removed, when all the pus-infected membrane
and granulation tissue lining the irregular tracks and cavities have been
scraped away with absolute certainty, and when the cavities so made have
been thoroughly sterilized by sublimate solutions and wiped clean with
aseptic sponges. Gerster recommends sublimate lotion (1 : 500) to be first
used, and to be subsequently washed away by a weaker sublimate solu-
tion, so that toxic effects may not follow the retention in the wound of
small quantities of the strong lotion.
FIG. I.33.
DRESS/NGS'.
Schede's method. Diagram showing relations of organizing blood-clot. (GERSTER.)
If it is impossible to remove a sequestrum, excision of a portion of the
bone or of the joint may be demanded. When the destruction of bone
has been very great, or the patient is already sinking from exhaustion,
due to long-continued bone-disease, amputation may be the most judicious
treatment.
CARIES, OR TUBERCULAR ULCERATION OF BONE.
PATHOLOGY..—The inflammatory disintegration or erosion, called caries,
is a process similar to ulceration in soft tissues, for the destroyed structure
is removed in small particles, usually in a more or less liquefied form.
In this circumstance caries differs from necrosis, in which the devitalized
portion of bone is separated from the surrounding living Osseous tissue in
masses. Caries, therefore, corresponds with ulceration of soft tissues;
necrosis with gangrene. As there is clinically a gangrenous ulceration of
the soft parts, in which the two processes are combined, so there may be a
necrotic caries of bone. Caries occurring without formation of pus is the
so-called rarefying ostitis, or dry caries, which has been mentioned when
Ostitis was discussed. The form of caries most often seen is that in which
the inflamed bone softens and disintegrates and causes the so-called “cold
abscess” within or upon the surface of the bone. It is due to infection
With the tubercle bacillus, and results from the breaking down of cheesy
tubercles and inflamed bone.
Caries is the result of bone inflammation, and therefore depends upon
the constitutional causes that induce ostitis. Ostitis is seldom, if ever,
followed by liquefying caries unless the part is infected with the tubercle
bacillus. Caries is often associated with inherited or acquired syphilis,
but it is possible that syphilis may not be the actual cause of the caries,
but simply a cause of lowered resistance which makes tubercular infection

314 D IS E A SES AND IN J U R I ES OF BO N E S.
easy. The cancellated tissue found in the extremities of the long bones
and in the vertebrae, carpus, and tarsus is especially subject to the invasion
of caries in those predisposed to this disease; but it may occur in any
part of the skeleton. In tubercular persons it often follows injury. An
ulcer of the soft parts may involve the periosteum and bone, and lead to
caries.
Caries causes bone to become softened, porous and friable, and of a
gray or brownish color before it breaks down into granular semi-liquid
material. Sometimes the mineral constituents are dissolved out in the
early stages of caries leaving the animal matter almost intact, so that the
condition resembles that of a bone after maceration in hydrochloric acid.
The organic constituents are destroyed subsequently. The removal of
the disintegrated area by absorption and liquefaction leaves irregular
hollows and cavities, called bone ulcers, which are occupied by the puri-
form products of the destructive process. The bone around the carious
focus is apt to become indurated, because Nature endeavors to construct
a barrier to the advance of the diseased action. If, however, the repara-
tive power of the patient is poor, and he, from some inherent constitu-
tional tendency is especially liable to bone disease, no such induration or
Sclerosis occurs, and the carious destruction spreads, involves the joints,
and attacks adjacent bones.
FIG. 134.
Caries of bone.
The products of carious destruction consist of oil globules, degenerated
cells, blood corpuscles, granular inorganic particles, and bone salts, with
which are found the bacillus of tuberculosis. The products are the results
of cheesy degeneration and emulsification of the Osseous tissue. Small
masses of necrosed bone will sometimes be found in the liquid, where the
two processes, caries and necrosis, have coexisted. Caseous masses, or
tubercles, will be found in the interior of the bone tissue, but the surface
of the bone is usually involved, either primarily or secondarily, and
localized periostitis and inflammation of the overlying soft parts arise.
As a rule, a puriform collection, or “cold abscess,” subsequently occurs
in the tissues over the bone, which spontaneously opens and affords an
avenue of escape for the liquefied bone material. So long as the carious
disintegration continues to furnish a discharge, the sinus, left by the col-
lapsed abscess, will not permanently close. Septic and pyogenic infec-
tion frequently occurs secondarily, and contributes to this condition. The
sinus may cicatrize superficially, because but a small amount of fluid is
formed in the depths of the track, but as soon as a few drops collect the
tissues inflame and the orifice reopens. Very occasionally, as in some
cases of caries of the vertebral bodies, so little discharge is furnished that
it is entirely absorbed, leaving no caseous or puriform deposition. These
may be called cases of dry caries.
Bone ulcers heal, as do ulcers in soft parts, by granulation and cicatriza-
tion. The loss of tissue is partially or entirely replaced by a granulation

CARIES, OR TU BERCULAR U LC E RATION OF BONE. 315
tissue which undergoes ossification. The attempts of nature to fill up the
cavities left after caries with scar tissue may be quite successful, so far as
utility of the parts is concerned, if the destruction has not been very
great; but depressions, though with rounded margins, are usually left. . A
great deal of bone is often formed in the endeavor to fill up deep cavities,
which remains in the form of protuberances and bridge-like masses. The
granulation tissue by which cicatrization is often effected may in turn be-
come infected with the tubercle bacillus, and be, therefore, useless as a
reparative agent, because of its continuing indefinitely to undergo cheesy
degeneration.
SYMPTOMS.–The early symptoms are necessarily those of ostitis and
periostitis, or of both, and are followed by those of “cold abscess” of the
soft parts. When this puriform collection has been evacuated, either
spontaneously or by incision, the cavity does not promptly heal, but
leaves a sinus which discharges thin puriform fluid continuously or
intermittently. A probe passed down this sinus will come in contact
with the bared and roughened bone, if the track is not too crooked to be
followed to its bottom. The carious surface of bone is, as a rule, not
tender when touched with the instrument, but it may bleed. If it is im-
possible to feel the diseased osseous tissue with the probe, the diagnosis
may be made by persistent failure to effect permanent healing of the
sinus, for which no other cause exists, and by chemical examination of
the fluid showing a large amount of calcium phosphate. The discharge
is often offensive in odor because of putrefactive infection, and contains
gritty particles of bone. If there is much disease, several sinuous tracks
with characteristic orifices surrounded by a little elevation of granulations
will probably be found converging toward the same region of bone.
When the overlying tissue has been ulcerated away, the diseased bone
will be exposed to view, though covered in places more or less completely
with fungous granulation tissue. Coxitis, angular curvature of the spine,
called Pott's disease, and the various forms of joint disease, formerly
called white swelling, are instances of caries or tuberculosis of bone.
When caries attacks bones near the joints, or involves the articular
ends of the bone, as it often does, ankylosis is likely to occur, because of
inflammatory involvement of the joint structures. On the other hand,
the tubercular synovitis may occur first, and lead secondarily to caries of
the bone by first involving the articular cartilages.
TREATMENT.—Iodide of iron, cod-liver oil, combinations containing
phosphoric acid, good food, healthy surroundings, sea air, and similar
therapeutic and hygienic agents are essential factors in the management
ºf tuberculosis in bone. Even stimulants may be required. Antisyph-
ilitic remedies are often required in full and long-continued doses, but
combined with tonics.
In the early stages while the disease is active, cleanliness, disinfection
of the parts, and the prevention of external sources of irritation or infec-
tion are the indications for local treatment. Rest of the parts, complete
and constant, is imperatively called for, especially when the vicinity of
* Joint is affected. This is to be obtained by preventing motion by
*ºns of gypsum or silicate of sodium splints, by permanent extension, and
similar mechanical appliances. This does not necessarily imply that the
Patient must be kept in the house or in bed. Confinement is often dele-
terious while open-air exercise is valuable.
When liquefaction of the tubercle occurs free incision should be made
for the escape of the fluid, and the whole of the diseased and softened
316 I) IS E A S E S A N ID IN J U R IES OF B O N E S.
bone should cut away with gouges. This should be done antiseptically
and the resulting cavity dusted with iodoform. When the cavity is in-
accessible or very large it may be injected with solution of iodoform in
ether (1:20). Of this from 1 to 3 fluidounces should be used and then
Squeezed out after it has been brought in contact with the whole interior
of the cavity in the bone and soft parts. The possibility of iodoform
poisoning must be recollected, if large quantities are used in cavities, such
as those of psoas abscess, where it is difficult to press out the excess of fluid.
Cure can often be hastened by the early operative removal, even before
liquefaction has occurred, of the soft, devitalized bone and fungous gran-
ulation tissue, which impede repair, Natural processes can effect the
removal of this material only after the lapse of many weeks or months,
and the protracted discharge necessitated not only debilitates the patient,
but has a tendency to cause waxy degeneration of the liver and kidneys.
Sulphuric or hydrochloric acid diluted with equal parts of water has
been recommended to dissolve away the softened bone. It may be injected
into the sinuses or brushed upon the surfaces exposed by a flap incision.
If the bone can be reached by incisions not too extensive, scraping
away the spongy and devitalized Osseous tissue, and the fungous granula-
tions, is more prompt and sure. To do this effectually Esmarch's appa-
ratus should be applied to prevent hemorrhage obscuring the view. With
a gouge, chisel, scraper, or the rotating burr of the surgical engine the
surgeon removes the unhealthy structures. The operation should be dis-
continued when healthy bone is reached, which is recognizable by its
comparative hardness, and the hemorrhage occurring from its surface.
When the healthy bone is of nearly the consistency of the diseased parts
it can be recognized by the pink color due to its vascularity. The cari-
ous bone when washed with water will be white, gray, or black. The
possibility of general tuberculous infection from the tuberculous area
leading to acute tuberculosis and death, is a factor strongly pointing to
operative removal of the local tuberculous focus when it can be readily
and safely done.
In extensive caries, excision, arthrectomy, or amputation may become
necessary, but these capital operations should not be done hastily, since
caries is a disease of chronic type. The lapse of a few months devoted
to a general constitutional treatment and local measures may change a
hopeless looking limb or joint into one that will be much more serviceable
than any artificial one. The possibility of fatal exhaustion from the
long train of progressive bone disease may lead one to amputate at a
rather early date. Passive motion of joints affected with tuberculosis
may be cautiously begun, when cure seems to be fully instituted by the
absence of heat, pain, and discharge, and even when some discharge is
present, if it is small in amount.
While believing that tuberculosis of bone or other tissues may be the
local disease from which general infection of the patient may occur, I am
still sure that cure of the local disease and subsequent freedom of the
patient from other tubercular infections are not infrequently obtainable
without operation. It is here that good judgment and experience are
valuable.
CENTRAL CARIES OR TUBERCULAR ABSCESS OF BONE.
The process usually called circumscribed “suppuration " of Osseous
tissue, or “bone abscess,” is probably more common than is usually Sup-
TU B E R C U L A. H. A. BSC ESS OF B O N E . 317
posed. Such collections of puriform fluid are instances of caries and are
probably always due to the tubercle bacillus. They may occur in any
part of a bone, but are more common in the cancellated structure of its
extremities. The head of the tibia is the common site. These tuber-
cular collections within the structure of the bone must not be confused
with abscess in the medullary canal and suppurative Osteomyelitis, which
is a different pathological condition. The cavity may be lined by a soft
membrane, or its walls may be roughened carious bone. Sometimes
there is a narrow track or sinus leading from the cavity to the exterior
of the bone, which in such a case would possibly have a carious surface;
but often the pus is completely enclosed in a bony prison. The symptoms
are usually very chronic in their progress and resemble those of ostitis,
which is to be expected, as so-called abscess is merely a consequence of
tubercular ostitis. Long-continued Osseous pain distinctly localized, es-
pecially if near the extremity of a long bone and severe, should always sug-
gest abscess. Circumscribed myelitis, necrosis, and cysts within the bone
structure may give somewhat similar symptoms, but the treatment is
similar in all these conditions and a differential diagnosis is not very
important. Accompanying periostitis may add its symptoms to those of
bone abscess.
Treatment affords prompt relief from pain, and consists in dissecting up
the soft tissues and periosteum and applying the trephine to the bone at
the most tender spot, so as to open the cavity, to give vent to the puriform
fluid, and to permit curetting of the interior. If the inner surface of the
wall is carious, it should be cut away with the gouge or burr; if necrosis
exists the sequestrum should be re-
moved. If no pus-like fluid is found
the trephine may be applied at an-
other spot, or better, perhaps, a drill
may be made to perforate the bone in
Various directions from the bottom of
the first trephine hole.
Trephining should always be done
early, as it is at once followed by cure
if a puriform collection is present. If
no fluid is present the operation does
no great harm, and will probably ame-
liorate symptoms by decreasing tension.
If no collection of pus-like fluid is
found in the body of the bone it is well
to bore into the marrow cavity before
desisting, as it is possible that a chronic
medullary abscess may be the cause of
the symptoms. The wound is to be º
wº º and dressed antiseptically. Bone abscess in which trephining was
tan * abscess nºy QPen Spon dome; but the abscess was not discov-
eously into a neighboring joint, ered at the operation. a. Trephine
°ºusing, arthritis. This is another wound. (Pacº ARD.)
"eason for early operation. Acute ab-
* of the medullary canal, or acute infective osteomyelitis, has been
discussed in the preceding section.
º
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3.18 I) I S E A S E S A N D IN J U R I ES OF B O N E S.
EPIPHYSITIS.
Inflammation of the cartilage situated between the shaft of a bone and
its epiphysis occurs at times in children, especially in those of low vitality.
The inflammatory bone conditions already discussed are apt to be asso.
ciated with epiphysitis, though it is possible that it may be primary in its
origin. The symptoms are similar to those of periostitis and arthritis,
except when separation of the epiphysis and the preternatural mobility
and crepitus there evoked show the loss of the uniting cartilage. Close
scrutiny will usually prevent confounding epiphysitis with arthritis. The
symptoms, prognosis, complications, and treatment are similar to what
has been detailed in the consideration of Ostitis. Early and free incision,
even if no pus is suspected, is good surgery. Even those cases that
recover without extensive destruction of tissue are apt to show subsequent
arrest in development of the bone, because the Osteogenetic function of
the cartilage has been impaired. Tonics and nourishing diet are neces-
sary in all cases.
HYPERTROPHY AND ATROPHY OF BONE.
General increase of a bone in length and thickness, to which the name
hypertrophy is often applied, is in most cases an inflammatory enlarge-
ment due to chronic ostitis, periostitis, and epiphysitis. Even after the
inflammatory process has subsided the bone retains its increased dimen-
sions. This is not hypertrophy in the true
FIG. 136. pathological sense. Hypertrophy may occur,
- however, when unusual functional demands
are made upon a bone. An instance is seen
in the increased size and strength of the fibula
occurring when the tibia has been destroyed
by necrosis.
The fibula, being gradually called upon to
support unaccustomed weight, becomes hyper-
trophied from increased functional activity.
A localized increase in bulk of a bone is more
properly called an Osteoma or bony tumor.
Hypertrophy of bone in itself neither demands
treatment nor is amenable to it. Exostoses
and other forms of osteoma may be excised if
disfigurement or other reasons make operative
treatment desirable.
Atrophy of bone is said to occur in two
forms, in both of which there is decreased
weight. In one variety the bone becomes
º smaller in size, with simultaneous absorption
º of the cancellated and compact tissue, and
diminution of the calibre of the medullary
\
||
|
;4.
}
i
|
t º canal. This change occurs after long disuse,
Senile atrophy of head and as in stumps after amputation, and in joints
neck of thigh-bone. (GRoss.) where ankylosis, dislocation, or paralysis has
long existed. It is observed most frequently
in the long bones, and is a not uncommon senile change, which, when
occurring in the neck of the femur, may produce shortening of the limb

S OF TEN IN G O F BO N E. 3.19
and lameness, and thus simulate fracture at that point. As such localized
atrophy, which is frequently associated with fatty degeneration, may hap-
pen after injuries, the practical knowledge of this possibility is great.
Some cases of so-called atrophy of bone may be imperfect development,
due to unrecognized or forgotten injuries or disease of the epiphyseal car-
tilages in early life. In the other form of atrophy the bulk of the bone
is not altered, but the compact Osseous tissue gradually becomes rarefied
and changed into cancellated structure, whereby the bone becomes very
light and brittle, and is easily broken by slight injuries.
The distinction between atrophy on the one hand and interstitial absorp-
tion and fatty degeneration of bone on the other hand is perhaps not suffi-
ciently observed. The absorption of bone or rarefying ostitis due to
pressure of tumors, for example, does not appear to be an instance of
atrophy in as true a pathological sense as the disappearance of the alve-
olar process of the jaw after loss of the teeth. It is true that in the
former case the thinning and erosion may be due to interference with
circulatory and nervous supply, causing atrophic change ; but the dimin-
ution of structure following disuse corresponds more nearly with the idea
of atrophy.
Treatment is of no avail in curing Osseous atrophy. In cases where
the function can be restored, as in ankylosis of long duration, the bone
may, however, regain some of its lost bulk.
OSTEOMALACIA. SOFTENING OF BONE.
This very rare affection, also called mollities ossium, seems to be a gen-
eral disease, though the chief changes are found in the skeleton. Its
nature is exceedingly obscure. Some authors have suggested a possible
identity with fatty degeneration, malignant degeneration, or atrophy of
bone. Others have called it rickets of adults, since it resembles rickets,
but has been observed only in adults.
The clinical characteristic of the disease is progressive softening of the
bones, which become so soft that a knife can readily cut them. At the
same time they lose weight and are either flexible or easily broken.
Various portions of one bone, and as a rule many parts of the skeleton,
are affected. The external compact portion becomes little more than a thin
shell, while the cancellated structure has become more spongy than
normal and filled with a reddish, gelatinous, fatty material. The earthy
constituents of the bone have been removed by a process of decalcifica-
tion, and a sort of mucoid degeneration of the animal portion of the
Osseous structure has apparently occurred. The medullary tissue is at
the same time very vascular. Lactic acid has been described as found in
the bony tissue and in the urine.
Osteomalacia is more frequently seen in women than in men and seems
to be induced by pregnancy. It is a disease of adult life. The pro-
longed administration of lactic acid has been mentioned as a possible
Call Se.
The symptoms are pain of a rheumatoid character and a tendency of
the bones of the extremities or trunk to bend like softened wax. If the
Compact Outer tissue of the bone is not much decalcified, however, brittle-
ness instead of flexibility will be present and fractures from slight injuries
Will frequently occur. The urine usually contains a remarkable amount
of phosphates, evidently derived from the degenerating bone tissue.
320 D IS E A SES A N ID IN J U R IB S OF B O N E S.
Phosphates have been found also, it is said, in the saliva, tears, and other
fluids. Albuminuria has been observed. The patient finally becomes
bedridden, because locomotion is impossible, and dies exhausted. Osteo-
malacia, unlike rickets, is painful, never occurs in children, and progresses
until death occurs. The softened bones of rickets usually become hard
again; such is not the case in osteomalacia. There is no efficient treat-
ment known. Phosphates of lime, sodium, and potassium with cod-liver
oil and tomics should be administered. Bedsores should be expected, and
prevented if practicable.
TUMoRS IN BONE.
Bones may become the seat of tumors of various kinds, such as sar-
coma, Osteoma, chondroma, fibroma, angioma, myxoma, and hydatid cysts.
It was formerly believed that carcinoma was a not infrequent growth in
Osseous tissue. Such is not the fact. Except when it occurs secondarily
to carcinoma in other structures this form of neoplasm is practically
unknown in bone. Sarcoma, however, is common. True cystic tumors
are seldom found except in the jaw bones, where they are at times devel-
oped from the mucous membrane of the antrum and the structures about
the teeth. Tumors containing fluid found in other bones, unless hydatid
cysts, are, as a rule, sarcomas, chondromas, or myxomas which have under-
gone cystic degeneration. Vascular tumors, that is to say, angiomas,
are occasionally seen ; but the pulsating tumors formerly described as
aneurisms of the arteries in bone are probably always highly vascular
S8. I’COID 3'S.
Tumors of bone may be developed from the lower layer of the perios-
teum or from the medulla or endosteum. Periosteal growths are usually
oval or pyriform in shape, of a smooth surface, and have a capsule derived
from the periosteum. The adjacent bone may be normal, hardened, ab-
sorbed, eroded, or fractured. The growth, if malignant, may spread to
the medulla by the Haversian canals. Endosteal or central tumors are
usually spherical, smooth on the surface, and when handled may give rise
to a crackling sound. The enlargement of the growth causes disappear-
ance of the bone, but the periosteum becoming inflamed constantly forms
new layers of bone tissue. These are absorbed in turn, but new plates
of Osseous tissue are continually developed. Thus the mass acquires a
more or less bony capsule, and when the patient is examined a crackling
sound is elicited by the motion imparted to the membrano-Osseous encase-
ment. This is the explanation of the apparent dilatation of the bone
and the parchment-like crackling elicited by pressure.
Non-malignant growths in bone do no harm, as a rule, other than to act
as impediments to motion, and to cause deformity. They may be excised
with chisels and saws if such action is demanded by the disability or dis-
figurement. Sarcomas spread into the surrounding parts and involve dis-
tant structures by secondary involvement through the blood-current.
Amputation, early and at a considerable distance above the disease, is
always demanded.
& INJURIES OF BONES.
Bone, together with its periosteum and marrow, may receive contused,
incised, lacerated, and punctured wounds. Such wounds of bone are fre-
quently obtained in war from bullets, balls, sabres and arrows, and occa:
sionally are seen in civil practice. Fractures are lacerated wounds of
F. R A CT U R ES, 321
bone, and are common everywhere. Osseous wounds are followed by peri-
ostitis, ostitis, and osteomyelitis, which may be localized or diffused. The
wounds should be treated as similar wounds of soft parts and their Se-
quences on the principles detailed in the section on diseases of bone.
Fractures, which are wounds or solutions of continuity, usually involving
the entire thickness of the bone injured, will be discussed in the following
section of this treatise. Contusions of bone may become of grave import,
when a viscus, such as the brain, within the bony case, is simultaneously
or secondarily involved, or when atrophy of the bone, as in the neck of
the femur, is so induced. The induction of Osteomyelitis by contusion is
another serious complication of what may seem a trivial injury.
Bending without fracture occurs at times in very young bones or in
those softened by rickets or osteomalacia. The treatment is to bend
them forcibly into proper shape, or to do so gradually by means of well-
padded splints or the elastic tension of rubber straps. Muscular action
or the elasticity of the bone may correct such deformity in children with-
out much treatment. The surgeon should not hesitate to straighten such
bones by making a complete fracture if there is a probability of perma-
ment deformity.
FRACTURES.
DEFINITION.—A fracture is a sudden breaking or tearing apart of
Osseous fibres; in other words, a lacerated wound of bone.
A solution of continuity due to disease or to division by saws or sharp
instruments is not a fracture, though in its treatment and mode of repair
it may be similar. The term fracture is also applied to breaking of car-
tilaginous tissue.
CAUSES.–For the production of a fracture an exciting cause must
always be present, but certain characteristics of the patient or of the
special bone may act as predisposing causes. The atrophy of bone occur-
ring in old age and in the subjects of locomotor ataxia, osteomalacia,
rickets, and malignant diseases of bone, are efficiently predisposing causes,
for they render the bony tissue less able to resist strain. Syphilis and
tuberculosis have been called predisposing causes, but probably on insuffi-
cient evidence. General paralysis of the insane seems to be associated
with brittleness of bones. This is probably due to atrophic changes in
the Osseous structure. Stimson states that the greater fragility of bone in
the aged is to be attributed to senile atrophy, and not, as is often asserted,
to a greater relative proportion of inorganic material. A bone, by reason
of its exposed position, its curves, its function as a lever, or its small pro-
portion of compact osseous tissue, may be more liable to suffer fracture
than the adjacent pieces of the skeleton. On the other hand, a flat,
movable bone, surrounded by muscles, such as the scapula, is very unlikely
to be broken.
The exciting causes of fracture are external violence and muscular
action. External violence is said to act directly when the bone is broken
at the point of impact. It is a crushing force that causes disruption of
the Osseous fibres in these cases. Gunshot fractures and fractures caused
by kicks and by falling timbers are thus produced. External violence is
Said to act indirectly when the fracture occurs not at the point struck,
but at some distant part of the skeleton. The force is transmitted thither
through the intervening bones, and tears the bony fibres apart by lever-
age, torsion or traction. Muscular action is not a very frequent cause of
21 •
322 D IS E A SES A N D IN J U RIES OF B O N E S.
fracture except in fracture of the patella. That powerful muscular con-
tractions may cause fracture of long bones is proved by instances occur-
ring in athletic persons during efforts of throwing or lifting. Similar
injuries have been reported as taking place during tetanic or epileptic
spasm of muscles. Fracture of the patella, olecranon, of the posterior end
of the calcaneum and of the coracoid process of the scapula is usually
due to powerful muscular action.
Breaking of the patella by contraction of the four-headed extensor of
the leg may possibly be at times rendered more easy on account of lever-
age action exerted upon the bone as it lies in contact with the condyles of
the femur. Stimson, however, believes that it is usually a giving way, as a
rope, from direct traction, exerted by the muscle. The muscles, by hold-
ing the bones in fixed positions, may indirectly assist external violence in
causing fractures. This will be understood by considering that a cadaver
thrown from a height is less likely to sustain fracture than is a living
body.
Fºcure occasionally take place in the uterus; due usually to violence
inflicted upon the foetus by injuries received upon the abdomen of the
mother. A rachitic foetus is prone to suffer such Osseous lesions from com-
paratively slight force. It is possible, however, that some supposed intra-
uterine fractures are really instances of defective ossification.
VARIETIES.—There are two kinds of fractures; the open and the
closed. The open fracture is one in which the broken surfaces are ex-
posed to atmospheric contact by reason of a communication with the
FIG. 137.
FIG. 138.
º
º
º \,\!
St. -
l;
Diagram of comminuted fracture. Impacted fracture of neck of ſemur.
(MUTTER MUSEUM.)
surface through a wound of the muscles, fascia, and skin. A closed
fracture is one with which no such wound coéxists, and which is therefore
protected from atmospheric influences. The former are often called com-
pound fractures; the latter simple fractures. As these terms are not


F. R A C T U R E S. 323
self-explanatory and are otherwise objectionable, they should be dis-
carded. Closed fractures are sometimes denominated subcutaneous frac-
tures. This use of the word, though convenient, is misleading, because it
seemingly implies that the fracture is an open one whenever the skin in
the vicinity of the fracture is laid open. Such is not the fact. Com-
munication with the air is the requisite of an open fracture; hence the
muscles and fascia, as well as the skin or mucous membrane, must be
perforated or divided.
The open character of a fracture may be due to the vulnerating force
causing laceration of the soft parts, to its continuance inducing protrusion
of the fragments, to the weight of the unsupported limb giving rise to a
similar protrusion, or to secondary ulceration and suppuration.
Open fractures are much more serious than closed fractures, because
pyogenic bacteria gain admission to the wound and suppuration generally
occurs about the ends of the fragments. Union is, therefore, less rapid,
and osteomyelitis of a severe type and septicæmia are more likely to
arise. The modern or antiseptic methods of surgery have rendered open
fractures as little liable to these complications as were closed fractures
formerly.
FIG. 139.
| t|
º
ſº
|
(a) Transverse fracture and (b) oblique fracture. (HAMILTON.)
. Yarious terms are applied to both open and subcutaneous fractures to
indicate the characteristics of the broken structure: A comminuted frac.
* is one in which several inter-communicating lines of fracture split
the bone into a number of Comparatively small fragments. If a bone is
broken at two or more different places and the lines of fracture do not
*n into each other, the injury is a double or triple fracture, not a com-
minuted one. tº º
In an impacted fracture one fragment is driven into the cancellated





324. D IS E A SES A N D IN J U R IES OF B O N ES.
structure of the other and firmly fixed there. It is rather rare, and can
only occur, as a rule, at the extremity of bones where there is much can-
cellated tissue. The lower end of the radius and the neck of the femur
are the localities in which it is likely to be seen.
In a transverse fracture the plane of fracture makes a right angle, or
at least an angle of not less than 70°, with the long axis of the bone.
Transverse fractures are rare, except in the patella and at the lower end
of the radius, and when observed are usually caused by either direct
violence or muscular contraction. They are probably more common in
children and the very aged than at other periods of life.
FIG. I.40. FIG. 141.
º
ſº
{ º
|É
|||ſº
i | º|
i
º
li
Tºlº"
w º i
s § |
|º#
i:.|
;
|º§
ºi§º:t|
º-iº-!
||
-;|.."- *
;ºg
.
#i
§
}:
;
Longitudinal fracture. (STIMSON.) Incomplete fracture of femur. (GURLT.)
Longitudinal fractures are those in which the line of fracture is not
further from the long axis of the bone than 15° or 20°. They are very
rare, except as accompanying such perforating fractures as are caused by
gunshot injuries.
Oblique fractures are those in which the line of separation is neither
transverse nor longitudinal. The majority of fractures are oblique.
A complete fracture of a long bone crosses the long axis of the shaft
and divides the bone into two or more pieces. A fracture of a flat bone
to be complete must involve its entire thickness. Under the head of in:
complete or partial fractures of long bones are included the so-called
“green-stick’ fractures, in which some fibres are torn and others bent,
fissures, separation of mere splinters, detachment of bony prominences,
and perforating fractures, such as are made by bullets. Indentations of
flat bones by forces not sufficient to cause fracture through the entire
thickness, are instances of incomplete fracture,
Incomplete fractures may become very serious injuries; for example,














F. R. A. CT U R E S. 325
fissures communicating with the marrow, if open to the external air and
infected with putrefactive or pyogenic germs, may be followed by
dangerous osteomyelitis. The injury sometimes called “sprain fracture,”
in which a small fragment of bone is torn away at the point where a
ligament is attached, is an incomplete fracture. , Rupture of the main
artery, laceration of the chief nerve, extension of the line of fracture into
a joint, dislocation, and other lesions may occur simultaneously with a
fracture and complicate the treatment.
A diastasis, or forcible separation of an epiphysis from the shaft of a
bone, presents the symptoms of a fracture, and requires like treatment.
Ossification of all the epiphyseal cartilages has usually occurred before
the twenty-fifth year; hence epiphyseal fracture or separation can rarely
happen at a later period of life than this. The line of separation is of
necessity usually transverse; and commonly some scales of bone are torn
from the shaft with the layer of cartilage. The innominate bone may be
separated by injury into its three primary segments by a similar separa-
tion through the cartilages. Arrested growth is not unusual after epiphy-
seal detachments.
|FIG. 142. FIG. 143.
W §
W §
§§§
R\\ \
Fissure of humerus. (GURLT.) Diastasis, or epiphyseal separation of the head
of humerus. (MooR.E.)
tº PATHOLOGY:-When a bone is broken hemorrhage occurs from the
arteries and veins in the Haversian canals and medullary cavity, and the
Periosteum is more or less extensively lacerated. The muscles and fascia.
about the seat of fracture are usually implicated in the violence, even in
closed fractures with little displacement; hence extravasation of blood in
and from the surrounding soft parts is common. The blood from the torn
sºft parts usually shows as a blue discoloration of the skin a few hours
after the inj ury. That effused from the osseous structure itself does not
*ach the surface for two or three days, because it can only leak through the


326 D IS E A SES A N D IN J U R IES OF B O N E S.
deep fascial coverings by means of small openings existing where nerves
and bloodvessels approach the exterior. By gravitating or travelling
under fascial or muscular layers it may appear quite far from the locality
of fracture.
The periosteal laceration may correspond with the line of fracture, but
this is uncommon, because the majority of fractures are oblique, and
in them the periosteum is apt to be stripped up from the bone in the
vicinity of the fracture before it gives way under the tension of the dis-
rupting force. This renders the line of tear irregular. In comminuted
fractures some of the fragments may be held in position by untorn peri-
osteum, while others are entirely denuded of this membrane. The latter
are not apt to become necrotic unless the wound is infected with micro-
organisms. Very occasionally it happens that a bone is broken and the
periosteum left intact or nearly so. Little displacement then occurs and
rapid cure without deformity is to be expected.
Around the locality of fracture inflammatory processes at once occur,
varying in intensity with the severity of the damage done to the bone
and the soft parts. The interference with return circulation caused by
the pressure of the inflammatory products may give rise to oedema of the
distal portion of the limb, even in cases of fractures of very moderate
gravity. The fever and other general symptoms depend on the type and
degree of the inflammatory action. Albumin, tube casts, and fat have
been observed in the urine of patients suffering with fractures, apparently
as a sequence of the Osseous injury."
The fragments of bone, except in cases of mere fissure, seldom retain
their normal position. Continuance of the injuring force for a moment
after the disruption of the bone has occurred, attempts to use the injured
member, as in walking, dropping of the unsupported limb below the
injury because of its intrinsic weight, and tonic or spasmodic muscular
contraction are all displacing causes. Fractures in children show less
displacement than those in adults, because greater elasticity of the bone
makes the line of fracture more irregular and therefore the fragments are
more apt to remain interlocked. Moreover, the periosteum is less com-
pletely torn and the muscles are less powerful.
Angular, rotary, transverse, or longitudinal deviation may occur at the
seat of fracture. Usually, however, the displacement is a combination
of these malpositions. Occasionally, as in some comminuted fractures,
the displacement is too complex in its nature to be classified under these
heads. As a rule, it is the distal fragment that occupies the abnormal
position. Transverse fracture of the patella, fracture of the olecranon,
and similar injuries afford exceptions to this rule. Angular displacement
or tilting, in which the axes of the fragments form an obtuse angle, is
typically represented in green-stick fractures and bending of bones, in
which, indeed, it is the only form of malposition possible. In rotary dis-
placement one fragment is twisted on its long axis. A good example is
fracture of the shaft of the femur in its upper third. Here the weight
of the limb usually rotates the lower part of the bone outward. When
one fragment is displaced laterally or antero-posteriorly, transverse devia-
tion exists. This form of displacement seldom happens except in com-
bination with one of the other varieties. It may occur alone, however,
in transverse and serrated fractures. If the ends of the fragments slip
1 Riedel, quoted by Stimson, Treatise on Fractures, 111.
F R A CTU. R. E. S. 327
past each other the muscular tonicity causes overlapping, unless an un-
broken parallel bone, as in the leg or forearm, prevents its occurrence.
FIG. 144. FIG. 145. FIG. I.46. FIG. 147.
(!, b
ſ |-
| w
s |
| t i
{ }= ==
}
Fig. 144.—Diagram of angular displacement.
Fig. 145 —Diagram of rotary displacement.
Fig. 146.-Diagram of transverse displacement.
Fig. 147.—Diagram of (a) longitudinal displacement; (b) impaction.
Longitudinal displacement is a change made in the long axis of the
bone. It consists in overlapping of the fragments, in penetration of a
broad fragment by a narrow one (impaction), or in actual crushing of the
Osseous structure into small pieces. In rare instances, as in fracture of
the patella and olecranon, the longitudinal deviation consists in separation
of the pieces of bone. This is dependent upon a powerful muscular
attachment to one of the fragments. Muscular action in nearly every
other fracture causes shortening. It is not always possible to predict the
character and extent of displacement that will occur in a fracture at a
given locality, for it depends on the direction and nature of the line of
fracture as well as on the muscular attachments and other above-men-
tioned causes of deformity. All the forms of displacement occur in a
marked degree in oblique fractures, while little deviation is seen, as a
rule, in transverse ones.
SYMPTOMS.–A case of suspected fracture should be examined as soon
as practicable after the receipt of the injury, unless the intensity of ner-
Vous collapse or some similar circumstance makes such examination more
hurtful than a few hours' delay in determining the exact character of the
injury. When a case is not seen until some days after the accident and
Very violent inflammation has already supervened, it may be wise to wait
a day or two and endeavor to lessen the inflammatory symptoms before
undertaking the manipulations necessary to establish an accurate diag-
nosis. In obscure cases anaesthesia should be induced that a thorough
examination may not be prevented by reason of pain. In order to give
the patient time to recover equanimity after the surgeon's entrance, as
Well as to learn the facts of the case, questions concerning the accident
should be asked before the examination is begun. If this is not done the
nºrvous excitement due to pain from the examination or the insensibility
of anºthesia will make the obtaining of definite answers impossible. The
Possibility of deformity from previous injuries and the history of the
case should be fully considered. The surgeon should then grasp the
Parts firmly and examine carefully and thoroughly for deformity, abnor-
mal, mobility, crepitus, and any other objective symptoms necessary to
establish a diagnosis. Needless repetition of movement is to be depre-
*ted as much as inefficient firmness of grasp during the manipulation is

328 ID IS E A SES A N D IN J U R IES OF B O N E S.
to be avoided. A wound near the seat of fracture should be cautiously
explored with the finger and probe to see whether the fracture is an open
or closed one. If oil globules escape from the wound within twelve hours
the wound probably connects with the fracture. It is the injured marrow
that furnishes this fat. A good deal of venous oozing is also suggestive
of the fracture being an open one, because the veins of soft tissue cease
bleeding sooner than those of bone. The latter cannot collapse so readily.
The symptoms, which, when occurring together, make the evidence of
fracture conclusive, are: deformity, abnormal mobility, and crepitus or
grating. One is often sufficient to establish the diagnosis, but their
coexistence is pathognomonic. If one of these symptoms gives unmistak-
able evidence of fracture, it is often well to desist from endeavors to
develop the others, since such action but adds to the pain, and may
increase the displacement of the fragments. In many fractures one or
two of these symptoms, as will be shown subsequently, may be absent.
Deformity is principally due to the displacement of the fragments.
Extravasation of blood may aid in the primary deformity, and inflamma-
tory swelling in that which occurs later. The forms of displacement,
which have been already discussed on a previous page, may give rise to
marked or very slight deformity. Slight deformities are often, however,
much more difficult to correct than great ones. When the periosteum is
slightly torn there is no deformity, because this fibrous membrane retains
the fragments in apposition. Mere fissures give rise to no deformity.
The recurrence of deformity, when external restraining forces are relaxed,
is a characteristic of most fractures, serving to differentiate this class of
injury from dislocation of joints. In estimating the degree or existence
of deformity, previous fractures and injuries, periosteal nodes, exostoses,
and shortening from old joint inflammations, or contracted tendons, must
be eliminated. Sprains and dislocations often give distortions similar to
fractures near corresponding joints, and must be discriminated by other
symptoms. The two sides of the body should always be compared with
the bones in exactly the same position. Angular and rotary displace-
ment are generally easily recognized ; but shortening.due to overlapping
is often difficult to verify, because accurate measurement is almost im-
possible. The bony prominences taken as standards of comparison are
rounded, therefore the tape-measure can seldom be stretched between
exactly corresponding points. Another element of doubt is the well-
known normal inequality in length of bones of the two halves of the body.
Shortening in very oblique fractures, as of the thigh, may amount to sev-
eral inches.
A clot of blood, a limited condensation by crushing, or a localized
swelling of the soft tissues, sometimes simulates deformity from displaced
bone. This is a frequent source of error in head injuries. A long needle
thrust through the skin and muscles will, by impinging on the hard bony
structure, clear up this uncertainty in some cases. In fractures involving
joints the peculiar deformity due to the synovial sac being filled with
blood or inflammatory products may aid in proving the existence of a
fracture.
Preternatural mobility after injury is absolute proof of a fracture,
except in those rare instances where dislocation with very great tearing of
the ligaments allows unusual motion at a joint. Increased mobility is
sought for by endeavoring to move one part of the bone independently of
the other, and so to produce angular, rotary, or transverse deformity at
the seat of injury, or shortening or elongation of the bone or entire limb.
F R A C T U R ES, 329
The best method of developing these features is to hold one extremity of
the bone immovable, while an attempt is made with the other hand to
move the other extremity. If preternatural local motion can be obtained,
and it is usually shown by the production of the deformities mentioned,
the existence of fracture is undoubted. Absence of mobility must not be
asserted until endeavors have been successively made to lengthen, shorten,
bend, and rotate the bone at the seat of supposed fracture, because some-
times the line of fracture is such that only one direction of force will
develop the abnormal mobility.
When the injury is near a joint where motion is a normal condition,
when the bone is so short or so deeply located that its two ends cannot
be firmly grasped, and when, as in the case of the ribs, sternum, and
fibula, considerable normal elasticity exists, which, upon manipulation,
can simulate mobility, it is difficult to be certain that preternatural
motion is present. Swelling also may sometimes prevent a just apprecia-
tion of the existence of mobility. Fractures, moreover, may exist with
little or no increased mobility of parts. Such is the case in impacted, in
partial, and in interlocked toothed fractures. When one of two parallel
bones is broken, the mobility is often slight. When the shaft of a bone
is broken near the middle, the unnatural seat of motion may be sufficiently
demonstrated by merely placing a hand under the limb and endeavoring
to lift it upon this single point of support. Motion and consequent angular
distortion are at once evident. In searching for motion by rotation the
fragment moved should be twisted but slightly, since the muscles may
connect the fragments sufficiently closely to cause the rotation to be trans-
mitted to the fixed fragment when any considerable degree of rotary
movement is attempted.
When a bone is intimately associated with and held quite fixed by
other bones, alternating pressure with the thumbs or fingers applied on
each side of the point of injury may develop motion. This method is
especially applicable to the fibula and the ribs. In transverse fractures
motion will be developed best by force applied laterally, and in oblique
fractures by forces tending to elongate or shorten the bone in the direc-
tion of its long axis.
Crepitus is the grating sensation felt by the surgeon when he rubs the
rough surfaces of the broken bone together. There is often some noise
produced by this manoeuvre, but the diagnosis rests more on the vibra-
tions conducted along the bone to the hands of the surgeon than on any
noise appreciated by his ears. Mobility and grating are usually, though
not always, coexisting symptoms. Grating cannot be felt without moving
the fragments, but motion may sometimes be produced without making
any grating sensation or crepitus perceptible. The development of crepi-
tus requires, that the surfaces should be rough, and that they should be
sufficiently in contact to render friction of one surface upon the other
Possible. If the ends are separated, as in fracture of the patella; if they
greatly overlap so that the smooth surfaces of the sides of the bone are in
°ontact; if portions of muscle, periosteum, or fascia lie between the pieces;
or, if the broken surfaces have by lapse of time become covered with
§ranulation tissue, the surgeon will fail to observe distinct crepitus until
he alters these conditions. No grating is possible as a symptom of im-
Pacted or green-stick fracture unless the parts are previously rendered
movable. Sometimes a certain manipulation will give rise to distinct
°repitus, but afterward will utterly fail to produce a similar result. This
330 iTY
DIS E A S E S A. N. L) IN J U R I ES OF B O N E S.
is because by reason of muscular or external forces a different relation of
the fractured surfaces has been assumed in the interval.
To elicit grating the surgeon manipulates the parts in such a manner
as to produce motion. In fact, preternatural mobility and crepitus are
demonstrable at the same time and in a similar manner.
When possible, it is best, perhaps, to move the two fragments in oppo-
site directions, as this gives a greater degree of friction. When there is
much overlapping extension must be made before grating can be felt.
Placing the palm of one of the hands over the seat of injury is sometimes
a good method of feeling grating in bones that are not easily grasped with
the fingers. Motion is then obtained by the other hand alone. This often
avails in fracture of the neck of the femur or great trochanter, or in rib
fractures. In the last the proper motion may at times only be obtained by
deep inspiration or coughing. If the limb is heavy, an assistant may steady
or move one portion of the bone while the surgeon has hold of the other.
In most cases the surgeon is able to control both parts with his own hands.
When the presence and character of crepitus have once demonstrated the
existence of fracture, no further manipulations should be attempted. The
character of grating varies with the character of the fracture. It may be
a single slip or snap, or it may resemble the sensation perceived when two
pieces of roughened dry wood are rubbed together with the hands. In
greatly comminuted fractures the sensation imparted is that of motion
among a number of loose pieces of hard material. If any sound is heard
at the same time it will similarly be a sharp click, a dull, muffled scraping,
or an irregular crackling. The character of crepitus, however, will not
always give a correct idea of the nature of the fracture. A sensation of
loose grating may be felt when the bones are held closely together. The
best manner of conveniently illustrating the peculiar sensation called
crepitus is to take an animal's bone, obtained from the markets or else-
where, and after wrapping it tightly in a towel to break it. Motion of
the fragments in various directions will give almost typical grating:
Fracture crepitus may be confounded with, and, therefore, must be dis-
tinguished from the friction-grating of diseased joint surfaces and that of
a dislocated bone rubbing on the periosteal surface of another bone. It
may also be simulated by the fine crackling of inflamed tendons and
bursae, that felt and heard in subcutaneous emphysema, due to puncture
of the air-passages or decomposition of cellular tissue, pleuritic or pulmo-
mary sounds, and the crackling of coagulated blood in the tissues. Joint
grating is said to be finer and moister than fracture grating, but sometimes
it is impossible to assert with positiveness which kind of crepitus is
present. Those conditions giving impressions similar to fracture crepitus
can usually be eliminated by collateral evidence if the surgeon merely
recollects the possibility of their existence. A piece of necrotic bone may
give rise to sharp grating sensations and sounds, if in a position where
another piece of bone can rub against it.
A curious fallacy is this: that occasionally the crepitus perceived
appears to be developed in a certain bone when it is really due to fracture
of a contiguous part of the skeleton. Direct auscultation over the seat of
suspected fracture, either with or without a stethoscope, is probably of
little value, because the sensation of rubbing, rather than the sound, is
the important diagnostic feature. Perhaps auscultation may be applicable
and serviceable in fractures of the ribs and sternum.
The grating produced by motion of the fragments is frequently per:
ceptible to the patient. Occasionally a giving-way sensation, accompanied
F. R A C T U R E S. 331
by a sharp crack, is noticed by the patient at the time of the accident. A
similar symptom is liable to occur, however, when a tendon is suddenly
torn, or when a dislocation with great ligamentous laceration takes place.
Hence, this snap, even when noticed, has little diagnostic value. It is
more often observed by the patient in fractures from muscular contraction
than from violence.
The characteristic symptoms of fracture, then, are deformity, preter-
natural mobility, and crepitus. Pain, ecchymosis, loss of function, and a
variety of other symptoms may be present, but they also exist in such
diverse lesions that they have, as a rule, no diagnostic value.
A persistent tenderness after injury limited to a small area of bone is,
however, very suggestive of fracture without displacement. The opinion
of the laity, that pain in fractures increases when the fragments of bone
are becoming united, is erroneous. Painful muscular spasms, due chiefly
to irritation of the muscles by the sharp points of the broken bone, are
frequently experienced in the early stages of fractures.
Swelling deserves little recognition as a symptom of fracture, but is a
factor of very great importance in the determination of the best methods
of treatment. When the inflammatory swelling is rapid, numerous vesi-
cles may occur on the surface. These may be filled with bloody serum.
It is well not to rupture them, as the blood is often absorbed quite rapidly.
Intractable ulceration at times follows if the epidermis is rubbed off before
new epidermis is formed beneath that which is pushed up by the fluid.
Ecchymosis about the seat of lesion is often due to mere contusion of
the soft parts. If it first appears after the lapse of several days, and
especially if the black-and-blue discoloration is found at some distance
from the seat of injury, a fracture is probably present. This tardy ap-
pearance and distant location are due to the difficulty which the blood
extravasated from the broken bone, periosteum, and marrow has in reach-
ing the surface through the fascial layers. This slowly occurring ecchy-
mosis, particularly when the swelling of the parts results in the formation
of blebs on the surface, may be mistaken by the inexperienced for incipient
gangrene. Absorption of this extravasation from the deep vessels is
always effected in a tardy manner. Indeed, the fracture may be united
before all the discoloration has disappeared.
Blood extravasated from large vessels may, it is said, cause synovitis
by coming in contact with the outside of the synovial membrane. It is
not essential that the synovial sac be perforated or ruptured. Rupture of
a large artery as a complication of fracture is of grave import, because it
gives rise to great extravasation in the tissues.
Loss of power of the part often occurs after fracture, sometimes from
fear of pain, sometimes from loss of continuity in the bony lever. This
Symptom is absent in many cases of impacted, serrated, or partial frac-
ture, and also in those in which the periosteum is slightly torn. Patients
bºve walked considerable distances with a fracture of the femur or tibia.
Motions which do not give pain at the seat of fracture, and which do not
require rigidity of the particular bone that is broken, can be perfectly
performed in nearly every case. Movement of the fingers, for example,
is often unimpaired in fracture of the radius. When there are two
Parallel bones, one may serve as a support to that which is fractured, and
thus prevent impairment of its ordinary functions.
Intermittent muscular spasms are often an annoying symptom of frac-
"re. They are due to pricking of the muscles by the fragments, and to
332 D IS E A SES AN ID IN J U R IES OF B O N E S.
general nervous excitability. Numbness and other nerve symptoms may
be present from coincident injury to nerve trunks.
The constitutional symptoms of fracture, after the period of shock, are
those of inflammation and its consequences. In an uncomplicated closed
fracture there are scarcely any constitutional symptoms. A slight febrile
rise is often noticeable, however, during the first three days. In open
fractures suppuration is usual, unless care is taken to make the wound
aseptic immediately after its receipt, and to keep it so during cicatrization.
Open fractures, managed as described, are usually free from suppuration,
and cause as little trouble as closed fractures of similar location and
extent. Great debility, erysipelas, tetanus, fat embolism, septicæmia, and
pyaemia may all be seen as sequences of fractures if they are not treated so
as to be free from germ infection. In old age fractures may prove fatal
from the consequent debility that is induced.
DIAGNOSIS.—The symptoms described will usually render the diagnosis
of fracture easy; but when deformity, preternatural mobility, and grating
are not all found, or, if found, are not well marked, the true nature of
the injury may be obscure. Especially is uncertainty apt to arise when
the lesion is near a joint, for here there is a great deal of normal mobility,
and joint-grating may, from some cause, be present. Careful examination
under ether, with the corresponding healthy limb uncovered so that com-
parison can be made, will usually disclose the true nature of the lesion.
Severe bruises can be discriminated from fractures in a similar manner.
Dislocations, because of the resulting deformity, may resemble frac-
tures near joints, but in dislocations, unless there is unusual laceration of
ligaments, the normal motions of the articulation are impaired ; and the
surgeon generally finds by manipulation that a sudden and abnormal
check to free movement occurs in certain positions of the bones. This is
not the case in fracture, for there the motion is almost unlimited. Again,
in dislocations there is some resistance when an attempt is made to over-
come the deformity by putting the parts in position, but when this has
been accomplished there is little tendency to recurrence of distortion. In
fractures, on the other hand, the deformity is remedied with ease, but the
mere weight of the limb or a slight force will reproduce it. Voluntary
motion is, as a rule, not so impaired in dislocations as in fracture, for the
long lever is intact, and there is simply a change in the bearing-points of
the articulation. Fractures have an appearance or “physiognomy” of
helplessness; dislocations a “physiognomy” of rigidity. The normal
relation of the bony prominences about a joint should be familiar to the
surgeon, so that any deviation by dislocation or fracture may be detected.
The various “test-lines” used for determining these relations will be
spoken of in discussing fractures near special joints.
The diagnosis between a separated epiphysis and a fracture in the same
region is often difficult; but it is not very important, since the treatment
is identical. A separated epiphysis gives a smoother and less distinct
grating than a fracture, and is apt to be followed by diminished growth
in length of the bone.
More difficult than the determination of the simple existence of fracture
is the localization of the exact position and line of fracture. This is often
of importance, and may be determinable only by careful fingering, accu-
rate measurements, and close observation of changes in relative position
of the prominences. Oftentimes the exact line of break is only to be
inferred.
The conduction of percussive vibrations from one end of a bone to the
F. R A CT U R. E. S. 333
other will at times prove the non-existence of a line of complete fracture
between the two points. Let the examiner grasp or place his fingers on one
extremity of the bone, and then give the other several quick, sharp blows
with his finger-tips or a small hammer. If the vibrations are distinctly
conveyed along the bone, complete or impacted fracture is improbable.
PROGNOSIS.—Closed fractures, if uncomplicated, usually do well. Open
fractures are more serious than closed fractures of a similar degree of
bone injury, only when infected by putrefactive or pyogenic bacteria.
Oblique fractures usually leave some shortening of the bone, though this
may be very slight and scarcely noticeable. Fractures in children unite
more rapidly than those in adults; and fractures of the upper more
quickly than those of the lower extremity. Small bones become united
sooner than large ones. Some permanent stiffness is the rule after frac-.
tures involving a joint. Many fractures will be followed by imperfect or
bad results, notwithstanding the best surgical treatment.
It is a common mistake to suppose that when the bone becomes united
the patient will at once have a normal limb. Stiffness of the articula-
tions, a dry and rough skin, Oedema and congestion, especially when the
limb hangs down, and pain aggravated by changes in the weather are the
most frequent sequelae of fracture. Many months may pass before they
all disappear. Sometimes one or more of these symptoms is permanent.
Stiffness, when not due to actual involvement of the articulation in the
line of fracture, depends on the simultaneous occurrence of a sprain,
hemorrhagic extravasation around or into the synovial sac, the entangle-
ment of tendons in the Ossifying callus, or retraction of the ligaments and
peri-articular tissues during the period in which the joint was kept
immovable by the fracture dressing. This joint stiffness subsequent to
fractures is most marked and more persistent in old persons and those of
a rheumatic diathesis.
QEdema results from pressure of the fragments or callus upon the deep
veins, or from phlebitis and coagulation secondary to the injury. The
coagula formed in the inflamed veins give rise in very rare instances to
embolism. Sudden lividity or pallor, dyspnoea, precordial pain, and death
occurring from three to six weeks after the receipt of fracture point to
venous thrombosis and embolism. Less severe symptoms of the same
character, followed by localized lung consolidation and cough, are due to
detachment of a smaller embolus, and may terminate in recovery. If
phlebitis is suspected, it is wise to keep the patient quiet and the limb at
rest until absorption of the internal coagulum has occurred. Its frag-
mentary detachment from the walls of the vein is to be feared.
Cases of death after fracture have been attributed to what is termed fat
embolism. It is supposed that the crushed marrow furnishes free fat
globules, which, taken up by the veins and lymphatics, produce embolic
plugging of the lungs, kidneys, brain, and other organs. The symptoms
are similar to those of shock" and of the venous embolism ; but occur
later than the former, and earlier than the latter. Not immediately after
injury, as are symptoms of shock, but after the lapse of one or two days
have symptoms attributed to fat embolism been observed.
. Death, it is said, may occur very promptly from obstruction of the
pulmonary circulation by these fat emboli; or it may be delayed for a
Week or ten days and be due to inflammation of the lungs, brain, or
kidneys, secondary to the embolic process. Some observers suggest that
* Holmes's System of Surgery: Packard’s edition, vol. i. pp. 144 and 145.
334 D IS E A S E S A N D IN J U R IES OF B O N E S.
traumatic delirium and hypostatic pulmonary congestion after fracture
may be the result of fat embolism. Dxperiments show that disastrous
results are only liable to occur when very extensive fat embolism is
present. Otherwise the fat is eliminated, perhaps by the kidneys, for fat
has been found in the urine. Subjects of chronic alcoholism and the aged
are presumed to be specially liable to suffer severely from fat embolism,
because the weakened heart cannot propel the fat circulating in the blood-
current, nor are the damaged viscera able to resist the effects of the
embolic injury. No secondary abscess occurs in fat embolism.
The indication of treatment is to prevent the occurrence of fat embo-
lism by keeping the crushed limb quiet and avoid further laceration of the
marrow. If amputation is demanded by the extent of the injury, it
should be done promptly before much fat is absorbed. Intravenous injec-
tion of ether, as suggested by Packard, may perhaps be indicated.
Fractures may be complicated with, or followed by, dislocation, syno-
vitis, gangrene, caries, necrosis, injuries to viscera, laceration of arteries,
veins or nerves, and delirium. These circumstances greatly affect the
prognosis. Whiskey-drinkers and the aged seem especially liable to
traumatic delirium after fractures.
JRepair of Fractures.
As has been shown is the Section on healing of wounds, repair of most
soft parts results in a cicatricial tissue which is analogous to, but not
identical with, the structure wounded. In bones, however, as in nerves,
a much more perfect regeneration occurs. Indeed, the uniting bone, if
examined sufficiently long after the time of fracture, has the microscopic
structure of true bone.
Bones are repaired by the same general processes as are other tissues.
The cells of the periosteum and marrow, and those lining the Haversian
canals and the lacunae of the bone multiply. By this proliferation is
formed a mass of granulation tissue, which fills the spaces between the
pieces of bone and sometimes infiltrates the parts around the bone. This
new material gradually becomes ossified by the deposition of earthy
salts at numerous points, and the subsequent coalescence of these Ossific
centres. The time after fracture at which bony particles are first formed
in the bond of union is probably two or three weeks. The transition
from granulation tissue to bone is usually through the connective tissue
stage; though occasionally the granulation material, at least in some
parts, becomes cartilage before it is transformed into bone. Some of this
new bone, which is at first spongy in structure, becomes compact; some
of it becomes more rarefied, and some is entirely absorbed ; until, finally,
if the fragments have been kept in correct apposition, the bone is so well
restored to its normal condition that, even when the dried bone is sawn
open, no line of fracture can with certainty be distinguished. In fact, the
changes occurring in repair of fractures differ only in a degree from those
observed in the normal growth of bone. The location and degree of in-
jury and the relative position of the fragments modify the number of
Nature's resources, and change the character and amount of the repara-
tive work to be done. Hence must be described more minutely the
various steps of repair in closed, in open, and in epiphyseal fractures;
and under closed fractures the differences between fractures of the shafts
R. E. PA I R O F. F. R A C T U R E S. 335
of long bones or portions of bone with a medullary canal, and fractures
running into joints.
After the shaft of bone is fractured the periosteum, torn and stripped
up from the bone though it may be, often forms a sort of ragged sheath
around the seat of fracture. Within the limits of this imperfect perios-
teal sheath new tissue to unite the bone is principally deposited. The
periosteum, the injured marrow, and the broken cylinder of compact bone
all become inflamed and furnish cellular elements, which, mingling with
the blood-clots and effused serum, form an inflammatory exudate which
becomes granulation tissue.
The bone is the least active and slowest in furnishing new tissue,
because it normally has fewer cells of its own than the marrow and peri-
osteum, but at length granulations appear on the ends of the fragments
and finally coalesce across the gap. This granulation tissue filling up
the space between the ends of the fragments and lying within the confines
of the periosteum and other tissues surrounding the seat of fracture, has
of course no firmness until Ossification begins. When it begins to be firm
it is called callus. During this early period of repair the connective tissue
in the structures outside of the periosteum is also filled with proliferating
cells, and thus steadies the broken bone by glueing the adjacent muscles,
tendoms, and fascias together.
The granulation tissue formed usually ossifies in man as connective tissue
without showing any cartilaginous stage; but when fractures in man are
kept perfectly at rest the granulation tissue which lies between the frag-
ments and around the bone may become cartilaginous before being ossified.
In any event it requires weeks for the callus to gain the hardness of bone.
Ossification through the cartilaginous stage is the common event in the
lower animals.
During this period the marrow callus, which has occluded the medullary
canal like a plug, and the external callus have held the fragments firmly in
position. These depositions go by the name of provisional or temporary
Callus. As the interosseous callus—that is, the callus between the two
cylinders of bone, called the permanent or definitive callus—becomes hard,
the external callus, as well as the internal callus which lies in the medul-
lary canal, is absorbed. Thus the surface of the bone is finally given its
normal contour, and the medullary canal, which had been completely
ºp in both fragments for some distance from the break, is reëstab-
1S [162Cl.
Small pieces of comminuted bone may be imbedded in the callus and
assist in increasing its bulk. These fragments, even if entirely denuded
of periosteum, do not die, unless the fracture is infected with pyogenic
germs or other septic organisms. Sometimes such pieces become necrotic
and remain in the callus as foreign bodies, giving little trouble; though
they are apt to cause prolonged irritation and interfere with union.
If there is much displacement union is effected between the nearest
lateral surfaces of the bone, the open medullary cavity is covered in by
new Osseous structure, and the displaced ends of the fragments become
round and smooth as in a stump left after an amputation.
Fractures of short and flat bones and of the ends of long bones are
not accompanied by injury of marrow in a medullary canal. The pro-
Qess of union is, with the exceptions due to this fact, identical with that
in the shaft of long bones. Unless there be much motion during the
time of union, very little callus is found around the seat of fracture, and,
therefore, the prominent oval mass felt in the form of fracture just de-
336 DIS E A SES AND IN J U R IES OF BONES.
scribed is absent. This absence is probably due to the fact that the peri-
osteum in these locations is less easily stripped up by the injury. Less
laceration and less displacement therefore occur. Union is favored, more-
over, by the broad surfaces of spongy and vascular bone which are in
contact and by the less liability to motion from involuntary muscular
spasms. Hence less callus is formed, for a large amount of callus usually
means difficult repair because of great displacement or much motion.
When the line of fracture invades the articular surface of a bone the
deposition of callus differs from that described in fractures not involving
a joint. The bony surface covered with cartilage and bathed in synovial
fluid does not usually furnish granulation tissue and callus as do the parts
of the bone which are covered with periosteum and surrounded by mus-
cles and fascias. Hence when union occurs it is by callus furnished by
the envelope of the extra-articular portion of the bone and by the fracture
surfaces themselves. There is no ensheathing callus on the articular sur-
face to aid in repairing the edge of the fracture there.
The articular cartilage which is split by the same line of fracture does
not unite; or if so the normal structure is replaced by cicatricial fibrous
tissue only. As a result there is shown on the joint surface a groove in
the cartilage or a line of uncovered bone to mark the position of the
former fracture. Sometimes in injuries of this sort, as for example in frac-
ture of the patella, where correct apposition has not been obtained, the bond
of union is very imperfect, being mostly fibrous instead of osseous.
Open fractures, if aseptic, unite in a manner identical with that which
has been described in closed fractures. If suppuration occurs, the repair
is slower, because the warfare between the cells and the microörganisms is
followed by death of much new tissue as well as destruction of the sur-
rounding bone, muscle, and fascia. Violent inflammation of a mycotic
kind is added, therefore, to the simple traumatic inflammation of aseptic
fractures. Repair, therefore, is antagonized, and open fractures, unless
they are early converted into closed fractures by primary healing of the
soft parts next the bone, require a long time to unite. Superficial areas
of bone or detached splinters may become necrotic and greatly retard
healing of the soft parts and union of the main fragments. If much bone
is lost by necrosis or by the shattering force causing fracture, bony union
across the wide gap may be impossible, because the ossific influence is
not great enough. Fibrous union then occurs.
Epiphyseal separations, or fractures, seem to unite as readily as true
fractures. The union is said to be at once a bony one instead of by the
normal epiphyseal cartilage as previously. The growth in length of the
bone is retarded by this precocious union between the shaft and epiphysis.
Agnew thinks that in some cases the epiphyseal cartilage at the other end
of the bone acts in a compensatory manner by allowing an unusual length-
ening there. Very little is known of the peculiarities of union in this
form of injury.
Fractures of cartilages, such as the costal and laryngeal, which tend to
ossify with advancing age, unite as bones by a material resembling callus.
TREATMENT.—The essential points in the treatment of fractures are the
replacing of the displaced fragments as soon as possible, the prevention of
recurrence of displacement, attention to the condition of the soft parts
around the seat of fracture, and due consideration of the patient's general
health. The surgeon's object is to obtain prompt union with as little
deformity as possible. At times, unfortunately, more or less deformity is
unavoidable, because of the situation and direction of the line of fracture.
R. EPA I R O F F R. A. CT U R E S. 337
Every effort should be made, however, to make this as slight as pos-
sible.
After receiving a fracture of the upper extremity the patient can usually
walk to the place of treatment if the injured limb is supported by his
other hand or a sling. If the lower extremity is the seat of suspected frac-
ture, walking should be prohibited, and the patient carried by four men
on a stretcher, settee, or wide board. It is recommended by some writers
that these carriers should not keep step, because so doing has, it is said, a
tendency to impart a painful swinging motion to the litter. Other writers
advise them to step simultaneously. It matters little which precept is
followed if the litter is held steadily and given no sudden jars; especially
is this so if the patient lies immobile and does not try to move his body
and limbs so as to neutralize the vibratory movements of the stretcher.
The patient must be carried in severe fractures of the upper limbs also
if shock is great. A crude splint of board, twigs, straw, pasteboard, or
any other material of sufficient rigidity to steady the fragments during
transportation should be bound to the limb. This may be done outside
the clothing. In fractures of the leg or thigh the opposite limb makes a
good splint to which to bind temporarily the broken one. Hay, rags, or
small pillows may be placed between the limbs before they are tied
together.
The bed for the permanent treatment of a patient with a fracture of a
leg or thigh should preferably be a narrow one, so that the attendants can
conveniently reach each side of his body. A firm mattress that will not
Sag down under the buttocks is necessary. One made of hair and laid
upon slats or woven wire is probably the best. The old-fashioned sacking
bottom for supporting the mattress is undesirable. Patients accustomed
to sleeping upon feather beds may be very uncomfortable unless they have
softer mattresses than hair. In such cases a thin feather bed may be
used if it is thoroughly supported by the framework beneath it. Good
Springs under a heir mattress are not objectionable if they do not permit
the upper surface of the mattress to become uneven. There is no neces-
sity for a specially made fracture-bed, if the bed-pan and urinal are care-
fully and intelligently placed when the contents of the rectum and bladder
are to be voided. The sheet under the patient should be kept smooth;
its edges may be tacked or tied to the sides of the bed. When a clean
sheet is to be put under him it should first be folded or rolled up longitu-
dinally for half its width. This doubled-up portion is to be carefully
pushed under the right side of the patient while he is very slightly turned
on his left side; then he is to be carefully turned on his back and slightly
on his right side until a second person standing on the left side of the bed
draws from under him the folded-up edge of the sheet. Very little move-
ment of the patient is made when this method is adopted.
. During long confinements to bed the sacrum, heels, and other points sub-
jected to pressure should be washed frequently with equal parts of alcohol
and Water, and every precaution taken to avoid the occurrence of bed-
* . Air mattresses may be demanded on this account in cases of frac-
* of the spinal column, where the accompanying paralysis greatly in-
Cl’éâSeS the tendency to bedsores. §.
Replacing the fragments in their normal relation, technically called
Reduction or “setting,” should be attempted as soon as the patient has
been conveyed to a convenient place. Early reduction—that is, reduction
before the advent of inflammatory swelling—is nearly always demanded.
t is less painful to the patient, and adjustment can thereby be more easily
22
.338 DISE ASES AND IN J U RIES OF BONES.
and accurately accomplished than if the necessary manipulations are de-
layed. Moreover, the subsequent inflammation and chronic muscular
spasms will probably be less severe if the sharp points of displaced bone
are prevented by reduction from continually irritating and wounding the
soft tissues. When the case has not been seen until severe inflammatory
action has stiffened the muscles and greatly distended the fascias and in-
tegument by interstitial swelling, it'may at times be proper to delay reduc-
tion until this condition has been relieved. Absolute rest of the part with
the fragments in moderately good position should be adopted and accom-
panied, perhaps, by antiphlogistic local treatment, and sometimes even by
incision through the constricting skin or fascia. After the lapse of a few
days accurate reduction may be effected. The manipulations necessary
for accurate adjustment, if made when the limb was stiff and so swollen,
might cause rupture of vessels or nerves, or by increasing the internal
pressure lead to gangrene. It may be judicious, perhaps, to delay also
when there is evidence that the principal artery or nerve has been torn by
the original injury, because the consequent gangrene might be attributed
by a court and jury to the early manipulations made for reduction.
As a rule, however, fractures are to be reduced and dressed imme-
diately; and only in exceptional instances should the surgeon be deterred
from attempting accurate adjustment. --
When subcutaneous hemorrhage or inflammatory swelling endangers
the safety of the limb by arresting circulation, as shown by coldness and
numbness of the fingers or toes, free incisions should be made through
the tense integument to permit the fluids to drain away and thus relieve
the pressure upon the vessels and nerves. Great stress is laid upon this
measure, as threatening gangrene may often be averted by several
cutaneous incisions of two, three, or four inches in length.
Reduction of displacement should be attempted even if the case is first
seen several days or weeks after injury. More force will be required
under such circumstances; but of this more will be said under the dis-
cussion of Refracture of Deformed or Vicious Union of Fractures.
Reduction is sometimes readily effected by merely relaxing the muscles
tending to cause displacement, whereupon the fragments fall into place.
At other times some additional pressure and manipulation with the fingers
are necessary before the more or less numerous pieces of bone are pressed
into correct apposition. In still other cases an extending force must be
applied to the limb on the distal side of the fracture, while counter-ex-
tension is exerted upon the other side of the seat of injury. By counter-
extension I mean a resistance to the extending force so that the body will
not be pulled in the direction of the force used to make traction on the
overlapping fragments. Extension and counter-extension are to be made
by grasping the limb above, and below the fracture, and pulling with
one hand while the other resists or pulls in the opposite direction. In
dealing with a large, heavy limb it may be necessary for the counter-
extension and sometimes the extension also to be made by an assistant.
Such duties are also entrusted to assistants when the surgeon needs his
fingers to mould the fragments into position. Extension-traction should
be steady, continuous and moderate, and exerted in the axis of the limb,
No greater force than can be obtained by the firm grasp and strength of
the surgeon or assistants should be applied to the reduction of a recent
fracture. Pulleys are never justifiable. What is required is a firm,
steady pull of moderate force that will tire out the contracted muscles.
Anaesthesia is often desirable, as it relaxes spasm and prevents pain. In
R. EPA I R. O. F. F. R A CT U R ES. 339
many cases ether has already been given to enable the surgeon to make a
careful examination, therefore the reduction is at once effected and the
fracture dressing applied before consciousness is regained. Extension
overcomes shortening due to overlapping of fragments, but if there is
lateral and rotary displacement, coaptation with the fingers and rotation
of the limb should be added to the extension. These combined manipu-
lations will usually correct the deformity. In impacted fractures and in
open fractures with one fragment thrust through the integument, as
through a button-hole, much difficulty may be found.
When a portion of bone into which a muscle is inserted is broken off
it is to be put and held in position by traction exerted against the muscle.
Fractures of the olecranon and patella illustrate this point.
Sometimes difficulty is experienced in properly and completely reduc-
ing the fragments. This may be due to impaction, to a fragment being
entangled in or thrust through muscles or fascias, to one fragment being
locked behind another and held there by muscular tension, or to actual
crushing and powdering of portions of spongy bone. Inability to obtain
a firm hold on one fragment may also be a cause of imperfect reduction.
If muscles or fascias prevent reduction, subcutaneous section with a teno-
tome is justifiable to prevent permanent deformity from this cause.
An incision of skin and muscles is not infrequently required in open
fractures before reduction can be obtained and also to permit thorough
disinfection of the wound cavity and to make provision for free drainage.
Whenever replacement is difficult, an endeavor should be made to replace
the fragments along a course the exact reverse of that which was given
by the vulnerating force. The portion of displaced bone should retrace
the steps by which it reached its abnormal position.
After reduction has been obtained the limb should be compared with
the sound side, and the test lines verified, to establish the correctness of
the replacement. Swelling may make appearances deceptive. Great care
in this respect is necessary in fractures near joints. Continuous extension
by means of weights is often employed to overcome overlapping. It acts
by gradually tiring out the displacing muscles, and thus effecting reduc-
tion. It is the usual method in fractures of the femur.
Closed fractures seldom require any lotions or other external medicinal
applications. Lead-water and laudanum and similar remedies, applied
to the skin, can avail little in relieving inflammation of broken bones
and torn muscle. Immobility and freedom from muscular spasm are
therapeutic agents of far more value than external lotions.
After reduction has been satisfactorily accomplished, displacements may
recur through the action of gravity, muscular contraction, or restlessness
of the patient. The surgeon must guard against such recurrence by
applying some form of fracture dressing, which will retain the fragments in
Proper position. The best form of dressing will be that which corrects
the tendency to displacement in the individual case, and, at the same time,
steadies and immobilizes the limb. The special tendency to displacement
Varies in each case with the line and position of fracture, and should be
recºgnized before the form of dressing is decided upon.
. There are occasions in which no retention apparatus is needed, but these
*stances are rare. The confidence of the patient and greater safety
º displacement are obtainable by adopting some mode of fracture
dressing.
Fracture dressings may be grouped under three heads: ( 1) Those which
give moderate continuous traction, or maintain extension which was applied
340 DIS E A S E S A. N. D. IN J U R IES OF B O N E S.
when the fracture was first adjusted; (2) those which, by virtue of their
rigidity or fixedness, resist retraction ; (3) those which, by virtue of their
inflexibility, prevent angular or lateral displacement by giving lateral
support to the fracture. These forms may be combined in the treatment
of a given fracture. The simplest apparatus is the best. The articles
employed in dressing fractures are: roller bandages; padding, such as
cotton or oakum ; adhesive plaster; splints of any rigid material, such as
wood, felt, pasteboard; cotton fabrics stiffened with gypsum, silicate of
sodium, or starch ; fracture boxes; and weights for making continuous
traction. As a rule, no roller bandage should be applied immediately to
the limb under the splint, for the inelastic constriction thus made may
lead to gangrene, if unexpected inflammatory swelling occur, and is, at
any rate, of no service. Bandaging of the distal portion of the limb,
beyond the splint, tends to prevent odema there; which is often seen,
because the fracture dressing, even when properly applied, interferes
somewhat with venous return. It is usually preferable not to bandage
even this portion of the limb.
The oedema, unless excessive or accompanied by discomfort, is of no
importance. In dressing fractures of the shaft of bones, the nearest joint
above and that below should, as a rule, be made immovable by the splint,
because motion allowed at such articulations may cause displacement of the
approximated fragments. Splints, if not moulded to the patient's person,
should be padded with a thin layer of cotton-wadding, so as to make
equable and elastic pressure, and thus accurately conform to the contour
of the limb. A board slipped into a long bag, afterward smoothly stuffed
with cotton, makes a good splint.
The splints after adjustment are to be held in place by spiral or reverse
turns of a roller bandage, applied with sufficient firmness to maintain the
apparatus in position, and thus make the limb rigid so that no motion can
occur at the seat of fracture. The fingers or toes should usually be left
uncovered that lividity, coolness, or Cedema, due to improper constriction,
may be noticed. The turns of the bandage can be kept from slipping by
painting a broad line of mucilage or silicate of sodium down the outside of
the completed dressing, or by applying a marrow strip of adhesive plaster
down its exterior so as to hold the folds of the bandage. Another method
is to stitch the bandage to the covering of the splint. Before applying
the fracture apparatus, the skin should be washed with soap and water
and shaved. In open fractures this is exceedingly important. Anti-
septic lotions are to be used in these cases freely, to destroy any germs which
may have gained access to the wound. Sublimate (1 : 500 or 1: 1000)
solution is probably the best; and can subsequently be washed out of the
wound by a weaker solution. All recesses must be made aseptic, and
drainage tubes used to drain all dangerous pockets. Counter-incisions
are often demanded, and all devitalized parts should be trimmed away.
In truth, the wound must be treated and dressed exactly as any other
lacerated infected wound, and then have fracture appliances adjusted.
Conformable splints of metal, felt or pasteboard, or moulded splints, such
as will be described below, are far better than any form of carved
wooden splint. A thin board may be made flexible transversely by cut-
ting six or eight parallel longitudinal incisions in it, extending almost,
but not entirely, through its thickness. A sheet of rubber adhesive-plaster
may then be smoothly fastened over the uncut side, in order to strengthen
the hinges made at the incisions when the board is bent.
R E PA I R O F F. R A C T U R. E. S. 341
Moulded splints are a most desirable form. They are at first suffi-
ciently soft to be accurately fitted to the inequalities of the limb, but
subsequently become hard. Felt, gutta-
ercha, and pasteboard may be thus FIG. 148.
moulded after being made soft by heat
or moisture. Strips of gauze or any
woven fabric with wide meshes can be
converted into excellent splints by
saturating them with a watery mixture
of gypsum, the so-called plaster-of-Paris.
Ten to twelve of these pasty strips, one
over the other, are applied to the limb
while it is held in proper position. They
soon become rigid by the “setting ” or
hardening of the gypsum. Lateral or
anterior and posterior splints of any
shape may thus be made and held in
position by roller bandages. If it is pre-
£ §
ferred, the limb may be encased in #º
sheets or bandages of gauze saturated =º
with gypsum. This method is that used | Fº
in making, the so-called immovable # =
dressings, which are often very valuable -
É
after the primary inflammation of in- WWW
jury has subsided. These hardened -- ãº
encasements, if made with silicate of º
sodium, glue, or any material with some & ãº
elasticity may be split open on one side, Posterior gypsum splint for fracture of
so that they can be sprung open, some- the leg. (STIMsoN.)
what as a book, and thus become mov-
able splints. They may be furnished with eyelets, and thus laced like a
shoe when reapplied.
The gypsum powder for this purpose must be kept dry, for, if it absorbs
moisture, it will not “set.” It may be mixed with enough water to make
a paste of the consistence of cream, which is rubbed into the gauze at the
time of dressing the fracture, or the dry powder may first be rubbed into
the meshes of the gauze and the gauze strips or bandages dipped into
Water as needed. If gypsum gauze is not used at once, it should be pre-
served in a dry place. The setting can be retarded by the addition of a
little dissolved glue, of borax, or cream of tartar to the water, and
hºstened by using hot water or adding salt. A little skill in cutting out
V-shaped pieces of the sheets of gauze, and in overlapping the edges thus
made when corners are to be turned, will enable the surgeon to make
moulded splints to suit fractures in all regions. Such splints may be
Varnished to prevent absorption of fluids, and strengthened by incorpor-
*ting strips of zinc between the layers. In open fractures which have
become infected, and are therefore Suppurating, openings may be made
in the splints, so that the wound may be dressed without displacing the
fracture apparatus. Strips of metal to strengthen the dressings, or wire
*ings for suspension, may be incorporated within the layers.
Reduction of overlapping fragments is sometimes best accomplished by
99ntinuous traction by weights. The displacing muscles are thus tired
9Mt, and their tendency to either tonic or clonic spasm overcome. The
°ord carrying the weight passes over a pulley and is attached to the limb


342 D IS E A S E S A N ID IN J U R I E S OF B O N ES.
by strips of adhesive plaster. The tendency to lateral displacement is
then obviated by coaptation splints at the seat of fracture. This method
FIG 149.
W
Anterior and posterior gypsum splints with wire rings applied for suspension in
fracture of leg. (STIMson.)
is most employed in fractures of the femur, but is at times useful else-
where.
It is a safe plan always to remove the splints within twenty-four hours
FIG. 150.
Adhesive plaster and foot-board applied for continuous extension.
FIG. T 51.
^
}_2
§ —A)
* --~" | | \
* -----. ! # ! A W
Sºcz \ ! | : | \ *
**, * * : A i) \ ºld
º t A. : º!" § º ği R, |### s:
Encasement in immovable gypsum dressing for fracture of leg. (STIMSON.)
after the first dressing. Bad fractures should be visited within a few
hours after the original dressing, lest unusual swelling may have occurred











R E PA I R O F F R A C T U R E S. 343
and rendered the dressings too tight. If, after the second dressing, no
undesirable symptom has occurred and the limb feels comfortable, re-
moval of the apparatus is not called for oftener than two or three times a
week. Daily inspection of the patient should, however, be enforced for
ten days or so, even if no change is made in the dressing. When the sur-
geon takes off the splints the limb should be held by an assistant, who
should firmly grasp it above and below the fracture and allow no motion
or displacement. After the skin has been washed with soap and water,
or with alcohol, the limb should be dried and carefully examined for
abrasions or bedsores, due to pressure, and for any renewal of deformity.
It should ever be recollected that absence of discomfort is not a token of
absence of deformity. Dressings which allow the seat of fracture to be
always under observation are therefore desirable, though it is not always
convenient to adopt them.
If no untoward symptom occurs within two weeks, change of dressing
once a week is sufficiently often ; but the possibility of angular displace-
ment, even so late as four or five weeks, must be remembered. Loosening
of bandages or sinking in the bed may cause lateral or rotary movement
at the seat of fracture.
Retention apparatus may, as a rule, be discarded in uncomplicated
fractures of the upper extremity at the end of from four to six weeks, and
of the lower extremity at from six to eight weeks. The bones should be
subjected to no muscular strain for two or three weeks subsequently.
During this time, and often longer, slings or crutches are needed. The
union becomes firm in children sooner than in adults.
Persistent pressure of the splint or bed upon any bony protuberance is
liable to cause a localized chronic sloughing of the skin and subcutaneous
cellular tissue, technically called a bedsore. This result must be avoided
by careful padding, frequent change of the points of pressure, and bathing
the cutaneous surface with water or alcohol. A patient can often change
his posture in bed without detriment if a rope, attached to the ceiling over
his head, is allowed to hang within reach. Bedsores often occur without
any sensation of pain or burning. The surgeon must look for them, and
not be satisfied with a reply that there is no pain. If a dark spot is seen
on the heel, elbow, sacrum, or other prominence, a bedsore already exists.
The slough must be detached before the sore will get well. Hence, moist
antiseptic dressings should be applied for a time. The ulcer remaining
after the detachment of the slough is to be treated by antiseptic dressings
to prevent suppuration, and possibly by applications, such as chloral in
solution or ointment (gr. x to Bj), nitrate of silver and iodoform.
The inflammatory symptoms at the seat of injury in closed fractures
usually need no treatment. Correct apposition and prevention of motion
are the essential features. The blebs that sometimes form on the surface
may be let alone, unless they are large; then they may be punctured with
a needle to allow the bloody or straw-colored serum to escape. Wrapping
the limb in cloths saturated with lead-water and laudanum, before apply.
Ing. the splints, is improper. Such measures do no good, and the dressings,
acting as poultices, may cause blebs to arise which otherwise would not
have appeared. Muscular spasm about fractures is best combated by
morphia given by the mouth or hypodermically. Retention of urine re-
quiring catheterization is not infrequent after fracture of the thigh.
Abscesses, traumatic fever, delirium, tetanus, erysipelas, and other com-
Plications, must be treated on general principles. Gangrene due to
arterial rupture or thrombosis simultaneous with the fracture occurs at
344 D IS E A S E S A N D IN J U R IES OF B O N E S.
times; it may also follow constrictive pressure from excessive inflamma-
tory swelling beneath the skin and fascia. When the last condition is
feared, free cutaneous and fascial incisions, as previously described, will
relieve the tension by allowing gaping, and thus often avert the calamity.
Injudicious bandaging has often caused gangrene. In gangrene from any
of these causes it is usually well to wait for the line of demarcation before
amputating. If, however, the destructive process is rapidly spreading,
immediate amputation at a high point may be judicious.
FUG. 152.
\
W
A.
**
*
º
Suspended and fenestrated gypsum encasement for fracture of leg.
Immovable or fixed dressings, which, however, allow no inspection
of the fractures, are often used when the fracture has been reduced and
there is no fear of swelling. They should not be employed in the early
days of a fracture. It is much safer to wait until all inflammatory
action has subsided and there is some solidity given to the broken bone
by the beginnings of repair. The end of the second or third week is
early enough for their employment. Encasements are made from
bandages or cloths saturated with gypsum, silicate of sodium, or glue,
as has been mentioned above in describing moulded splints. Before the
immovable apparatus is applied the limb should be smoothly enveloped
in soft flannel or a layer of cotton wadding. Then the roller bandage
soaked in gypsum should be applied circularly to the limb, without being
drawn at all tightly. Silicate of sodium solution may be used instead
of gypsum. It dries more slowly than gypsum, but makes a more
elastic encasement, which, when split, can rather more readily be pulled
apart, so that the limb may be lifted out and examined. Such a split
encasement then becomes a movable splint. I usually so employ the
so-called fixed dressings. As the limb shrinks because of absorption
of inflammatory deposits, the splint will become too loose and allow
displacement of the fracture. It should then be removed and replaced
by a new one, unless it is elastic enough to be opened, padded, and
reapplied. Eyelets and laces may be inserted for the purpose of regu-
lating the degree of constriction. The seat of fracture or wound may be
left open to inspection by an opening in the encasement. Powerful shears
are the best instruments for dividing fixed dressings which are to be
removed, but a saw or knife may answer. Gypsum encasements may be
softened before using the knife by applying muriatic acid along the line
of proposed division.
Fractures running into joints are apt to be followed by ankylosis be-


T R E A T M E N T OF O PEN F. R A CT U R ES. 345
cause of the arthritis that arises secondarily to the bone injury. The
joints adjacent to a fracture are usually kept immovable by the splints in
order to prevent motion at the point of fracture. Hence, when the
apparatus is finally removed these joints often show considerable stiffness,
due to disuse for several weeks and to the inflammatory exudate among
the muscles and fascias. Passive motion of these joints by the surgeon at
the time of rearranging splints during the treatment of the broken bone
is often insisted upon. Such motion, unless very slight, may displace the
fragments. Hence, it has long been a mooted question whether the
surgeon should commence these manipulations early or late. In any case
where there is probability of passive motion displacing the fragments it
should not be commenced until firm union has taken place. Four weeks
is early enough in all these doubtful cases. If arthritis has occurred as a
complication, absolute rest is indicated and passive motion will do harm.
If no arthritis has occurred, the stiffness due to disuse can readily be
overcome by passive motion at a later date when there is no risk of inter-
fering with bony union. Then the patient can supplement the passive
motion employed by the surgeon by rubbing and moving the limb with
his own hands or pulling against a resisting force. Passive motion which
is followed by pain and tenderness of the joint is usually deleterious, for
it means that arthritis exists.
FIG. 153.
Shears for cutting through gypsum dressing.
When a fracture is complicated by dislocation of a neighboring joint,
the surgeon should endeavor to reduce the dislocation at once. " The
necessary leverage may often be obtained by applying such temporary
Splints as will steady the broken bone. Afterward the same or other
fracture dressings may be utilized for the treatment of the fracture.
Treatment of Open Fractures.
The treatment of open fractures—that is, of fractures complicated by
*Wound, leading to the seat of fracture which communicates with the
* -Varies with the character of the injury. The indications are to
replace and retain the fragments in apposition and obtain rapid healing
of the wound. The last indication is usually, though not always,
Possible of fulfilment if the wound is promptly made aseptic and kept
59. Hence, the surgeon, after reduction of the fracture, should cleanse
the wound with antiseptic washes, such as corrosive sublimate solu-
*% (1 : 500 or 1000), and treat it so as to avoid virulent consecutive
inflammation due to infection. When a portion of the bone protrudes
through the skin, manipulation, relaxation of muscles, enlargement of
º wound, tenotomy, and resection of the ends of the fragments should
* Practised to accomplish replacement. . When the bones constantly

346 D IS E A S E S A N ID IN J U R I ES OF B O N ES.
slip out of apposition resort should be had to wiring them together
by means of holes drilled obliquely through the extremities, or by
driving sterilized bone pins or steel nails into the Osseous tissue and
twisting the wire around them. Loose splinters and all foreign bodies
should be picked out of the wound. Portions of bone still maintaining
periosteal attachments should be permitted to remain. Fractures com-
plicated with wounds are almost certain to suppurate unless they are
managed with rigid antisepsis, because they have been infected before
they are seen by the surgeon. They should be thoroughly washed out by
antiseptic lotions after the surrounding parts have been scrubbed with
soap and water under anaesthesia, and only closed after provision for free
drainage has been made by means of counter-incisions and drainage-tubes.
All dirt and foreign material must be removed. The method of render-
ing such injuries aseptic has been described under the Treatment of
Wounds; for an open fracture is a lacerated wound of soft parts and
bone. When washing out an open or compound fracture with the anti-
septic solution, provision should be made for the outflow of the blood-
stained fluid, so as not to leave poisonous fluid in the cavity on the one
hand or to fail to get rid of septic bacteria on the other. Counter-open-
ings or enlargement of the original wound may be demanded for this
object. Intramuscular or subcutaneous lacerations often extend up and
down the limb a long distance from the seat of fracture. These may re-
quire long incisions in order that efficient disinfection may be accom-
plished. After thorough irrigation, the wound is to be dressed on general
principles with a voluminous antiseptic gauze dressing. If the attempt
to get primary union has failed, the first indication of suppuration is to
be followed by immediate opening, sterilization, and drainage of the
wound. The surgeon's nails, hands, and instruments must be sterilized
before undertaking these manipulations. Failure to get primary union
of the soft parts is evidence that the wound was not made sterile.
Ordinary fracture apparatus, to maintain proper position of the frag-
ments, must next be applied outside of the gauze dressings.
When a simple fracture shows signs of becoming open because of
cutaneous sloughing, an effort should be made to prevent as long as
possible the separation of the eschar by keeping it aseptic.
Some open fractures demand immediate amputation, because the injury
is so severe that the sloughing sure to follow will probably prove fatal.
If, after an attempt to save the limb, unexpectedly severe symptoms
occurred, it was formerly considered to be usually better to delay ampu-
tation until suppuration and sloughing had been fully established. In
other words, intermediary amputations in such injuries were apt to be
disastrous. Immediate amputations—that is, those done as soon as reaction
from shock had occurred, and those done after the lapse of about ten days,
when suppuration was fully established—were thought more likely to be
followed by recovery. This is no longer a rule, as antiseptic methods
have altered the clinical history of all wounds, and will reduce the amount
of suppuration and the degree of septic poisoning in those cases where
the impossibility of obtaining a sterile wound has prevented primary
Ullſ]] Ol).
Antiseptic methods have enabled surgeons to save many limbs sub-
jected to open fractures, that under previous methods of treatment would
have required immediate amputation to save life. Almost any open frag-
ture in which the tissues are not absolutely devitalized can be successfully
treated if made perfectly sterile and kept so. I have been astonished at
UN UN I T E D F R A CT U R E O R P S E U I) A R T H R O S I S. 347
my success in these cases. Amputation is usually required in railway and
other injuries which cause crushing of the bones and pulpefaction of the
soft parts. Similar treatment is often demanded when the main artery
has been opened by the injury. In the upper extremity conservative sur-
gery is attended with less risk to life than in the lower limb, , Moreover,
the fact that artificial legs are very serviceable, while artificial hands and
arms are practically useless, argues something in favor of not taking too
much risk by trying to preserve a doubtful leg. It must be remembered,
however, that amputations high up in the thigh for any cause have a
somewhat high death-rate. Open fractures involving large joints may
often be treated by primary or secondary excision of the joint instead of
amputation. Gunshot fractures involving joints are an exceedingly serious
form of open fractures. If in open fractures running into joints the
limb is to be saved, antiseptic cleansing, free drainage, perhaps by many
counter-openings, antiseptic irrigation, and in extensive fracturing, ex-
cision must be the resorts of the surgeon. Excision may sometimes be
delayed and performed as a secondary operation when it can be better
determined how much bone must be sacrificed. Rigid and thorough pro-
vision for escape of all wound fluids must be insisted upon in all these
injuries. Drainage is an essential factor in open fractures.
Umunited Fracture or Pseudarthrosis.
PATHOLOGY..—It is occasionally found that some degree of mobility
and pain on motion persists after the lapse of what ordinarily would be
sufficient time to cause consolidation of a given fracture. Such instances
are denominated cases of delayed union. If successive weeks or months
pass without union occurring at the seat of fracture, the condition is un-
united fracture, false joint, or pseudarthrosis. Delayed union is usually
the result of deteriorated general health, while false joint in almost all
instances depends upon some local condition pertaining to the fragments
themselves. Many cases of delayed union finally terminate in complete
consolidation without any special treatment beyond building up the pa-
tient's health. False joints, however, whether sequences of delayed union
or cases showing from the beginning no tendency to union, persist, and
require either the adaptation of apparatus to supply the normal rigidity
of the limb or active and judicious surgical treatment. Efficient appara-
tus is more easily obtained for non-union in the upper than in the lower
limb, because of the weight-sustaining function of the latter.
It is not customary to apply the term ununited fracture to the fibrous
union that frequently occurs when short, spongy bones and the spongy
ends of long bones are broken, or when prominences for muscular attach-
ment are torn loose. These fractures would probably unite by ossific
deposition, as other fractures do, if correct apposition was obtained and
maintained. They actually, therefore, are cases of unuited fracture,
though not called so. The bond of union holding the fragments together
ºfter healed fracture occasionally undergoes softening and absorption
during the progress of phlegmonous inflammation of the limb, scurvy, or
other grave disorder. It is manifestly improper to apply the term un-
united fragture to this condition when it occurs subsequent to complete
*ion of the Osseous lesion. Atrophy of the bone itself sometimes occurs
after fracture.
Ununited fracture is a comparatively rare condition. The cases may
348 D IS E A SES A N D IN J U R IES OF B O N E S.
be divided into three classes: 1, those in which there is no bond whatever;
2, those in which there is more or less successful attempt at union by means
of bands of fibrous tissue and nodules of bone; 3, those in which a crude
joint is formed as exhibited by cartilaginous material on the apposing
surfaces of bone, synovial fluid, and a capsule. The first and third varie.
ties are very unusual. The second form is that usually found when un-
united fractures are dissected. The length and disposition of the fibrous
bands vary in accordance with the relation of the fragments. There
may be a mass of callus partially ossified and little fibrous tissue; or little
callus with bands of fibrous tissue uniting the fragments somewhat like
interOsseous.ligaments. This kind of non-union gives a flail-like limb if
the bands of fibrous tissue are long. It is more movable than the form
described as having a joint-like structure.
CAUSES.–Syphilis, pregnancy, advanced age, acute diseases, and other
Sources of physical deterioration and malnutrition have been described as
causes of ununited fracture. They apparently, however, have little influ-
ence in giving rise to non-union, though delayed union may perhaps be
due to them. Non-union is nearly always the result of a local cause, and
this local cause is usually mechanical. The most frequent agencies are:
(1) unfavorable relation of parts, such as great separation of the frac-
tured surfaces by reason of displacement, actual loss of substance, or
necrosis; (2) defective treatment, by which immobility of the fragments is
not secured; (3) portions of fascia or muscle, and bullets or other foreign
bodies lying between the fragments; malignant and other growths in the
same location. Destruction of the nerves coming from the trophic centres
in the lower part of the spinal cord, or of the centres themselves, has been
with apparent reason assigned as a cause of ununited fracture or pseudar-
throsis. It is also stated that softening or absorption of callus may follow
the too early use of a broken limb. This occurrence is doubtless the
result of motion at the seat of a partially ossified callus union and comes
under the head of defective treatment mentioned above.
DIAGNOSIS.—The diagnosis of ununited fracture is made by preter-
natural, and, in most cases, painless mobility existing long after the time
for consolidation has passed. Near a joint such mobility may simulate
the normal articular movement; or, a joint with relaxed ligaments
may simulate ununited fracture. The character of the defective union
is often obscure. If it is simply delayed, an elastic mass of callus,
which is the seat of pain on strong passive motion, will probably be
discerned by palpation. If a crude joint has been developed, no callus
and no pain will be found ; nor will the flail-like mobility of long fibrous
attachment exist. Careful palpation and puncture with long needles will
at times determine the position and shape of the fragments.
TREATMENT.-The treatment of delayed union consists in friction of
the limb, change of air, nourishing diet, and the administration of alka-
line phosphates and carbonates, and of tonics. A few additional weeks
under good hygienic circumstances is all that is usually demanded.
Ununited fractures, whether fibrous or articular, demand much more
active measures, of which the milder forms, however, should first be
employed. Rectification of any displacement that seems to interfere
with union should be accomplished, after which the immovable gypsum
dressing should be applied and worn for a month. If any increase of
consolidation is observed this dressing should be continued for several
months, during which time the patient may go about on crutches if it is
the lower limb which is the seat of injury. If the part becomes painful
UN UN I T E D F R A CTU R E O R P S E U D A R T H R O SIS. 349
from excoriation, the encasement may be split and laced or removed, and
a new one applied. . The latter method is probably the better. During
this period the hygienic measures noted above for delayed union should
be adopted. The application of the descending constant current has been
recommended, but is probably valueless.
Failure to accomplish anything by these plans necessitates the adoption
of operative measures, unless more support by apparatus to give rigidity
is acceptable to the patient and surgeon. º º
The operative plans aim either at setting up inflammatory action at the
seat of non-union, and thus stimulating functional activity; or, at con-
verting the old ununited fracture into a recent one with freshly sawed SUlT-
faces in apposition. Violent bending and rotation, such as will tear apart
the fibrous connections and cause the ends of the fragments to be rubbed
upon each other, will often be followed by consolidation. These manipu-
lations may be repeated daily until tenderness and swelling follow. º Upon
the appearance of these symptoms the limb should be immobilized in
splints and treated as a recent fracture. As a rule, the fibrous union can
at one sitting be torn up and the ends rubbed with sufficient degree of
force to cause the advent of tenderness on the following day. The bones
may be bent at right angles and extensively rotated and extended
without endangering the safety of vessels or other tissues. To be ol
service the manipulation must be thoroughly done; usually under influ-
ence of an anaesthetic. When the operation does not succeed in causing
deposition of callus and consequent union, subcutaneous drilling of
the fragments may be tried. A bone drill is introduced through a
small puncture in the skin and the ends of the fragments perforated in
various directions. Afterward retention apparatus is applied. Ostitis
is the result of this treatment, and may be followed by union. A similar
ostitis has been induced by driving an ivory peg through or into each frag-
ment, in which a hole has been previously made by means of a drill. The
fibrous bands should previously be ruptured by passive motion. The pegs,
which do not pin the bones together, are withdrawn in a few days when
pain is felt in the Osseous tissue. A better plan, when practicable, is to
bore holes into the fragments and pin them together by means of metal
screws or pegs of ivory or bone. These may be cut or broken off close to
the surface of the bone, and the tissues allowed to heal over them. Thus
the fragments are held in position while productive ostitis furnishes callus
to join them firmly and permanently. The ivory and bone pegs will be-
come absorbed, the steel screws encysted. If the surgeon prefers, the
screws or pegs may be allowed to project from the wounds of entrance
and be withdrawn in two or three weeks, when consolidation is partly
accomplished. This method is more apt to permit purulent infection and
cause suppuration than the former, but may in some instances be prefer-
able. The bone pegs are readily made from bone knitting needles,
The most radical operation for ununited fracture is resection of the
Wounded ends of bone. It makes an open fracture, but it is often the
only method that will lead to a cure. This is especially so in cases where
the non-union has caused the formation of a joint-like structure, and
where the failure of union is due to dead bone or portions of muscle be-
tween the ends of the fragments. The danger formerly belonging to this
prºcedure is obviated by the methods of antiseptic surgery. Suppuration
will seldom occur. A longitudinal incision is made, the ends of bone
turned out and sawed off after saving as much as possible of the perios.
teum, the limb put up in splints, and the wound treated antiseptically, as
350 D IS E A SES A N I) I N J U R IES OF B O N E S.
in open fractures. The chisel, bone cutters, or saw may be used to remove
the pieces of bone. Sometimes the ends may with advantage be fastened
together by wire, sterilized bone pegs or screws, as in accidental open
fracture. These substances may be cut off short and left in the wound,
or be taken out in about three weeks. As little as possible of the bone
should be sacrificed, only enough to give a broad, fresh surface of contact.
Sometimes shoulders are cut so that the fragments may be interlocked
or mortised together. Transplantation into the gap of small portions
of bone from the human subject or from lower animals has been prac-
tised with apparent success. It may happen that the excision of the ends
of the fragments with pegging or wiring them together will, if done anti-
septically, produce so little irritation that there is not enough productive
inflammation to cause union. When this is feared, it is best to leave the
wound in the soft parts open and plug it with antiseptic gauze, so that
more irritation will be induced and union occur only by second intention.
The outside dressing must be carefully applied, so as to prevent putrefac-
tive or purulent infection. Death frequently occurred formerly after
operations for ununited fracture from suppuration and sepsis.
Amputation is not to be considered in cases of ununited fracture, except
under exceptional circumstances, and when resection or one of the other
operations has been followed by gangrene or diffuse suppuration.
Deformed or Vicious Union of Fractures.
PATHOLOGY..—Absence of proper treatment in cases of fracture often
gives rise to deformed union, because callus will be furnished and consoli-
dation of the bony structures usually occurs, even when the fragments
have not been placed in correct apposition. Great disability may thus
result, especially in the lower limb. Angular deformity or overlapping
will cause shortening; the presence of an abnormal projection near a joint
may interfere with flexion and other articular movements. Change in
the long axis of the fragments and rotation may cause the weight of the
body to throw unusual strain on the lateral ligaments of the knee and
ankle, and produce secondary deformity in these situations. Vicious
union may also give trouble by causing painful pressure upon nerves, or
by inducing ulceration of the skin over projecting portions of bone. In
the forearm pronation and supination may be obstructed by bridges or
masses of callus attached to the radius and ulna. Deformed union some-
times allows muscles and tendons to become entangled in the callus, and
thus, if not remedied at an early day, gives rise to permanent impairment
of muscular action.
There are two methods of freatment: subcutaneous refracture, and divi-
sion of the deformed union. The former is less dangerous than the latter,
and, in fact, is practically devoid of danger, because it merely creates a
closed fracture which unites promptly, and there is naturally much less dis-
turbance of the soft parts than in similar fractures of accidental origin.
Hence little reaction follows. Experience shows that refracture or rup-
ture can be done as late as six and twelve months after consolidation has
occurred, and that with proper precautions the bone need never be broken
at other than the seat of original injury. Gradual bending and attempts
to soften the callus by applications or medication are a useless waste of
time.
Angular deformity is the variety that most frequently demands cor-
DE FOR MED OR VIGIOUS UNION OF FRACTURES. 351
rection. Fortunately it is also the most amenable to improvement.
Refracture of malunion a few weeks old can usually be accomplished by
seizing the limb firmly with the hands and forcibly bending the bone at
the seat of the old fracture. The bending is generally made in such a
way as to attempt at once straightening the bone. Sometimes it is better
to bend first in the direction of the flexion, as is done in breaking up an
ankylosed knee. It may be necessary to place a fulcrum, such as the
operator's knee or a block of wood, against the convex surface of the
angular deformity. Another method is to have the limb projecting over
the edge of a table and steadied upon the table by an assistant, while the
operator takes the distal end and suddenly throws his weight upon it. A
sudden force is much more effectual than gradual bending, which will be
found unavailable in all but recent cases. It is often well to bind a
straight splint to the limb below the seat of proposed refracture and
another above it, but neither of them should overlap the mass of callus.
These splints prevent motion and strain of the joints, give the operator
more leverage, and avoid the remote possibility of fracturing at any other
than the desired point. Strong extension and counter-extension by means
of pulleys may be applied at the time the cross-breaking strain is exerted.
The attachment of the pulley-rope can be satisfactorily made by the
notched extension plate of Dr. R. J. Lewis. When shortening is great
it may be well to continue anaesthesia and excessive extension for an hour
or so after refracture, to gain as much length as possible before dressing.
Some form of osteoclast, such as Taylor's or Rizzioli's, may be employed
in very firm consolidation."
FIG. 154.
Levis’s notched extension plate.
When the deformity depends upon lateral application of the two bony
cylinders rupture must be attempted by flexion across the bond of union,
combined with rotation in the axis of the limb, and strong extension and
Counter-extension. These cases are not as amenable to treatment as
angular malunion.
Division of the deformed union should only be employed when correc-
tion by refracture is impossible, because it creates an open fracture, and
may lead to suppurative dangers from neglect of antiseptic precautions.
An incision in the soft parts is made, and through this a small chisel or
saw is introduced. The callus is then divided, the deformity corrected,
and dressings applied as in open fractures. If simple division of the bony
tissue will not permit adjustment, or if the tissues of the concavity are very
tense, . wedge-shaped piece with its base at the convex surface may be
€XCISecl.
' See Edinburgh Medical Journal, July and August, 1878.

352 D 1 S E A S E S A N D IN J U R I ES OF B O N E S.
Projecting spurs of bone, acting deleteriously because of pressure or
their position near joints, may be removed with the saw or cutting forceps,
very much as an exostosis, and usually with as little risk. The operative
FIG. I55.
--~ſ
2. \
º
!
º
§º
º§
§
§
sº s w
...; ºft
fºº!'" *:::$$$$$
#jº
º iš * >
|iº
[. .
Taylor's osteoclast.
treatment of malunion in the forearm interfering with promation and
supination is surrounded with a good deal of difficulty. In some cases
division or excision of callus is justifiable.
SPECIAL FRACTURES.
Fractures of the Vertebrae.
Fractures of the vertebral column derive their chief importance from
the damage to spinal cord and nerve trunks, which so often accompanies
them. The spine requires solidity and flexibility in order to give support
and movement to the head, trunk, and limbs; but its protective function,
as regards the spinal cord, is even more essential to life and health. As
in cranial, so in spinal fractures, the surgeon is more anxious concerning
the integrity of the contained nerve elements than he is about the Osseous
lesion.
The vertebral column quite frequently sustains fracture from an in-
direct violence which tends to produce over-extension or over-flexion of
its normal curvatures. For example, a man falling from a height on his
head or buttocks, or being crushed under a weight falling from above
upon his head or shoulders sustains a fracture of the spine, because the
limit of flexion or extension has been exceeded and the bony Segments are
crushed or lacerated by the force. The fracture in such instances usually







F. R A C T U R ES OF T H E W E R T E B R AE. 353
occurs where a movable portion of the column joins a more rigid portion,
because here the sudden check to movement occurs. Hence, clinical ex-
perience shows spinal fractures from this form of injury to be more frequent
near the dorso-lumbar junction and in the vicinity of the fifth and sixth
cervical vertebrae.
PATHOLOGY..—The bodies of the vertebrae seem to suffer from fracturing
forces oftener in the lower than the upper region ; while the arches
are more frequently broken in the neck than elsewhere. Fracture of the
spinous process occurs most often in the dorsal region. The lines, of
fracture and the number of vertebrae involved depend upon the direction
and degree of the force. Dislocation often accompanies, the fracture.
Indeed, the two conditions are frequently indistinguishable except by
post-mortem examination."
Contusion, compression, and laceration of the spinal cord may be
caused by displacement of the fragments. It requires considerable dis-
placement to pinch the cord, for the canal is much wider than the
spinal cord and its membranes. As the cord ends at the level of the first
or second lumbar vertebra, fracture below this point can only compress
the leash of nerve roots and branches called the cauda equina or horse-
tail. Hemorrhage from the venous plexuses between the bony wall and
the dura mater may be a result of the fracture. Such hemorrhage and
inflammatory products may exert pressure on the nervous structures.
Extravasations of blood into the cellular tissue in front of and around
the spinal column often occur, and after a time may appear upon the
surface of the face, chin, neck, and other regions.
SYMPTOMs.—There is often in vertebral fractures no noticeable de-
formity, preternatural mobility, or crepitation. The diagnosis must then
depend upon the rational symptoms, which are, for the most part, refer-
able to lesion, either primary or secondary, of the spinal marrow. De-
pression may sometimes be discovered over a fractured spinous process or
vertebral arch, or an angular prominence may be perceptible posteriorly
after crushing fractures of one or more vertebral bodies. Unusual
mobility may be observed at times, especially in fractures of the cervical
region, and occasionally movable regions may become more or less immobile,
because of spasmodic contraction of the muscles about the fracture, or
because of interlocking of the fragments. Crepitation may be present,
absent, or discernible only by the patient. The manner in which the
spinal column is bound together with ligaments and surrounded with
muscles often prevents the discovery of these symptoms of fracture, even
When extensive fracturing exists. Localized pain, increased by manipu-
lation or motion, is usual in fracture of the vertebrae, but is not diagnostic
of the character of the injury.
In spinal fractures intelligence is unimpaired, except, perhaps, during
the stage of shock. Paralysis of the parts supplied by the nerve branches,
leaving the cord at or below the seat of injury, is a common symptom. In
locating a fracture by this symptom it must be recollected that the nerve
roots and branches run obliquely downward within the vertebral canal,
and do not escape at the inter-vertebral openings corresponding to their
Points of origin from the medulla. For example, paralysis of the legs
and trunk, extending as high as the distribution of the first lumbar nerve,
Would suggest that the fracture was located about the eleventh or twelfth
dorsal Vertebra. The paralysis is usually both motor and sensory, and is
Fºtial or complete, according to the character of lesion in the cord.
When complete, the area of cutaneous insensibility is sharply defined.
s) &
2. C.
354 DIS E A S E S A. N. D. IN J U R IES OF B O N E S.
Pricking the surface with the point of a pin is an easy method of deter-
mining the paralyzed area, and of estimating its increase as the cord
becomes involved in inflammatory processes extending upward. The lower
limbs alone will be motionless, if the fracture is below the origin of the
brachial plexus. Otherwise the arms will be paralyzed also. There is
usually no reflex contraction upon pricking or pinching the paralyzed
limbs, and electrical contractility is soon lost. If the paralysis is incom-
plete, hot and cold sensations may be distinguished. Sometimes cutaneous
hyperaesthesia exists. Darting pains may be felt in the limbs when the
partially paralyzed extremities are moved, though spinal pressure elicits no
such symptom. The occurrence of such pains is under some circumstances
a sign of returning innervation, and, therefore, a symptom of beginning
improvement. Tonic or clonic spasms of the muscles are occasionally
observed, and may be excited by manipulation, drafts of cold air, and
similar irritants. The paralysis may not be present immediately after
injury, but may supervene upon movement causing displacement, or arise
from an intraspinal hemorrhage or the development of inflammation of
the cord or its membranes. The superficial branches of nerves coming
from the medulla above the lesion may supply the integument for a con-
siderable distance below the injury, and thus deceive the surgeon as to
the location of the fracture.
As a result of the paralysis retention of urine occurs, to be followed
after a time by overflow and incontinence. Alkaline fermentation of the
urine within the bladder, and cystitis, soon supervene. Constipation, fol-
lowed by incontinence of feces, is another paralytic phenomenon. Tym-
panitic distention of the abdomen also takes place. In fracture of the
upper regions the respiratory distress due to paralysis of the abdominal
and other muscles of respiration is increased by this tympanitic distention,
which prevents full descent of the diaphragm. Bedsores appear, often
within two or three days, because the insensitive and motionless limbs do
not change the points of pressure. The probable occurrence of bedsores
is increased by the difficulty of keeping the sheets free from urine and
feces, which are evacuated unconsciously.
Persistent vomiting and marked elevation of temperature of the palsied
region have been observed in fractures of the upper part of the spine.
Priapism, more or less marked, is a common accompaniment of spinal
fracture. It seems to diminish in frequency as the injury occurs lower
in the vertebral column. Seminal emissions sometimes take place. In-
troduction of the catheter to relieve the distended bladder, though not
felt by the patient, may increase the erection or cause a partial erection
if none was previously present. I am not cognizant of erection of the
clitoris having been noted in females suffering from fracture of the spine.
Analogy suggests its probable occurrence.
A careful clinical study of the symptoms of spinal injuries will lead to
a more correct localization of the seat of fracture than is possible by a
cursory survey of the case. Spinal localization, as cerebral localization,
needs more consideration at the hands of surgeons. This matter has
been referred to in the chapter on Intraspinal Inflammation. Brain
lesions may coexist with spinal fractures and complicate the problem.
Fractures of the atlas and axis are very dangerous because they are
apt to involve the integrity of the medulla oblongata, with its numerous
nerve centres, and are above the roots of the phrenic nerves which, going
to the diaphragm, are the chief respiratory nerves. If cord injury occurs
and death is not immediate, the paralysis will almost certainly involve
F. R A C T U R ES OF T H E W E R T E B R AE. 355
the trunk, arms, and legs. Fractures below the axis and not lower than
the second dorsal vertebra are of unfavorable prognosis, because this in-
cludes the roots of the origin of the phrenic nerves and brachial plexuses.
The phrenic nerves emerge between the third and fourth cervical verte-
brae, coming from the fourth cervical pair alone or having accessory roots
from the third and fifth cervical nerves. The brachial plexuses are de-
rived from the fifth, sixth, seventh, and eighth cervical and first dorsal
nerves. Hence injury at, or no higher than, the fourth cervical vertebra will
involve the innervation of the arms, but will allow the functions of the
phrenic nerves to go on unless intraspinal hemorrhage or inflammation
extends above the level of the fracture. Lesion of the cord above the
fourth, sufficient to induce paralysis, will probably involve the phrenics
and cause death promptly by respiratory failure due to paralysis of
the diaphragm. When the other muscles of respiration, but not the
diaphragm, are paralyzed, the character of breathing is peculiar. In-
spiration occurs from diaphragmatic action alone and expiration from the
abdominal walls and viscera pressing the diaphragm up. Expiration
is consequently passive and feeble; hence the patient is unable to talk,
cough, or sneeze forcibly and the lungs become clogged with mucus.
Change of posture, by changing the pressure, may alter the complexion
of symptoms.
The character of the lesion in the cord determines the extent and
nature of the symptoms. Palsy may affect one or both arms or only
certain groups of muscles in the upper extremities. So the phrenic nerves
may be slightly involved and slow the movement of the diaphragm in-
stead of stopping it entirely and causing immediate death. Slow pulse,
some cyanosis, delirium, and coma may be observed in the clinical history
of fracture of the cervical vertebrae. Irregularity in the posterior wall
of the pharynx may be observed if the cervical vertebral bodies are
fractured or displaced. The paralysis of the legs, bladder, and rectum
will occur in a manner similar to what is observed in fractures lower in
the dorsal region, and in the upper lumbar vertebrae.
PROGNOSIS.–In spinal fracture accompanied by paralysis the prognosis
is unfavorable. Many cases die from spinal meningitis and myelitis
and from the exhaustion of bedsores and cystitis. Cases do at times re-
gover, but usually with considerable disability from loss of power in the
legs and imperfect control of the bladder and rectum. The lower the
seat of fracture the better the chance of recovery both as to life and to
function. In cases which finally prove fatal, life is the more prolonged
as the site of fracture descends the spinal column. In patients who finally
recover more or less completely, sensation usually returns in the palsied
region before motion.
TREATMENT.-The management of spinal fracture usually resolves
itself into catheterizing the bladder, preventing the occurrence of bed-
Søres, and treating the spinal injury and inflammation in accordance with
he rules laid down in the section on Diseases of the Nervous System.
The patient should be transported and turned when in bed with great
care. Especially in cervical fracture is this caution important, for there
unexpected displacement from movement is more liable to happen.
Sudden death from pressure upon the medulla may be thus induced. It
has been suggested in fracture of the neck to keep the patient lying on
his back with his head supported in a hollow made in a bag of sand.
In fracture lower down gypsum jackets have been applied after etherizing
*nd suspending the patient. The suspension gives an opportunity to
356 D IS E A SES A N ID IN J U R.I ES OF B O N E S.
reduce the fragments by extension and direct pressure, and the jacket
prevents subsequent displacement. The jacket is best made by soaking
at one time several sheets of gauze cut the proper shape, in a paste of
gypsum and water, and applying these layers around the trunk.
If displacement is discoverable and paralysis present, reduction of the
displaced fragments by means of extension, rotation, and pressure is justi-
fiable. Especially is this so because of the frequent impossibility of diag-
nosticating dislocation from fracture.
The urine should be drawn with a soft-rubber catheter three times in
the twenty-four hours, beginning as soon as retention occurs, which is
usually at once. The surgeon must look to this, for the patient will
feel no pain from the distended bladder. The dribbling that takes place
from overflow when the bladder is distended to its utmost may deceive
the nurse, who will think the urine is being passed incontinently. This
incontinence of retention calls for catheterization. Proper and early use
of the catheter delays the advent of cystitis. When true incontinence
occurs the catheter is no longer demanded. When cystitis has supervened
the bladder should be washed out daily or every other day with warm
water passed through a rubber catheter from a reservoir held a foot above
the patient's abdomen. The solution may be medicated as is detailed
in the section on Cystitis. Spinal fracture rarely gives rise to pericystitis,
pelvic abscess, or sloughing of the bladder wall, but may do so.
Bedsores are to be avoided by using an air- or water-bed and keeping
the patient clean. Careful turning to change the points of pressure is
often essential. A cheap water-bed can be made by filling a trough with
water and tacking a rubber blanket over the top.
Trephining, sawing, or cutting away the arches of the vertebræ for the
purpose of removing pressure on the spinal marrow has been attended
with some success, and should be adopted more frequently than has here-
tofore been the case. To a great extent the want of success is owing to
the fact that the injurious pressure is often caused by the displacement of
the vertebral bodies, which, being in front, are not easily reached; and to
the circumstance that operative interference is delayed. Reduction by
extension applied to the patient's shoulders and legs, and operative relief
of spinal cord pressure should be undertaken immediately after the receipt
of injury. Perhaps the cord may at times suffer pinching by a temporary
displacement of the fragments at the moment of accident. In such cases
operation would be of no service, because the bones have resumed their
normal relations. Operation is always justifiable if the fracture is definitely
located and there is no reason to suspect irrelievable displacement. It
must be attempted under most rigid asepsis or antisepsis.
Bromide of potassium, cupping and ice to the spine, belladonna, ergot,
iodide of potassium, Strychnia, massage, counter-irritation, and electricity
are therapeutic resources to be employed in accordance with the direc-
tions given under the treatment of Intraspinal Inflammation.
Fractures of the Cranium.
PATHOLOGY..—Cranial fractures differ from those of other regions in
not being subject to displacement from muscular action; in requiring
no retentive apparatus to maintain apposition of fragments, and in having
mo tendency to non-union. Their importance and interest, moreover,
centre, not in the damage dome to bone, but in the associated injury
F. R A C T U R ES OF THE C R A NIU M . 357
sustained by the brain and its membranes. The cerebral injury may
be contusion or laceration due to the same force that broke the bone;
or it may be inflammation and irritation occurring secondarily to de-
pression and splintering of the bone, and to bacterial infection through
the fissures in the bone, or to overgrowth of callus at the time of
repair.
It should be remembered that the walls of the cranium consist of
two tables, separated by a greater or less amount of soft and vascular
cellulated bony structure called the diploé. The inner table is nearly
always more extensively broken than the outer, because the fracturing
force, as a rule, is supplied from without inward. The greater shat-
tering of the inner table is especially marked in comminuted fractures.
The thinnest parts of the cranial wall are in the orbital, ethmoid, squa-
mous, and inferior occipital regions. The frontal region is remarkable,
after the age of infancy, for the existence in it of large cavities, the
frontal sinuses, between the two tables of bone.
The prognosis in cranial fracture is favorable, provided the brain sus-
tains no primary or secondary damage. Under opposite conditions death
often occurs. Epilepsy and insanity sometimes follow as remote results,
especially in fractures during childhood.
Union is rather slow because the callus is FIG. 156.
furnished by the osseous tissue rather
than the external periosteum and dura
mater. As the bony tissue is not very ſº
spongy and vascular, the amount of cal- º \
lus is small; hence openings left by re- ſ | º
moval of fragments or after trephining ſº # º º
are usually closed principally by fibrous º § sº
tissue. The button of bone, if kept asep- ºº: \
tic, may be replaced. It will usually º; º
unite with the surrounding bone and |#### º
cause bony closure of the opening. The º
fracture may be a single fissure or a series Repair by fibrous tissue after tre-
of fissures traversing the cranium for a phining.
great distance, even running across sev-
eral sutures. There is in such cases little or no separation or displace-
ment of the edges. Separation of the sutures is sometimes caused by head
injuries. This condition is practically the same as a fracture. Localized
Violence, if sufficient to cause fracture, gives rise, as a rule, to comminu-
tion of bone, and very often to displacement. This displacement is gen-
erally depression, though occasionally elevation of a fragment may be
observed. The depressed portion may be attached to the surrounding
bone along a part of its margin, thus having an oblique plane; or it may
be driven in so deeply that separation of its entire circumference has
9CCurred. One or more edges may be locked under the solid bone. Very
frequently the edges of the fragments are bevelled, because the inner table
breaks at a greater distance from the point of impact than the outer.
This is a frequent cause of interlocking, and of consequent difficulty in
elevating the depressed piece. A few cases of fracture of the inner table
Without fracture of the outer have been recorded. The diagnosis of
§ch gases during life must be obscure, unless the symptoms of brain
isturbance are sufficiently localized to justify trephining. Fractures of
the ºuter table without breaking the inner may be produced where
the bone is thick by any force only sufficient to drive the fragment
|:
§
§ º \





358 I) I S E A S E S A N ID IN J U R I ES OF B O N E S.
into the soft diploic structure between the two tables. In children per-
manent depression of the bone may occur after injury without actual
fracture. This is identical with what has been described as bending of
bones and as green-slick fracture. It is probable that some osseous
fibres at least are torn. Such a condition in the adult is unknown.
SYMPTOMS.–Fractures of the cranium, whether of the vault or base,
show no special rational symptoms that may not arise from cerebral con-
tusion, laceration, or hemorrhage without fracture. Marked depression
of the fragments, however, can be perceived through an untorn scalp by
palpation, as can the area of a greatly comminuted fracture which feels
soft and is easily depressed by the finger and perhaps shows crepitus.
Local subcutaneous emphysema in the mastoid region is diagnostic of
fracture into the mastoid cells. A translucent, pulsatile swelling of the
scalp is indicative of escape of cerebro-spinal fluid from the ventricles or
subarachnoid space, and is conclusive evidence of solution of continuity
in the cranial wall. It is, however, a rare phenomenon. Laceration of
arteries may give rise to large fluctuating tumors under the scalp without
any bone injury; but these are not translucent, nor as a rule pulsatile.
Depressed fracture is often stimulated by the swollen and infiltrated tis-
sues forming a hard ridge alongside of a softened and less elevated area
of scalp. To the surgeon’s finger this condition at times feels identical
with a ledge of bone at the side of a depressed fragment. It must also
be recollected that congenital depressions and irregularities from old inju-
ries, periostitis, and senile changes may exist. When a wound is present
the diagnosis is easy, for the fissure in the bone is easily recognized by a
red line due to the blood staining the crack. This must not be confounded
with the serrated lines shown by the great sutures, and the sutures around
occasional Wormian bones. If the outer table is broken the inner one
seldom escapes similar lesion. Brain tissue, cerebro-spinal fluid, and
blood escaping from the interior of the skull may aid in establishing a
diagnosis of fracture. Quite profuse venous bleeding, increasing in vol-
ume during expiration, does not prove that a meningeal vessel or sinus
has been torn, for it may come from the vascular diploic bone tissue.
Fractures of the base of the cranium can rarely be seen or felt by the
surgeon’s finger. There may be no special sign of the injury. At times,
however, the escape of brain substance, blood, or fluid from the ear, nose,
mouth or orbit, or the occurrence of paralysis of some of the cranial
nerves may serve to confirm the diagnosis.
Bleeding from the ear, nose, or mouth to be of diagnostic value must
be profuse and continuous; since limited bleeding occurs from damage to
the soft parts in these regions. The appearance of blood at the external
orifices of the head after laceration of an intracranial sinus, artery, or
vein, is due to fracture of the bony walls of these cavities and rupture of
the mucous membrane. In escape of blood from the ear the drum mem-
brane is also ruptured. Sometimes, when the petrous portion of the tem:
poral bone is broken, and the drum membrane not injured, the blood
passes into the pharynx by way of the Eustachian tube, to escape by the
mouth or nose, or to be swallowed and subsequently vomited. Marked
extravasation of blood under the conjunctiva covering the eyeball, espe-
cially if it occur a day or more after the head injury, and it does not
appear in the eyelids till some hours later, is very suggestive of
fracture of the orbital plate of the frontal or sphenoid bone. Direct
external injury to the eyeball and violent vomiting or coughing may
also give rise to subconjunctival ecchymosis. So, also, may fracture
F R A CT U R ES OF T H E C R A N I U. M. 359
of the malar or upper maxillary bone. Signs of orbital aneurism, such
as protrusion of the eyeball, pulsation, and murmur, suggest the occur-
rence of damage to the internal carotid artery or the cavernous sinus and
make fracture of the cranial base probable. The late occurrence, after
injury, of ecchymotic spots in the suboccipital region or below the mastoid
process tends to confirm the diagnosis of basal fracture.
Discharge from the ear of an abundant, colorless, watery fluid, with
little accompanying hemorrhage, especially if it occurs promptly after
receipt of injury, and if the flow is modified by the position of the head
and by coughing, is characteristic of fracture of the petrous bone and
laceration of the tympanic membrane. It is cerebro-spinal fluid which
will be found highly saline and almost destitute of albumin. The escape
of watery liquid from the ear under other circumstances is of limited
diagnostic value. It may be the liquid of Cotunnius from the internal
ear, or blood serum escaping from a clot in the oral passages.
Cerebro-spinal fluid, in rare instances, may escape from the nose or
mouth because of fracture of the spheno-ethmoidal portion of the base,
or petrous fracture without rupture of the tympanic membrane. In the
latter event the intact membrane prevents escape from the auditory
meatus and the fluid passes into the pharynx by the Eustachian tube.
Escape of cerebro-spinal fluid or abundant hemorrhage in basal fractures
is an evidence of serious, but not necessarily fatal injury.
Paralysis of a cranial nerve occurring immediately after the receipt of
a head injury may be due to laceration of the brain near the origin of
the nerve or to hemorrhage within the nerve sheath. It is very suggestive,
however, of fracture of the base with synchronous rupture, contusion, or
compression of the nerve trunk. The pressure may arise from the ex-
istence of displaced bone or a large clot. The nerves most frequently
subjected to such conditions in basal fracture are the facial, auditory,
optic, and olfactory.
TREATMENT.-There has been until recently much discussion regarding
the proper treatment of cranial fractures. Some surgeons opposed oper-
ative interference in the great majority of cases, while others believed
that a more frequent adoption of trephining would give an increased ratio
of cures. As death from the associated or induced brain lesion is common
in fractures of the cranium, it is certain that the mortality will be de-
creased by early and more frequent antiseptic operations. Elevation and
removal of bone with extraction of splinters of the inner table, removal
of large clots, and incision even of the dura mater would avail nothing in
cases where there has been serious contusion or laceration of the interior of
the brain substance; but many cases undoubtedly die because peripheral
lesions immediately adjacent to the site of fracture are untreated by
mechanical means until the pathological process has advanced too far to
be remediable. Fractures of the base are amenable to but little operative
treatment, except that the nasal cavities and ears should be made aseptic
and plugged with gauze impregnated with beta-naphthol, carbolic acid,
ºr iodoform. The general treatment is identical with that proper in
fractures of the vault, as is the operative treatment when the lesion is
accessible.
The shock following head injuries is to be met by recumbency and the
*easures spoken of in the section discussing Concussion and Contusion of
the Brain. Care must be taken not to continue a stimulating line of
treatment after reaction has fairly begun, because the danger in these
*ses pertains to encephalitis, which is a possible sequence of the injury.
360 D IS E A SES A N ID IN J U R IES OF B O N E S.
As soon as the condition of shock will permit, therefore, elevation of the
head, cold to the scalp, low diet, perfect quiet, purgatives, and bromide
of potassium (3ij to 3iv in twenty-four hours) should be insisted upon.
Alcoholic stimulants should not be given unless the primary shock is pro-
found, and then should be speedily discontinued. Shaving the entire
scalp is a wise measure, since it permits more accurate examination for
scalp-wounds and cranial depressions, and, in addition, renders the appli-
cation of cold to the head more effective. A rubber bag or bladder filled
with cracked ice, a coiled tube with cold water circulating in it, or
cloths wet with ice-water, are easy methods of applying cold to the scalp.
If ice is used, a degree of cold sufficient to freeze the skin might be
obtained in careless hands. Retention of urine often occurs, and requires
the use of the catheter. General bloodletting or cupping at the back of
the neck may be necessary in the stage of inflammation. These questions,
however, as well as the symptoms of traumatic inflammation of the brain,
are all discussed under the head of Encephalitis, which should be referred
to in this connection.
Opinions still differ somewhat as to what circumstances render it justi-
fiable to convert, by incision, a closed cranial fracture into an open one,
or to perforate the skull by trephine or saw and thus expose the dura
mater. I look upon incision of the scalp and trephining as exploratory
rather than therapeutic measures. In many instances the uncertainty as
to the cranial lesion is more dangerous to the patient’s life or future
health than the conversion of a closed into an open fracture or the ex-
posure of the encephalon by perforation of its bony wall. Improved
methods of wound treatment have greatly lessened the risk from such
operative procedures, but encephalitis is as fatal as ever. The symptoms
denominated “compression of the brain * are probably the evidences of
encephalic inflammation rather than of brain compression. As this in-
flammation is frequently due to injury from spicules of the inner table of
the bone, to irritation from intracranial bleeding, or to septic infection, I
prefer to eliminate by operation the possibility of this inflammation being
due to local causes under the seat of fracture.
In punctured fractures immediate trephining to remove the depressed
and splintered bone, to sterilize the wound, and thus to avert encephalitis,
is advised by all authorities. This should be the line of treatment, even
when no cerebral symptoms have developed. Punctured fractures are
those open fractures with accentuated depression that result from blows
inflicted by the corner of a brick, the point of a spike, or any very local-
ized force that produces a puncture of the cranial wall with extensive
splintering and driving-in of the inner table. Gunshot fractures of the
cranium are, in my opinion, to be treated as punctured fractures.
The following tabulated statement gives my views concerning the
proper treatment of cranial fractures. I admit that it is more heroic
than that generally taught, but it has been written only after careful
consideration of the reasoning of those who hold the opposite opinion to
my own. Every case must be individually studied, and the patient's
chances of death, of return to perfect health, and of life with subsequent
epilepsy or insanity carefully weighed; but for a working rule to guide the
student and practitioner, I think experience will show the indications
given in the table to be correct. Trephining, properly performed, is in
itself so free of danger that in a doubtful case the patient had better be
trephined than allowed to run the risk of death, epilepsy, or insanity.
F R A CT U R E S OF THE C R A NIU M. 361
SYLLABUs of TREATMENT OF CRANIAL FRACTURES.
1. Without evident depression. Without brain symptoms. No operation.
& 4 © ( & 4 With { { £ 4 Incise scalp and tre-
phine.
cºlºured frac 4 3 With 4 & { { Without ‘‘ { { Incise Scalp and pos-
- sibly trephine.
4. * { & & & 4 With & 4 & 4 Incise Scalp and tre-
phine.
ſ 5. Without { { 4 & Without “ & £ Incise scalp and prob-
ably trephine.
6. ſº º & ºf { { With & C & & Incise scalp and tre-
Closed comminuted hine.
fractures. 7 With ( & & © Without ‘‘ & £ Incise scalp and tre-
hine.
8 { { & 4 & & With { % & 4 Hºralp and tre-
phine.
ſ 9. Without & & & K Without “ & 4 No operation, and
| treat wound.
Open fissured frac-4 10. 44 & C & C With { { C & Trephine.
tures. 11. With & & ( & Without, ‘‘ { % Possibly trephine.
12. { { { % { { With & 4 £ & Trephine.
( 13. Without & . £ 4 Without “ & 4 Probably trephine.
Open comminuted J 14. 4 & & & £& With & 1 { % Trephine.
fractures. 15. With Q & & C Without ‘‘ & & Trephine.
16. & C & 4 £ 4 With & & { { Trephine.
Pºn: } 17. In all cases . - e. - e - s - * . Trephine.
In classes 3 and 11 I should be inclined to trephine if the depression
was marked or the fissures sufficiently multiple to approach the character
of a comminuted fracture.
In classes 5 and 13 I should trephine unless the comminution was
found to be inconsiderable.
Operation, when decided upon, should be performed at once or certainly
not delayed more than a few hours. All cases, whether trephined or not,
should be treated as cases of incipient encephalitis.
When careful study of the paralytic and other symptoms accompany-
ing head injuries localizes the cerebral lesion near the seat of contusion
of the scalp, incision is to be resorted to promptly, even if there is only
a suspected fracture. If no fracture is found trephining should, as a rule,
be performed, because it is probable that a hemorrhage has occurred either
between the bone and dura mater or under the dura mater. Trephining
Will permit the surgeon to remove this source of trouble if outside the
dura mater; if absence of pulsation or change in color of the dura mater
is observed he should incise that membrane in the expectation of finding
a clot beneath it.
The study of cerebral localization should be cultivated by all surgeons,
for many cases of head injury would be treated much more successfully
than is usually the case if the neurologist and surgeon employed their
skill in combination. The symptoms and cranial lines by which neurolo-
gists locate brain lesions have been referred to in the section on Encephal-
itis, which should be read in this connection. Incision of the dura mater,
*Spiration of the brain substance, and the excision of brain tumors will
become less unusual when all surgeons are familiar with the principles of
Cerebral localization." In fracture of the cranium trephining is sometimes
demanded by the paralytic and other symptoms localizing the lesion
under the seat of fracture, when the amount of damage seen in the skull
Wºuld lead one to abstain from operation. Hence cognizance of the sig-
*ificance of local palsies and spasms is demanded of the skilled Surgeon.
c º, greative Surgery of the Human Brain, by John B. Roberts. P. Blakiston &
362 D IS E A SES AN ID IN J U RIES OF BO N E S.
TREPHINING-Perforation of the cranium should usually be done by
means of a slightly conical trephine, which is safer than the cylindrical
instrument, except in the hands of one familiar with the operation. Holes
of various shapes can readily be made by the flat-face burr of the surgical
engine, but this apparatus is not always obtainable. Holes of any shape
Flg. 157.
sº
*ºº
&
Hopkins's gnawing forceps.
and size can be made by enlarging a small trephine cut with the gnawing
forceps. Since the usual object in cases of fracture is to get an opening
through which to insert an elevator to pry up the depressed fragments, a
small trephine should be employed. One not over three-eighths of an
inch in outside diameter at the cutting edge is large enough. In opera-
#ſſiſi.
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Author's aseptic trephine.
i
§
i
tions for removing brain tumors a trephine of one and a half to two
inches in diameter may be used. After the induction of anaesthesia, the
incision in the scalp should be made of a horseshoe shape, with its con-
vexity downward when the patient is recumbent, so that during the after-
treatment the drainage may be free. If a wound previously exists it may
be enlarged by a conical incision, though the horseshoe flap affords better




















F. R A CTU. R. E S OF T H E C R A N I U M . 363
exposure and should be made if the shape and position of the wound will
permit. The knife should divide the scalp and periosteum at the same
time in order that all the soft structures may be raised in one layer. If
any periosteum remains attached at the seat of operation it should be
pushed back with the knife handle.
In trephining for epilepsy, cerebral abscess or tumor the periosteum
need not be removed except at the point where the crown of the trephine
is applied. Indeed a circular incision in it the size of the disk to be re-
moved is all that is needed. When the aseptic button of bone is to be
replaced in the gap the periosteum upon its upper surface may then be
utilized for holding sutures passed through it and then through the peri-
osteum at the margin of the opening.
The crown of the trephine should be placed on the bone perpendicu-
larly to its surface, but before its application the centre-pin of the trephine
must be protruded about one-sixteenth of an inch. In fractures the in-
strument must be placed on solid and undepressed bone with about one-
third of the crown overlapping the portion to be elevated. If the latter
precaution is not observed, a bridge of solid bone will be left, which will
prevent the application of the elevating lever. Elevation and extraction
are often facilitated by removing a disk at the least depressed edge of the
depressed fragment. The trephine should be semi-rotated from left to
right and right to left, with moderate pressure against the bone. As soon
as the groove is made sufficiently deep to maintain the cutting edge in
position, the centre-pin is retracted lest it should perforate the inner table
and membranes. The trephine is
then reapplied and the groove cau-
tiously deepened. When blood begins
to flow it is evident that the diploic
structure is being cut by the sawing
edge, and additional care must be
exercised, since the inner table is
thin. In some skulls, however, the
diploé is practically absent. After , , ,
a few more half-turns have been :
made the trephine is removed, and $
the depth of the groove ascertained §:
by carrying along it the point of a º
probe or pin. If the skull is of un- ;
even thickness, as shown by the cran-
ial wall being completely divided in
One segment of the circle and not in
the remainder, the trephine must be
tilted toward the uncut side and cau-
tiously rotated, or a segment trephine
may be used. Very soon the disk
is found to be loose, and is readily
picked or tilted out by forceps or #
elevator. . If the Roberts's aseptic wº
trephine is employed there is less Author's segment trephine.
danger of Sepsis because there is no
°ntre-pin tube to retain bacteria. The disk is then dropped out of the
*ºn instead of retracting the pin when a groove is cut.
he point of an elevator is then pushed under the depressed fragment,
and used as a lever to raise the bone into place, Loose pieces and spicules
-SS
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-: sº *
ñº),
h * +
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; ;
IE
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º, Il Wººl
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364 DIS E A SES AN ID IN J U R I ES OF B O N E S.
of bone are removed by the elevator or forceps; but care must be observed
not to twist during extraction a large and interlocked fragment so as to
lacerate the dura mater. It is better to saw away the ledge or point of
bone interfering, or even to make a second trephine hole. There is
usually in comminuted fractures one piece that acts as a keystone; when
this is removed or elevated, the other fragments are readily managed. The
Hey’s saw and gnawing forceps do good service in cutting away corners
of bone. Spicules driven into the membranes or brain should be searched
for with the finger, and at once removed. Finally, all sharp edges of
bone should be trimmed away, the wound washed with sublimate solution,
a drain of catgut or rubber tube inserted, the scalp flaps sutured in
position, and the gauze dressing applied. No metallic plate is ever used
after trephining. The bone wound closes usually by fibrous tissue, the
Scalp wound heals as do other wounds of the soft parts. It is common now
to replace all or some of the fragments of bone, in order that they may
aid in closing the gap in the skull, by furnishing Osseous tissue and in-
ducing Ossific deposition in the granulation tissue.
To accomplish this successfully, it is necessary that the fragments taken
out be thoroughly cleaned in an antiseptic solution, of a temperature of
about 105° F., and then kept warm in a similar antiseptic lotion, or
between warm antiseptic cloths, until the moment before the flaps are to
be sutured. The bony fragments are then laid loosely upon the dura
mater and covered by the scalp tissues. This procedure is most successful
in exploratory operations, because then there is less probability of the
grafts being septic.
Incision of the dura mater, hypodermic puncture of the brain, or even
incision of abscess in the brain, does not alter the method of procedure,
So far as the preliminary trephining and after-dressing are concerned.
The dura should, however, be sutured with catgut if large incisions have
been made in it. The bone grafts can then be laid upon it; but provi-
sion should be made for removal of serous exudations and blood by
drainage. The drainage tube or threads may be removed in thirty-six
hours, if the wound is aseptic.
If it is possible to avoid doing so, the trephine should never be applied
over the Superior-longitudinal sinus, the lateral sinus, the torcular
Herophili, or the middle meningeal artery where it grooves the anterior-
inferior angle of the parietal bone. Hemorrhage from wounding these
structures may prove very serious.
The removal of comminuted bone, however, may lay open these vessels.
Bleeding from the artery may be arrested by ligation, by forcing a piece
of wood into the bony canal, if there is one, or by seizing the vessel and
the bone in a pair of spring forceps, which can be left in position for
several hours. Hemorrhage from the venous sinuses may at times be
controlled by forcing a little pad of absorbent gauze or sponge between
the vessel and the overlying solid bone. Ligatures or a suture carried
around the bleeding vessel by means of a needle should be tried when the
hemorrhage persists. Trephining over the sinus, at a point a little distance
from the wound, might be required to enable the surgeon to apply such a
suture; but this event must be exceedingly rare. Hemostatic forceps
may be left in situ until the first dressing is changed. In trephining over
the air-cells in the frontal bone, called the frontal sinuses, a large trephine
should be used to perforate the outer table, and a smaller one to bore
through the inner.
FRACTU RE OF T H E N A SAL BONES AND C A RTIL AGES. 365
Fractures of the Bones of the Face.
Fractures of the facial bones are usually the result of great direct
violence; hence several of the bony components of the face may be broken
by the same injury. Owing to the great vascularity of the parts, union
takes place quickly and with the formation of but little callus. It is im-
proper to remove splinters of bone which seem to have but slight attach-
ment, for necrosis of such pieces is uncommon.
Fracture of the Nasal Bones and Cartilages.
Injuries of the nose producing fracture may involve, in addition to the
nasal bones, the nasal processes of the Superior maxilla, the frontal spine, and
the perpendicular plate of the ethmoid upon which the nasal bones are
supported. The cartilaginous septum is often bent or broken, and the
lateral cartilages may sustain similar lesions, or be torn loose from the
lower end of the nasal bones. The womer likewise may be broken. It
is said that fracture of the cribiform plate of the ethmoid may accom-
pany fracture of the nasal bones. I can scarcely conceive of this occur-
ring, unless the force was violent enough to cause fracture first of the
frontal bone. Such instances are properly considered and treated as
fractures of the cranium. In young children the arch made by the junc-
tion of the two nasal bones, may, it is said, be flattened from the suture
opening on the posterior aspect. Blows received directly on the top of
the nasal bridge would have this tendency.
Fractures of the nose are often comminuted, and attended with much
swelling. The swelling, which rapidly appears, is liable to conceal the
displacement, interfere with accurate diagnosis, and obstruct nasal
respiration. Congenital deviations of the septum may deceive the
surgeon. Emphysema of the face may occur from air escaping into the
subcutaneous cellular tissue during efforts at blowing the nose soon after
the injury. This symptom needs no treatment. Some suppuration often
occurs, because the mucous membrane is torn and bacteria get access to
the wound from the nasal chambers. Caries and necrosis are rather un-
usual, but may occur. Union generally takes place rapidly, and is com-
plete within two or three weeks. If the fracture
extends into the nasal processes of the superior FIG. I 60.
maxilla, the lachrymal duct may become occluded
by the displacement or by callus.
The risk of permanent disfigurement is so great
and union occurs so soon that careful examination
and replacement should be instituted promptly,
and, if necessary, under an anaesthetic. If the
nasal bones are depressed, a narrow and rigid in-
Strument, such as a grooved director, passed into
the nostril will probably enable the surgeon to ele- *
Vate the fragment. When there is a tendency for Author's method of pin-
the depression to recur, a steel pin or needle may ning nasal septum.
be thrust through the nose from right to left under-
neath the broken bone. A strip of rubber or adhesive plaster carried
across the dorsum of the nose is then attached to the ends of the needle.
Perforated shot may be clamped upon the ends of the pim to prevent

366 DISE As ES AND IN J U RIES OF BONES.
spreading and flattening of the nasal bridge. It is well to place a small
disk of rubber on the pin, between the skin and the shot, to prevent ulcera-
tion and to maintain elastic compression. The pin should remain in position
for about ten days. When a tendency to displacement of the cartilaginous
portion of the nose is present, the proper conformation should be main-
tained by transfixing the cartilages with pins, and, by a sort of leverage
action, pinning them in place. I have found this method effectual, after
incising the deformed cartilage in cases of nasal deformity from fractures
received many years previous to operation." Plugs and canulas in the
nostrils are uncomfortable, unnecessary, and inefficient... Cooling lotions
may be applied to the fractured nose, if there are much pain and swelling.
Patients should be cautioned against violently blowing the nose or snuffling,
for displacement may thus be caused.
If profuse hemorrhage occurs, the nostril on the bleeding side should
be plugged. The method recommended by Dr. R. J. Levis is the simplest
and best. To the end of a strong string, about eight inches long, a disk
of moistened sponge, about three-fourths of an inch in diameter and three-
eighths of an inch in thickness, is firmly tied. This sponge is oiled, and,
by forceps, pushed into the nostril and along its floor till it reaches the
posterior nares. Upon the string hanging from the anterior nostril four
or five similar disks of sponge are strung by central holes like beads, and
consecutively crowded into the nose until the cavity is filled. After the
lapse of twenty-four hours the disks are removed one by one. This
method is much better than that accomplished by means of Bellocq's
canula, and is applicable to idiopathic as well as traumatic bleeding.
Fracture of the Malar Bone and Zygoma.
These rare injuries are readily recognized by the deformity and the
irregular outline, which can be felt by the fingers. If fracture of the
malar bone extends into the floor of the orbit, the superior maxillary
nerve may be injured, subconjunctival ecchymosis appear, or protrusion of
the eyeball from intra-orbital hemorrhage take place. In fracture of the
zygomatic arch the mouth may not open freely, because the displaced
fragments obstruct the movement of the coronoid process of the lower
jaw. Pain and swelling sometimes simulate or increase this disability.
The treatment consists in replacement by pressure of the fingers upon
the cheek or within the mouth. If necessary, an incision may be made
for the introduction of a lever under the displaced bone, or a screw may
be fastened into the bony surface and used to pull the fragment upward.
Fractures of the Superior Maxillary Bone.
The alveolar, nasal, and other processes of the upper jaw bone are the
parts that most frequently sustain fracture. Even these injuries are
uncommon, except fracture of the alveolar process during the extraction
of teeth. The lachrymal canal, the orbit, and the superior maxillary
nerve may be involved in the injury, with results similar to those de-
scribed above under nasal and malar fractures. Union occurs in three
or four weeks. Separation of the suture between the two superior max-
illaries has been observed.
1 See Cure of Crooked and Otherwise Deformed Noses, by John B. Roberts, Phila., 1889.
FRACTURE OF THE IN FERIOR MAXI LLA R Y BON E. 367
Examination of the surface of the face and of the interior of the mouth
will disclose the nature of the lesion. In treating such fractures loose
teeth should be left in place, for they frequently become firmly fixed
again. Apposition can sometimes be maintained by keeping the teeth of
the lower jaw firmly closed against those of the upper by means of Bar-
ton's bandage or a band of adhesive plas-
ter passed under the chim with its ends FIG. I. 61.
crossed at the top of the forehead. Wiring
the teeth adjoining the line of fracture is
sometimes a good means of preventing
motion.
The inter-dental splint, which is a mould
of gutta percha or similar plastic material
made to fit the grinding surfaces of the
teeth of both jaws, will in most instances
act sufficiently. It is placed in position,
and the mouth kept shut by bandaging or
adhesive plaster. Cork cut to fit the teeth
in the same manner will answer a good Gunning's inter-dental splint, with
purpose if no dentist is at hand to make opening for introducing food.
the more complicated apparatus. During
the three weeks that closure of the mouth is enforced, liquid food is
introduced through the crevices between the teeth or by a tube passed
between the alveolar arch and cheek as far back as the last molar. Inter-
dental splints may be made thick enough to have a perforation for this
purpose.
Fracture of the Inferior Maxillary Bone.
The lower jaw is more frequently broken than any other bone of the
face. The seat of fracture is generally toward the anterior part of the
body of the bone. Fracture of the ramus is comparatively rare, and
fracture of the condyle and coronoid process even more unusual. The
body of the bone is said to be weaker and more easily broken near the
root of the canine tooth and the mental foramen than elsewhere. Loss
of teeth and consequent atrophy of the alveolar
process may reduce the normal strength of the FIG. 162.
bone in other situations, and be the predisposing
cause of fracture. The most frequent seat of
fracture, according to Gurlt's statistics, is near
the middle line in front. These statements
exclude from consideration mere splintering of
the alveolar process often produced by pulling
teeth and by other causes. Double fracture of
the lower jaw is not uncommon.
When the body of the bone is broken the
fracture often communicates with the mouth
through a tear of the gum. The fracture be-
gomes in such cases, therefore, an open one, and º
is accompanied by suppuration because it can- Fracture of lower jaw behind
not be kept aseptic. Suppuration is usually teeth.
not Very great, for drainage is free. The close
attachment of the fibrous tissue of the gum to the alveolus is a sufficient
explanation of this frequent complication. The inferior dental nerve


368 DISE A SES AND IN J U RIES OF BONES.
may be torn or bruised when its canal is involved in the fracture. An-
aesthesia of the corresponding half of the lower lip and chin is the result
of this nerve lesion.
The displacement and unnatural mobility in fracture of the body are
easily detected, but the surgeon must bear in mind the possibility of mal-
positions of the teeth from irregular development and irruption. In single
fracture of the body away from the median line the anterior fragment is
apt to be displaced inward toward the mouth. In double or bilateral
fracture of the body the middle or chin portion may be drawn downward
by muscular action. The displacement in fracture of the ramus is more
difficult of detection, but may often be recognized with the finger in the
mouth.
Pain, often increased by motion or deglutition, and excessive secretion
from the mouth are observed in fracture of the lower jaw. Perhaps the
increase of saliva and mucus is largely apparent, the excess observed
being really due to a want of proper control of these fluids within the
mouth. Fetor from decomposing food, pus, and other secretions is often
marked. Abscesses about necrosed pieces of bone, fistulous tracts, and
ulceration of the mucous membrane may add to the discomfort of the
patient, who perhaps becomes greatly debilitated by swallowing foul secre-
tions and being deprived of a fully nutritious diet.
|Union of ordinary fracture of the jaw takes place in five or six weeks.
The prognosis, even in bad cases, is ultimately good. Even if teeth are
lost the solid union which occurs gives a good basis for the adaptation of
artificial teeth.
FIG. 163. FIG. H64.
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t
º
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º w º
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22 2,2 °
23 - 2
2.
%
Barton's bandage for fracture Garretson’s modification of Barton’s bandage.
of jaw.
Reduction of the fracture by pressure of the fingers on the teeth is
usually easy, though occasionally comminuted fragments or displaced
teeth may cause interlocking and require removal before correct apposi:
tion is obtainable. Teeth which are simply loosened should not be pulled
unless they impede reduction. Tenotomy of displacing muscles is rarely
necessary. The liormal relation of the upper and lower teeth in most
mouths is that the upper incisors come in front of the lower when the
mouth is quietly closed. This should be recollected. Generally there is
little tendency to displacement after ten days have passed. Hence after





FRACTURE OF THE IN FERIOR MAXILLA R Y BON E. 369
the lapse of about three weeks the dressings may be removed, and the
patient given an opportunity to attempt mastication cautiously in order
to demonstrate whether the fragments have been adjusted in a manner to
give the best use of the teeth in chewing... Any slight change in adjust-
ment is then possible, for consolidation will not be complete. After re-
duction uncomplicated fractures of the jaw are to be treated by keeping
the upper and lower teeth in contact by means of the Barton figure-of-
eight bandage of the occiput and chin. The mouth must be cleansed
with disinfectant washes of carbolic acid or beta-naphthol, tincture of
myrrh (m_xv to fij of water) and similar drugs. Feeding, as in fracture
of the upper jaw, is accomplished by introducing milk and soups through
the crevices between the teeth, or by a tube passed behind the last molar
or through the nostril. The hair and beard of men should be closely cut
before these bandages are applied; otherwise they are apt to slip or be
very uncomfortable. *
When the simple bandage does not give sufficient firmness to cause
maintenance of correct apposition, or when the lateral pressure of the
bandage causes overriding, it is well to adapt a moulded splint to the out-
side of the chin. Pasteboard, felt, leather, gutta percha, or gauze stiffened
with gypsum are the proper materials from which to construct a hollow
cap to fit the front and lower surface of the chin. The splint should ex-
tend on each side nearly as far back as the angle of the jaw; and may
need a crescentic portion of its posterior edge cut away in order to avoid
pressure on the throat above the larynx. The splint is padded and placed
Over the chin and held in position by the bandage. Before applying the
bandage, the splint may be fixed in position by carrying a band of rubber
adhesive plaster over the splint and as high up on the cheeks as the
Zygoma.
FIG. 165. FIG. I66.
Original shape of gutta percha or pasteboard. Gutta-percha splint moulded to
fit chin.
If the tendency to displacement is persistent, wiring the fragments
together 9r some form of interdental splint becomes necessary. A strong
silver or iron wire may be fastened around several teeth on each side of
the fracture; or in open fractures the ends of the bone may be drilled
and, wire sutures passed through. Interdental splints are splints worn
*ide the mouth and so fitted to the teeth and alveolus that motion at
the seat of fracture is prevented. An impression of the teeth and alve-
olus is taken while the fragments are held in position. By means of this
*P*śsion a splint of metal or vulcanized rubber is constructed which
*ins indentations into which the teeth accurately fit. If such a splint
**pplied to the teeth of the broken jaw and fixed so that the jaw bone
ls kept continually in close contact with it motion at the seat of fracture
**Possible, because the crowns of the teeth are buried in indentations
on the surface of the splint. There are several methods of securing the

24
370 D IS E A S E S A N D IN J U RIES OF B O N E S.
splint to the jaw. Probably the best is to have the upper surface of the
splint fitted to the upper teeth. The jaws are then closed upon the splint
and kept in that position by a Barton bandage. Lateral motion is prevented
by the depressions into which the teeth fit. Such an interdental splint
can be made thick enough to permit openings for feeding between the
upper and lower surfaces of the splint. An illustration of this splint is
shown above under Fractures of the Upper Jaw. Instead of using the
upper jaw for immobilization the splints may be fitted to the lower jaw
alone and attached by rods coming out of the corners of the mouth to a
splint under the chin. A simple splint is made by softening a gutta-
percha strip in hot water, moulding it to the crowns of the lower teeth so
as to overlap the adjacent gum and hardening it by cold water. Such a
splint may be fixed in position by wires carried by means of needles
through the muscles and skin of the chin and twisted under the chin
over small rolls of plaster or pieces of cork. In subjects who have lost
all or nearly all their teeth interdental splints moulded to the atrophied
gums present about the only efficient means of maintaining immobility.
In all forms of splints greater immobility will as a rule be obtained by
bandaging the jaws together. If desirable, gutta-percha wedges may be
placed between the jaws on each side of the mouth in order to have a
space in the middle for introduction of food. A crude form of interdental
splint may be made of cork cut to fit the teeth of the two jaws.
Fracture of the Hyoid Bone.
The hyoid bone is rarely broken, and when sudden lesion is sustained
the bone usually gives way near the junction of the great horn and the
body of the bone. Fracture of the hyoid bone is at times associated with
fracture of the laryngeal cartilages, and is due to similar causes, namely,
pressure of the rope in hanging, grasping the throat by the fingers as in
homicidal assaults, and direct blows upon the bone. The symptoms of
hyoid fracture are sharp pain, increased by pressure, speaking, or swallow-
ing; swelling, displacement and motion of the fragments, and crepitus.
If the mucous membrane of the pharynx has been perforated blood will
appear in the mouth. Sometimes the surgeon's finger in the pharynx
will detect the displacement with ease. Coughing with paroxysms of
choking or asphyxia may follow attempts at swallowing food or protruding
the tongue. The treatment consists in replacing the fragments, keeping
the parts quiet by prohibiting talking, and feeding the patient on liquids
by means of a tube. Bandaging the throat is of no service.
Fracture of the Cartilages of the Laryma.
PATHOLOGY..—These injuries, owing to the exposed position of the
larynx, are more frequent than fracture of the hyoid bone. They are at
the same time more dangerous, because the intralaryngeal swelling is
very liable to cause fatal asphyxia. Blows, falls, hanging, and homicidal
throttling are the causes likely to produce laryngeal fracture. The
mucous membrane is frequently torn, leading to extravasation of blood
within the larynx and emphysema of the cellular tissue of the throat and
neighboring regions. The upper horn of the thyroid cartilage is someº
{
F R A C T U R ES OF T H E S T E R N U M. 371
times developed as a sort of epiphysis. Epiphyseal separation may then
OCCUll’.
SyMPTOMS.–The symptoms are deformity, motion, and crepitation,
accompanied by convulsive cough, alteration or loss of voice, dyspnoea,
painful deglutition, and in many instances frothy, bloody, expectoration.
The emphysema that is seen in many cases may spread over a large por-
tion of the neck, face, and trunk.
In severe fractures death is common from Suffocation due to subcuta-
neous hemorrhage, to free bleeding into the larynx, or to inflammatory
or emphysematous swelling. The fatal issue may suddenly occur several
days after the receipt of injury.
Repair occurs most probably by Osseo-cartilaginous material.
TREATMENT.-The treatment consists in remedies to allay inflamma-
tion, and cautionary tracheotomy, lest fatal obstructive swelling occur
unexpectedly in the larynx. The opening thus made may be of value in
giving the surgeon an opportunity to replace the broken fragments by the
introduction of instruments into the air-passages. It is unwise to post-
pone tracheotomy until dyspnoea becomes extreme, since asphyxia may
be sudden. The operation had better be done in all cases of severe frac-
ture before the patient is left by the surgeon. A permanent tracheal
opening is sometimes demanded after fracture of the larynx.
The tracheal rings occasionally sustain fracture. The diagnosis is often
difficult, but if such injury is discovered it should be treated as fracture
of the larynx by antiphlogistic measures and tracheotomy below the seat
of injury.
Fractures of the Sternum.
PATHOLOGY..—This is a rare injury, probably because the sternum is
protected from indirect violence by being connected with the elastic
costal cartilages and ribs. When fracture occurs it is usually due to
such great violence that associated injury to the ribs or thoracic viscera
exists; but a direct blow of moderate force may, if limited to a small
area, break the sternum. Violence which forcibly bends the spinal
column backward or forward may give rise to
Sternal fracture in some cases, as it may cause ver- FIG. I.67
tebral fracture in others. Great muscular efforts,
such as occur in lifting heavy weights or in par-
ºn, have been followed by disruption of this
One.
The first portion of the sternum, or manubrium,
and the last portion, or ensiform appendix, often
become united in adult life to the gladiolus, or cen-
tral segment, by Osseous material. In early life, and
Sometimes until much later, more or less perfect joints
exist at these points. Therefore it is difficult and
ºften impossible to say whether a given traumatic
displacement is a fracture or a dislocation. Dis-
Placement between the first and second segments, the
ºsult of direct violence, may be diagnosticated as c.
diastasis or dislocation rather than fracture when Fracture of sternum.
* Patient is young. The symptoms confirmatory
of this diagnosis are the half facets for the second ribs or a smooth upper
facet being felt through the skin, the cartilages of the second rib being

372 D IS E A S E S A N D IN J U R I ES OF B O N E S.
out of place and easily reduced to position, and no crepitus being dis-
coverable. In fracture the periosteum on the back of the bone is more
likely to be torn, hence inflammatory involvement of the mediastinal
structures becomes more possible, For this reason
FIG. 168. the differential diagnosis has some bearing on prog-
º Il OSIS.
Sternal fractures are generally more or less trans-
verse. Congenital fissure may be mistaken for lon-
gitudinal fracture, which is a very rare lesion. The
frequent irregularities of the ensiform appendix must
not be forgotten. Union usually occurs promptly,
and little annoyance arises from uncomplicated frac-
ture even if some deformity persists. Cases asso-
ciated with rupture of the lungs or pericardium, or
with profuse bleeding or consecutive suppuration in
the mediastinum, are of grave prognosis.
SYMPTOMS.–The symptoms of fracture of the
sternum are displacement, mobility, crepitus, pain on
motion, deep breathing or coughing, bloody expec-
toration, dyspnoea, and sometimes a stooping position
of the shoulders because of the shortening of the
breast bone. Replacement can best be accomplished
by traction and pressure. If a hard pillow is placed
under the patient's back and his trunk bent back-
ward over it, the fragments can often be easily
pressed into position. A deep inspiratory effort may
assist the reduction. Recurrence of the deformity
is not unusual. It has been proposed to screw a
Transverse fracture gimlet into the depressed portion of the bone, and
of body of sternum. thus pull it upward, or to insert an elevator or hook
(STIMson.) under it. These means increase the severity of the
injury, but are justified by symptoms arising from
pressure on the heart and lungs. Unfortunately the bone is rather
too cancellous in structure to give a good firm hold for such instru-
ments. Entering the mediastinal space or puncturing the pericardium
or pleural cavity is to be deprecated. After reduction, if there is a
tendency to displacement or much pain present, the chest should be
immobilized by a broad bandage of flannel or adhesive plaster firmly
applied, while the lungs are emptied by forced expiration. If intra-
thoracic symptoms arise, they should be treated on general principles.
Pus behind the sternum should be promptly evacuated by incision along
the side of the sternum or by trephining the bone. Stimson has sug-
gested removing a disk of bone without disturbing the posterior perios:
teum, and then puncturing this with the aspirator needle, which may be
passed in various directions until the suspected pus cavity is found or its
existence disproved. Antiseptic incision of the posterior layer of the
periosteum would seem to be better surgery. A post-sternal abscess may
simulate aneurism because of its transmitting the cardiac pulsation,
Fractures of the Ribs and Costal Cartilages.
PATHOLOGY..—Fractures of the ribs are frequently met with in adults,
but quite rarely in children. The greater elasticity of the bones and

F R A CT U R ES OF THE RIBS AND COST AL CART ILA G E S. 373
costal cartilages in childhood sufficiently accounts for this difference.
The occurrence of green-stick fracture may, perhaps, be often overlooked
in chest injuries among children, and even in adults the periosteum at
times remains almost intact, and thus obscures the symptoms of fracture.
The protected situation of the first and second ribs behind the clavicle,
and the mobility of the last two ribs, render fracture of these bones
unusual. The ribs most commonly broken are the fourth, fifth, sixth,
and seventh. Unless several ribs are simultaneously broken over-riding
is impossible, for the adjoining ribs and the intercostal structures act as
splints. Angular deformity is in the same way a good deal limited.
Comminution, when great, changes the rigid thoracic wall into a flaccid
membrane, moving in and out with respiration.
Direct violence, by driving the rib inward, causes fracture at the point
of impact, and generally with inward displacement. Indirect violence,
by depressing the chest, has a tendency to bend the rib and cause frac-
ture, beginning on the external surface. Outward displacement is prob-
ably the more common deformity in these cases. Erichsen thinks that
in indirect fractures the bone usually gives way near its angle, which is
the point of greatest convexity. Direct injury, of course, will give rise
to fracture in the anterior or posterior region, according as the violence
is received upon the one or the other portion of the bone. Direct
violence is more apt to cause splintering of the inner surface of the bone
and inward displacement; consequently there is, under such causation,
more likelihood of puncture of the viscera. Contraction of the extra-
thoracic muscles during violent respiratory efforts, as in coughing or
sneezing, may cause fracture of a rib. The rather frequent occurrence
of broken ribs in connection with general paralysis of the insane is said
to be due to trophic changes in the bones making them more brittle.
Injury to the thoracic or abdominal contents is not an infrequent asso-
ciate of rib fractures. The most common indication of such injury is
subcutaneous emphysema about the seat of fracture due to puncture or
rupture of the pleura and lung. This is probably more frequent when
the rib is broken at the situation of an old inflammatory adhesion of the
pulmonary and costal pleura than when no such adhesions exist. When
the wounded lung is previously non-adherent the air from the bronchioles
and vesicles sometimes escapes into the pleural cavity, giving rise to pneu-
mothorax instead of distending the subcutaneous cellular tissue and caus-
ing emphysema. The lung may actually become compressed and collapsed
by large quantities of air and blood in the pleural sac. When the emphy-
sematous condition spreads into the mediastinum and the interlobular
cellular tissue of the lung the patient's condition becomes critical. Peri-
gardial and heart injuries are infrequent except after very great violence.
It is to be recollected that laceration of the viscera may occur without
fracture of the ribs.
Laceration of an intercostal artery may happen even in fracture of a
not very serious kind. If the fracture is open so that such injury and
the consequent hemorrhage are detected, efforts should be made to secure
the bleeding artery by passing a ligature around it. This can perhaps be
done by a curved needle carrying a thread through the tissues in the
intercostal groove on the lower margin of the rib, or by drilling the bone
and passing a wire through it and around the vessel. The wound may be
enlarged so that a small key can be passed in and turned in such a manner
as to press on the vessel for a few hours. In some cases the centre of a
Square of muslim may be forced into the thorax so as to make a pocket
374 D IS E A SES A N D IN J U R RES OF B O N E S.
within the wall. Into this cotton should be pushed so as to make the
immer part of the packing larger than the opening. If the corners of the
piece of muslin are then pulled forward pressure will be made on the
intercostal artery. In closed fractures an incision should be made and
similar treatment adopted if the diagnosis of dangerous hemorrhage from
a torn intercostal artery is made.
SYMPTOMS.–The symptoms of uncomplicated fracture of the ribs may
be so obscure that certainty of diagnosis is impossible. Green-stick frag-
tures are scarcely recognizable except when a nodule of callus is devel-
oped at the seat of pain during recovery. Local pain induced or increased
by pressure, motion, full inspiration, or coughing is suggestive of fracture,
but may be due to mere contusion of the soft parts. Shallow or catching
respiration is a common accompaniment of broken ribs and is due to the
pain inflicted by deep inspiratory efforts. Cough is often present and has
been attributed to reflex irritation from injury to the intercostal nerve
lying in the groove of the bone.
Pain or ecchymosis at a distance from the part of the chest upon which
the violence was received is indicative of fracture. I have learned from
Dr. R. J. Levis a manipulation that has often convinced me of the exist-
ence of fracture in obscure cases. If the patient lie upon his back and
the surgeon make strong pressure upon the sternum and anterior part of
the chest, pain will often be experienced at the point of fracture. This
is due to the elasticity of the ribs and cartilages causing motion at the
seat of fracture even when it exists at the lateral or dorsal aspect of the
chest. If no fracture is present sternal pressure cannot give rise to pain
at a distant part of the chest wall. Preternatural motion may be difficult
to obtain and recognize, because of the normal mobility and elasticity of the
thoracic parietes. Crepitation may be elicited by applying the finger-tips
to the ribs on both sides of the suspected fracture and making alternating
pressure. Motion also may be thus detected. Sometimes crepitation is
more readily detected by laying the palm over the painful spot while the
patient coughs or the surgeon makes firm pressure in the neighborhood
of the injury with the other hand. Auscultation may detect crepitus
when other means fail. Subcutaneous emphysema, which is shown by
crackling when pressure is made upon the skin is an unmistakable sign
of fractured rib and puncture of the lung. The development of a pleur-
itic friction sound or of a local pneumonia a day or two after injury, is
very fair evidence of a broken rib. Bloody expectoration, pneumothorax,
and serous effusion or hemorrhage into the plural sac are suggestive of
fracture and simultaneous injury of the thoracic contents, but they may
also occur from violence that does not break the elastic ribs.
The prognosis is good in ordinary uncomplicated fractures of the ribs.
Union occurs in about four weeks by interosseous and insheathing callus
which often leaves an irregularity, even when no displacement existed,
because perfect immobilization is impossible. Sometimes when several
bones have been broken bridges of callus unite the upper and lower
borders. Hernia of the lung may occur if much displacement or commin-
ution exists after severe fractures. The cellular emphysema in the great
majority of cases is unimportant and soon disappears spontaneously.
Great dyspnoea from sudden congestion of the lungs or pneumothorax is
an important and at times a fatal symptom. Pleurisy, pneumonia, and
pericarditis occurring as complications add greatly to the seriousness of
the injury and should always be looked for by percussion and auscultation.
FRACTU RES OF THE RIBS AND COST AL C A RTILA GE S. 375
Recovery, however, is not uncommon after severe injury to the lungs and
other viscera.
Treatment.—Fractures of the ribs should be treated by reduction of
displacement and immobilization. At the same time the surgeon should
be on the alert to avert or relieve intra-thoracic inflammation. Doubtful
Fig. 169.
= --> º:... == -----------
- -, --> * *** -º *** **, - - - - - -
T** ~ *-*:: º
ſº...º.º.
* - sº . Fº & sº ..."
s Sºğ . . . . . .
tº:
º º:
§§§ §
§§§ſ.
#º:* - º §§ º º f/
.* • tº * .
º/ tº
f * *- - fºr tº º
§ 2" § f_*
º - - -* - º º f
% - ...A. ſe”
- [. ºre & º: % º
¥
º % ſ/
#ºsº %
§§ § §
--- .*\- *Nº. £ tº: § |
iº
ºt. , tº
United rib three months after fracture. (Holy(Es.)
FIG. 170.
Bridge of callus between broken ribs. (HolMEs.)
cases are to be treated as fractures. Pressure upon the ends of the frag-
ments or upon the sternum may correct deformity and at the same time
relieve the existing pain. Deep inspiration on the part of the patient
may be of assistance. Occasionally, when overlapping exists the outer
fragment may, by pressure, be sprung under the inner one, and its resili-
ency used to lift the latter outward into proper relation. If inward dis-
placement were causing important symptoms it would be proper to intro-
duce a hook or elevator under the depressed bone and thus bring it into
pºsition. In gunshot or other open fractures comminuted and detached
pieces may at times be extracted with propriety.
Immobilization is to be effected by encircling the chest with a broad
bandage so that thoracic breathing is restricted. The ribs are thus kept
Quiet and the patient required to breathe by the diaphraghm and abdom-
inal muscles. The bandage should be made of a piece of flannel or muslim
about eight inches wide and a yard and a half long, it should beapplied and
firmly fastened with pins during full expiration in order to be sufficiently
tight. If the patient is ordered to raise his arms over his head and to










376 DIS E A SES A N D IN J U R IES OF B O N E S.
breathe out as much as possible, the girth-like bandage can be firmly
adjusted. The gypsum dressing may be thus employed. If the patient
has pain from the circular constriction it may be made looser or entirely
dispensed with, since in order to avert pain the muscles will immobilize
the parts pretty well without external assistance.
The bandage must never be carried much below the ensiform cartilage,
lest it interfere with the play of the abdominal respiratory muscles. It
may be prevented from slipping downward by bands carried over the
shoulder. The arm of the adducted side should be bound to the chest
or carried in a sling if the motion of the pectoral muscles gives pain. If,
in comminuted fractures, displacement inward is caused by the bandage
it must be removed. A laced jacket of stout linen, such as has been used
in the Pennsylvania Hospital, is an efficient dressing for broken ribs.
The dressing may be discarded in about four weeks. A broad sheet of
rubber adhesive plaster or several overlapping strips of plaster may be
used instead of the bandage. Before applying adhesive plaster all hair
on the chest should be removed with the razor. In some cases constriction
of the entire chest is very uncomfortable; this is especially so when the
patient has asthma or chronic bronchitis. The adhesive plaster is then a
preferable dressing, for it is easy to apply it to the injured side only, with
the ends merely crossing the median line in front and behind.
FIG. 171.
FIG. I'72.
§
S
s
N
§
%
ag: %
Bandage for fracture of ribs.
Morton’s jacket for fracture of the ribs.
The intra-thoracic inflammations require treatment similar to that
indicated in similar lesions from non-traumatic causes. The cellular em-
physema accompanying many fractures needs no special treatment, as the
air is soon absorbed. The pressure of the bandage perhaps aids in its
disappearance. Even when great extension of the emphysema occurs no
danger is to be apprehended except when it gets into the mediastinum
and interlobular tissue of the lungs. In such an event incisions in the
skin or other operative interference could scarcely avail. Extreme Con-
gestion of the lungs, giving rise to grave dyspnoea, should be treated by
venesection. Pneumothorax, hemorrhage into the plural sac, or large
pleuritic effusion may demand aspiration or incision.



F R A C T U R ES OF T H E PEL WI C B O N E S. 377
Fractures of the Costal Cartilages.
These injuries are said to happen most frequently near the junction of
the cartilage and rib, and to occur in the seventh and eighth cartilages
oftener than elsewhere. The partially ossified cartilages of the old are
more susceptible of fracture than the cartilages of youth. Chondral
fractures are usually transverse or nearly so, and are seldom complicated.
Deformity is the most constant diagnostic symptom, though at times crep-
itus and mobility may be distinguishable. When it is impossible to deter-
mine whether fracture or dislocation of the cartilage has taken place the
termination of the rib may be made out by acupuncture, for the needle
will enter the substance of the cartilage. Union is accomplished not by
cartilage, but by Osseous or fibro-Osseous tissue in much the same manner
as in fracture of the ribs. The perichondrium seems to furnish the
ensheathing callus. The treatment is the same as that for fractured ribs,
Fractures of the Pelvic Bones.
PATHOLOGY..—Fractures of the pelvis are rare, and require for their
production a great degree of violence, except in instances where mere
projecting processes are split or torn off. Falling embankments, railroad
accidents, and the passage of loaded vehicles across the trunk are the kind
of injuries liable to produce fractures of the pelvis. The fracture lines
are apt to be multiple, because the crushing force which breaks the pelvic
FIG. I'73.
w \'
\\ \\ \ s sº
\\\\\", \\\\\\\\ S
\\ W sº S.
*::::: º * * V.
• *.*.*.*$33.5 wal ºl
Plan of development of innominate bone by three primary and five secondary
centres. (GRAY.) -
girdle brings strain at the same time on various parts. Separation of the
pubic and sacro-iliac synchondroses or joints is not an unusual result of
*matism, and in young persons the epiphyseal lines of the innominate
bone may be forced asunder by violence that in older persons would cause



378 DISE A SES A N D IN J U R IB S OF B O N E S.
fracture. The pubic, iliac, and ischiatic elements unite between the years
of fifteen and twenty; the secondary centres at about twenty-five years.
The usual severity of the causative violence and the relation of the
pelvis to the viscera render the prognosis as to life unfavorable. Lacera-
tion of the urethra, usually in its membranous portion, rupture of the
bladder, rectum, colon, or small intestines; injury to the uterus; rupture
of the iliac artery or vein; and contusion or laceration of the Solid viscera
are not at all infrequent complications. Death from secondary affections,
such as suppuration in the cellular tissue of the pelvis or necrosis, must be
recollected as a possibility. If no such complications occur, cure of even
severe fractures takes place. Union may be expected in from six to eight
weeks, but lameness is usual from more or less permanent disability of the
muscles injured by the accident, or restricted in their function by the
process of union or cicatrization. Deformities narrowing the pelvic canal
may occasion serious difficulty in subsequent parturition.
The character of fracture varies with the direction of application of the
fracturing force. Sometimes the fracture lines are vertical, one or more
passing through the rami of the pubes and ischium on one or both sides
of the middle line and another through the iliac portion of the innominate
bone into the sacro-sciatic notch. In the posterior segment of the circle
the sacrum may be split vertically, or the sacro-iliac joint torn open.
Lateral crushing may drive the head of the femur through the acetabulum
into the pelvic cavity; or, if less severe, may produce lines of fracture
radiating from the acetabular region. Parturition, forced abduction of
the thighs, and direct external violence have produced separation of the
symphysis of the pubes. The separation is said to occur between one of
FIG. I 74. FIG. 175.
-º-2%
.
#A
\
ū
Fracture of pelvis with head of
femur forced through acetabulum.
Fracture through ramus of pubes and sacro-iliac Autopsy several years after in-
junction. jury. (Bryant.)
the pubic bones and its attached cartilage rather than between the two
cartilages which the joint contains. The gap felt through the integument
may be as much as two inches wide. Occasionally the symphysis of the
ubes and one of the sacro-iliac articulations have been torn open so that
half of the pelvis and the corresponding leg have been markedly displaced
upward.
º: the fractures which involve the continuity of the pelvic ring, that
in the pubic region is most common, for here the bony constituents of the
pelvis are most fragile.




F. R A C T U R E S OF TEI E P E L VI C B O N E S. 379
Transverse or nearly transverse fractures of the sacrum or of the coccyx
are occasional lesions. In both the tendency is for the lower fragment to
be bent inward with its lower extremity pointing toward the interior of
the pelvis. , Dislocation of the coccygeal articulations is practically
identical with fracture of the ankylosed bone.
SYMPTOMS.—Displacement is not very great in the majority of pelvic
fractures; but palpation will, if the parts are accessible, usually show
either deformity, mobility, or crepitus. Vaginal and rectal exploration
will be servicable in a few cases. Shortening of the lower extremity from
upward displacement of the pelvis, and inability or indisposition to move
the limb will at times aid in the diagnosis. Loss of support, fear of pain,
and laceration of the muscles attached to the pelvis may all have part in
the production of this disability. A good deal of subcutaneous extrava-
sation of blood is frequently a feature of these injuries.
Careful observation of the relative position of the anterior spinous
processes of the ilium will at times serve to strengthen or weaken an
obscure diagnosis. Crepitus may be elicited and correction of deformity
secured by traction on the lower limb. Escape of blood from the urinary
meatus or rectum, retention of urine, bloody urine, and the rapid super-
vention of tympanites or peritonitis suggest the probability of fracture of
the pelvis in cases with appropriate history.
In sacral fracture, paralysis of rectum, bladder, and legs, from compli-
cating lesion of the sacral nerves, is said to be not unusual ; and pain on
coughing or defecation may be expected. Seizing the bone between a
finger in the rectum and the thumb on the dorsum will probably demon-
strate motion and crepitus, and perhaps correct displacement.
Coccygeal fracture occurs probably more frequently from parturient
efforts and manipulations than from other traumatism. Rectal examina-
tion will often establish the correct diagnosis and reduce the displaced
fragments.
Fractures of the crest or processes of the ilium are probably the least
important of the fractures of the pelvic bones, for they have as a rule no
serious complications, and confine the patient to bed for only a couple of
Weeks or perhaps not at all.
Mere fissure of the cavity of the acetabulum has no characteristic
Symptom.
Fracture of the rim of the acetabulum is worthy of consideration. It
usually occurs as the result of great violence applied to the hip, and as an
accompaniment of dislocation of the femur. Dislocation backward of
the head, with breaking of the posterior and upper margin of the ace-
tabular rim, is the ordinary form of the lesion. The symptoms are those
of dislocation of the head of the thigh-bone with crepitus, and a ready
recurrence of the dislocation after its reduction. Fracture of the neck
of the femur may be mistaken for dislocation and fracture of the
acetabular margin, because crepitus and recurrence of deformity are
essentially marked symptoms in the former injury. In fracture, however,
unless it is impacted, the limb assumes a position of outward rotation and
§tension, while in the posterior dislocations, which are the varieties
likely to be seen here, the limb takes the position of inward rotation and
flexion on the pelvis. Again, in fracture the trochanter is relatively
*rē, the anterior superior spine of the ilium than in dislocation. It
* Well in all cases of doubt to make sure of the actual position of the
head, and also to remember that dislocation of the femoral head compli-
*ed with fracture of the neck of the bone is not impossible, and that
380 D IS E A S E S A N 1) IN J U R I ES OF B O N E S.
the crepitus attributed to fracture of the acetabulum may exist really
between the fragments of the broken femoral neck.
TREATMENT.—The treatment of fractures of the pelvic bones varies
with the location of the injury; but in all the severer forms of fracture
the surgeon should at once introduce a catheter, in order that laceration
of the urethra may be discovered, if it exist, before extensive extravasa-
tion of urine has occurred. Shock must also be treated. If the end of
the catheter will not pass beyond the torn portion of the urethra into the
bladder, a perineal incision should immediately be made. This incision
should be made in the middle line and should open the tissues down to
the seat of rupture, to which the end of the catheter left in place is a
guide. Exit is thus given for the urine to pass from the opening in the
urethra to the exterior, and disastrous extravasation into the perineal
structures is averted. It is not proper to open the neck of the bladder
unless the bladder itself is ruptured. The incision down to and into the
urethra at the point of its rupture is all that is required to conduct the
urine to the surface. The case should then be managed, so far as this
feature is concerned, as one of external urethrotomy for stricture, by the
occasional passage of a bougie. If a catheter can be introduced through
the torn urethra into the bladder no incision is demanded, and the instru-
ment, preferably a rubber one, should be retained in the bladder for a
few days until danger of urinary infiltration has passed.
Violent manipulation may increase visceral damage in pelvic fractures
and should be avoided, though careful efforts at correcting marked dis-
placements are proper. Rest in bed in the dorsal, prone, or lateral posi-
tion, according to the comfort of the patient, and support to the pelvis
by encircling bands of adhesive plaster or by a broad girdle of muslin or
flannel will usually meet the indications. All pressure liable to cause
displacement or pain must be avoided by pads. A gypsum dressing may
sometimes be serviceable. Continuous traction by weights attached to
the leg and thigh as in fracture of the femur, may be the only means of
preventing upward displacement in double vertical fractures on the same
side of the median line. Fractures of the ischium may require pressure
to be applied within the rectum in order to effect coaptation of fragments.
The finger or a wooden lever may be employed. A few cases have been
treated efficiently by means of packing kept in the rectum for a series of
days to prevent recurrence of displacement. The packing, which should
be enclosed in a rubber bag, must be occasionally removed to allow defe-
cation and escape of flatus, unless a canula be placed through the centre
of the distending apparatus. A rubber bag distended with air or water
and well oiled, when inserted, would seem to be the most judicious means
for effecting this seldom required intra-rectal pressure. In fractures of
the iliac wings the encircling bandage must be omitted if it tends to press
the fragments abnormally inward. In fracture of the tuberosity of the
ischium the hamstring muscles should be relaxed by flexing the leg on
the thigh, while the thigh should be extended or semi-extended at the
hip. In instances of great comminution, followed by extensive suppura-
tion, provision for free drainage should be made, and detached splinters
of bone removed early.
The neuralgic affection, coccygodynia, whose symptoms are not unlike
fissure of the anus, may be a secondary result of fracture of the coccyx.
If subcutaneous division of the soft structure attached to the coccyx fails
to relieve the pain, removal of the bone by means of the cutting forceps
or saw, or with the burr of the surgical engine, may be performed.
F R A C T U R E O F T H E C L A VIC I, E. 381
Fracture of the Clavicle.
PATHOLOGY..—Direct violence and muscular strain, as in lifting heavy
weights, may cause fracture of the clavicle. By far the most common
cause, however, is indirect violence, for in falls upon the shoulder, elbow,
or hand the force of impact is transmitted to the clavicle, which consti-
tutes the only bony connection of the arm with the trunk. A tendency
to exaggerate the curves of this doubly curved and doubly twisted bone
is thus produced and the bone gives way as soon as the strain becomes too
reat. The mechanism of some cases of fracture is, it is said, a forcible
bending of the clavicle across the first rib, with which it normally is
often almost in contact. With the exception of the radius the clavicle is
the most frequently broken bone of the skeleton.
The outer part of the middle third is the most common site of fracture,
but from its obliquity the line may extend into the outer or inner third.
The small diameter of the bone and the sharpness of the curve at this
point, associated with the frequent causation from indirect violence, are
satisfactory reasons for the lesion showing this preference.
Comminuted, multiple, or open fractures of the clavicle are rare.
Green-stick fractures are common; and transverse breaks with little dis-
placement or laceration of periosteum by no means unusual. Emphysema
from puncture of the apex of the lung, paralysis from laceration or con-
tusion of the nerve trunks, and lesions of the subclavian vessels are pos-
sible but almost unknown complications.
FIG. I'76. FIG. I. 77.
Peformity from fracture of clavicle united with displace- Fracture of clavicle.
ment. (HAMILTON.)
§YMPTOMs. The usual deformity after the ordinary fracture of the
middle portion of the clavicle is produced by tilting upward of the outer
end of the sternal fragment, and displacement inward, forward, and down-
Wºrd of the inner end of the acromial fragment. The projection upward
of the former has been attributed to the lifting force exerted by the outer
fragment being thrust under it, and also to contraction of the sterno-
cleido-mastoid muscle. The displacement inward, forward, and downward

382 DISE A SES AN ID IN J U R IES OF B O N E S.
of the acromial fragment is due to the fact that the clavicle is the support
or stay which holds the scapula and its attached arm in proper relation
to the thorax. When the clavicle is broken, the scapula, partly by reason
of the weight of the arm and partly by the action of the great, serrated
and the lesser pectoral muscles, assisted, perhaps by the rhomboids, is ro-
tated forward around the dorso-lateral aspect of the chest in such a way
as to depress the acromion and carry it toward the anterior middle line
of the trunk. This displacement of the point of the shoulder and the
consequent relation of the clavicular fragments are well shown in the
diagram adapted from Stimson. It represents in a schematic way the
intact as well as the broken shoulder-
FIG. 178. girdle as the claviculo-Scapular combina-
\; ERT EBRA tion has been called. The inward and
forward displacement of the acromion is
seen at a glance. The downward deform-
ity, being in another plane, is of course
not exhibited. Shortening of the clavicle
is great in oblique fractures with over-
riding, and may amount to one and a half
or two inches. Sometimes, in transverse
fractures, interlocking of fragments gives
upward and backward angular deformity.
In all fractures the continuance of the
Diagram showing sliding forward fracturing force after rupture of bone
of scapula and tilting out of its pos- has occurred, and the line of break have
terior border in fracture of clavicle, influence in determining the amount and
direction of the displacement.
Fractures of the outer third of the clavicle are often transverse, and, in
reference to frequency, come next to fractures of the middle third. The
displacement is believed by some writers to be greater as the line of sepa-
ration approaches the acromion and gets outside of the attachment of the
coraco-clavicular ligament. This, however, is denied by the high au-
thority of Gurlt and Gordon. The deformity is usually angular, with
the acromial fragment thrown forward.
In fractures of the inner third the most usual deformity is due to dis-
placement downward and forward of the inner end of the acromial por-
tion of the bone, or angular distortion of both fragments in the same
direction.
The local deformity arising in fractured clavicle has been discussed;
but in addition there is falling inward and forward of the shoulder, and
projection of the inferior angle and posterior border of the scapula.
This is an especially prominent feature of the injury when great over-
lapping occurs in lesions in the middle third of the bone. On account of
the usually indirect causation of the injury, contusion, if existent, will be
found on the shoulder, elbow, or hand, and not at the seat of fracture.
Crepitus may not be perceptible until the shoulder is pressed outward and
backward, so as to bring the ends of the overlapping fragments together.
A loss of function, due to pain induced by movements, and not to
mechanical obstruction, is shown in inability to place the hand on the
head while the latter is held erect, or to raise the arm so as to hold it out
at a right angle with the trunk. In green-stick fractures fixed local pain
may be the single symptom, until, in the course of a fortnight, a small
nodule of callus is perceptible. This condition must be discriminated
from the localized pain and subsequent nodular deformity of syphilitic
STER NUNI

F R A CT U R E OF T H E C L A VICL. E . 383
periostitis. Fractures near the acromial end of the clavicle simulate
dislocation.
The vascularity of the collar bone enables union to become quite firm
by the end of the third week. Non-union is rare, and, when occurring,
produces a very moderate degree of disability. Impairment of function
from pressure of exuberant callus on the vessels and nerves behind the
clavicle is a remote possibility. The paralysis sometimes attributed to
such cause is oftener, perhaps, the result of injurious pressure of a large
axillary pad used in treating the fracture.
TREATMENT.—Cure, without deformity, of clavicular fractures present-
ing much primary displacement, seems, with our present appliances, to be
almost impossible. Fortunately the permanent distortion so often left is
a cosmetic defect rather than a disability.
The probability of permanent deformity after complete fracture renders
it wise to desist from too active attempts to straighten the bone of the
green-stick fracture, for if complete separation is caused by the manipula-
tion greater disfigurement is liable to occur. Straightening should, there-
fore, be attempted only with a moderate degree of force, especially as the
bent bone may even regain something of its normal shape during the
after-growth of the patient.
In complete fractures correction of deformity is to be attempted by
grasping the Scapula and swinging it around the posterior chest wall
toward the median line of the back, and holding its lower angle against
the ribs. This procedure tends to carry the acromion and head of the
humerus outward and backward, and thus to restore the position of the
shoulder, which has been changed by the loss of the support given by the
unbroken clavicle. At the same time moulding of the fragments at the
seat of fracture should be practised. A similar effect may sometimes be
produced by standing behind the patient and pulling the shoulder back-
Ward with one hand, while coaptation is secured by pressure with the
other hand at the seat of lesion. Good position is usually obtainable by
these manoeuvres. The difficulty in treatment arises from the impossi-
bility of retaining correct apposition for three or four weeks by apparatus
that can be tolerated by the patient and worn during walking.
Dorsal recumbency on a firm, level mattress, with the head bent a little
forward by a small pillow and the injured arm laid and fixed by a ban-
dage or adhesive strip across the chest with the elbows close to the ribs, is
the best method of treatment. In this posture the weight of the body
keeps the scapula pressed against the chest, and prevents it rotating for-
Ward. A bag of shot or sand may, if necessary, be laid upon the acromion
to hold the shoulder more firmly outward and backward. The position
Qf the arm also aids in maintaining coaptation and preventing over-riding.
Few persons, except perhaps women who occasionally dress so as to ex-
pose the neck, care to maintain this irksome posture for several weeks,
especially when informed of the fact that deformity, though unsightly, is
not prejudicial to good use of the arm. Experience, however, seems to
show that if this line of treatment is continued for ten days or two weeks
the solidification of the fracture becomes such that the erect posture may
be assumed, in conjunction with the ordinary fracture dressing, without any
great tendency to reproduction of displacement. The best treatment for
fºctured clavicle, therefore, is the recumbent posture for about ten days,
followed by the ordinary dressings, when the patient is released from his
ºnfinement in bed, for about three weeks more. When the least pos-
sible deformity is especially desirable, the recumbent posture should be
384 D IS E A S E S A N D J N J U R IF. S OF B O N E S.
retained for three or four weeks. Continuous coaptating digital pressure
could be maintained for several weeks, if necessary, to insure more abso-
lute perfection in the result. The free administration of chloral and
bromide of potassium will overcome the nervous restlessness which the
requisite immobility of the trunk engenders. g
When confinement to bed is objected to by the patient the dressing
of Bryant, Sayre, or Velpeau should be adopted. Bryant reduces the
fracture and then places a pad over the scapula below its spine and binds
the bone firmly to the chest by strips of adhesive plaster, extending
from the vertebral spines to the sternum. The arm of the injured side is
then supported in a sling, with the hand drawn upward toward the op-
posite shoulder. Sayre uses two strips of adhesive plaster about three
inches wide and one and a half to two yards long. At the end of one
strip a large loop, with the back of the plaster inward, is made by stitch-
ing with a needle and thread. After the skin of the chest has been
shaved, the injured arm is passed through this loop, which must be loose
enough not to constrict the vessels. The elbow is then drawn well back-
ward and fixed in that position by the free end of the plaster being carried
around the entire chest from back to front, as shown in the illustration.
FIG. 179. FIG. 180.
£2.2×
/****
i 2:S *:S | ſ
A Zºº
W #. §§& § A
y
w
§
*sº
First stage of Sayre's dressing for fractured Sayre's dressing for fractured
clavicle. clavicle completed.
This end should also be secured by stitching, if there is any probability of
the plaster slipping. The flexed forearm is now laid across the chest and
the elbow carried forward, so that the loop of the first strip is made to act
as a fulcrum. The middle of the second strip is then applied under the
olecranon and the elbow forced upward by carrying the ends of the plas-
ter along the forearm and across the back to the opposite shoulder. A
slit should be made in this strip at the elbow, to relieve the olecranon of
painful pressure, and pieces of lint should be placed under the forearm and
in the axilla to prevent irritation from sweating. In cool weather this
dressing may require no renewal during the time necessary to maintain
immobility. If the fragments project upward notwithstanding the dress-
ing, a compress may be placed upon the seat of fracture and held there
by a short strip carried down the back and front of the chest. A pad of
cloth, covered with plaster with the adhesive side outward, will stick to




FRA CTURES OF THE SCAP UL.A. 385
the skin and not easily slip out of position. The hand may be left free, if
desired, by passing the second strip along the ulnar side of the wrist. This
lessens the discomfort of the dressing.
A good dressing in many cases is that of Velpeau. After placing the
hand of the injured side on the opposite shoulder, a roller bandage is
carried from the scapula of the well side
obliquely over the back to the injured shoul- FIG. 181.
der, over this, down the outside of the arm, º
under the elbow, across the chest to the opposite
axilla and to the point of starting. When the
arm has been well supported by several turns
of this kind, the bandage is carried around the
thorax and arm by circular turns from elbow
upward. This dressing can be made more se-
cure by coating it with silicate of sodium or
gypsum, or by applying several narrow strips
of adhesive plaster, about a foot in length, ver-
tically over its folds.
A number of dressings for broken clavicle
employ an axillary pad, with the idea that it
acts as a fulcrum by which to force the shoulder
outward. The pad is probably of little value
unless too large and too firm to be worn with Velpeau's dressing for frac-
comfort and with safety to vessels and nerves; ture of clavicle.
but it may, perhaps, be serviceable if so applied
as to act as a compress upon the axillary border of the Scapula and pre-
vent sliding forward of that bone. It forms no part of any of the dress-
ings recommended above.
In children the dressing for fractured clavicle should be continued for
two or three weeks, in adults three or four weeks.
Fractures of the Scapula.
The mobility of the scapula and its environment by muscular masses
protect it quite efficiently from fracture under ordinary forms of acciden-
tal injury. Fracture, when it does occur, is usually of the body, acromion,
ºr surgical neck. The spine and the coracoid process also suffer fracture,
but these lesions are of great rarity. The rim of the glenoid cavity is oc-
casionally chipped off in dislocations of the head of the humerus, and the
Cavity itself may at times be fissured, but the obscurity of the symptoms
renders diagnosis almost impossible.
In suspected fracture of the body, placing the forearm across the chest
or behind the back will render the posterior border of the bone suffi-
ciently prominent to enable the surgeon to detect deformity from displace-
*nt. Crepitus is best obtained, perhaps, by placing the palm of one
hand over the scapula while the patient's arm is moved in various direc-
tiºns, or by the examiner insinuating his fingers under the inferior angle
of the bone and endeavoring to obtain motion while he steadies the upper
Pºrt of the bone with the other hand on the shoulder. The ridges some-
times so well marked along the borders and spinous process of the bone,
nust mot be mistaken for fracture with displacement.
Reduction of the fragments may be difficult but should be attempted
by pressure while the patient’s arm is moved in various directions. Broad

25
386 D IS E A SES A N ID IN J U R IE S OF B O N E S.
adhesive strips carried across the scapula and partly around the thorax,
and a bandage applied to raise the elbow and keep the arm against the
side in a more or less vertical position, furnish an appropriate dressing.
Union takes place in about four weeks and good use of the limb is to be
expected, even if some deformity persists. In open fractures suppuration
may occur from bacterial infection, and pus burrow under the scapula.
This should be averted by furnishing facilities for drainage as soon as
needed.
Fracture of the acromion and separation of the acromial epiphysis are
lesions often indistinguishable. The two centres of ossification for the
acromion appear about the sixteenth year, and Ossification is complete
between the twenty-second and twenty-fifth year. Hence, direct violence
falling upon the elbow or muscular contraction may easily cause epiphy-
seal separation even in adults.
The line in acromial fracture is usually either in front of the articula-
tion with the clavicle or at the root of the acromion process. Absence of
deformity and contusion of the soft parts may obscure the recognition of
the lesion. When the process is broken at its base much flattening of the
shoulder is produced by the weight of the arm pulling the fragment
downward and inward. Less deformity results when the mere tip is
broken off. Inability to abduct the arm usually accompanies acromial
fracture; and crepitation may be obtained by grasping the shoulder
while the elbow is forcibly pushed upward. Fibrous is more common
than bony union, probably because close contact of fragments is not
obtained. The indication for treatment is to immobilize the arm with the
head of the humerus forced well up against the scapula. Velpeau's dress-
ing for clavicular fracture answers the purpose very well, and should be
continued about four weeks. The least deformity is probably obtained
by keeping the patient on his back in bed with the arm extended at a
right angle to the trunk, in order to relax the deltoid, which is the dis-
placing muscle.
FIG. I. 82. ' FIG. 183,
tºº R
sº
gºss Nº. &
Šss=e:
S
Q Nº. §
§=#
Nº. * - *
Fracture of surgical neck of scapula according Spence's case of fracture of the neck
to Cooper. of the scapula. (GURLT.)
Fracture limited strictly to the constriction immediately behind the
glenoid cavity, which has been called the anatomical neck of the bone,

F R A CT U R ES OF T H E H U M E R U S. 387
is practically unknown. Fracture may take place, however, behind the
coracoid process in a line passing downward from the supra-Scapular
notch, or in such a direction as to split off most of the head of the bone
while leaving the coracoid process attached to the body of the scapula.
These rare lesions are called fractures of the surgical neck of the scapula.
The flattened shoulder, prominent acromion, and loss of voluntary mo-
tion of the arm make the lesion resemble axillary dislocation of the head
of the humerus; but the easy reduction and immediate recurrence of
deformity. the crepitation and the absence of the humeral head in the
axillary space, establish the distinction. The sinking of the outer frag-
ment of the scapula with the attached humerus into the axillary space
may mislead the careless surgeon into the belief that a humeral disloca-
tion has occurred. The treatment resembles that for fracture of the
clavicle, though an axillary pad to keep the arm out and steady the
scapula is perhaps more essential in this instance. The downward dis-
placement is to be antagonized by a short sling or bandage to lift the
elbow.
Fractures of the Humerus.
These injuries are conveniently grouped as fractures of the upper end,
fractures of the shaft, and fractures of the lower end of the bone.
FRACTURES OF THE UPPER END OF THE HUMERUs.—The usual lines
of fracture at the upper extremity of the humerus are through the ana-
tomical neck and tuberosities; at the surgical neck, which is the constric-
tion with indefinite boundaries seen below the tuberosities; and at the
line of the main epiphyseal cartilage. Fracture of the surgical neck is
*
FIG. IS5.
Fracture through tuberosities of humerus Specimen of fracture of the surgical
With head united to the shaft at a lower neck of the humerus. (BRYANT.)
level than normal. (STIMson.)
the most common of these. Fractures of the head alone, of the anatomi-
cal neck alone, and of the tuberosities alone are possible injuries; but are
*9 rare in occurrence and too difficult of exact clinical recognition to
Mºrant discussion in this treatise. The existence of such fracture lines
*99njunction with multiple splitting of the upper end of the bone is, of

388 DIS E A SIES A N D IN J U RI ES OF B O N E S.
course, not so unusual. Detachment of a portion of one of the tuber-
osities by muscular action happens occasionally as an accompaniment of
dislocation of the head of the humerus; and is, in fact, a lesion very
similar to what has been elsewhere described as “sprain fracture.”
Fractures through the anatomical neck and tubercles frequently show
little displacement, because the fragments are impacted or are held
together by untorm periosteum. There is no evidence that fractures
entirely within the capsule of the shoulder-joint fail to unite, or that the
superior fragment acts as a foreign body and causes violent arthritis.
Sometimes the lower fragment or shaft is drawn upward by the deltoid
muscle in such a manner that the upper fragment or head becomes united
to the former at a lower level than normal, and gives the joint the appear-
ance of being the seat of an unreduced dislocation.
FIG. 186. FIG. I.87.
§
\º
§
º,
§
§
y
§
º
º
§
N
*
-
**
:
Ž
º
Diagrammatic fracture of Surgical neck of Separation of upper epiphysis of
humerus. (GRAY.) humerus. (MooRE.):
The surgical neck of the humerus is frequently broken and sometimes
with but little displacement. Fissured lines may extend upward within
the articular capsule, and impaction is not unusual. Displacement of the
end of the lower fragment inward seems to be the most common deform-
ity. Separation of the main epiphysis, which consists of the head and
tuberosities, resembles in many respects fracture of the surgical neck;
but only occurs previous to the twentieth year of life. When displace-
ment occurs there is seen on the front of the shoulder, an inch or so below
the acromion, a prominence which on palpation is felt to be a smooth,
slightly convex end of bone, moving with rotation of the elbow. It is
the upper end of the humeral shaft. Preternatural mobility and soft
crepitus may be distinguished. Union of fractures of the surgical neck
and of epiphyseal separations occurs in six to eight weeks, and is followed
by good results if displacement has been corrected. The injury to the
epiphyseal cartilage is sometimes, however, followed by arrest of longi-
tudinal growth of the bone. Occasionally, the upper fragment is 80
rotated by the scapular muscles that its under surface looks forward and
outward. In such cases apposition may often be obtained by abducting




F. R A CT U R ES OF T H E H U M E R U S. 389
the arm and carrying the elbow up alongside of head until the lower
fragment becomes interlocked with the upper one. Coaptation will some-
times be maintained after this manipulation when the arm is gently
depressed again.
FIG. 188.
Epiphyseal separation at upper end of humerus. (BRYANT.)
DIAGNOSIS OF INJURIES ABOUT THE SHOULDER-JOINT,-In investi-
gating traumatic lesions in the vicinity of the shoulder, recognition of the
fact that fracture exists is more important than a knowledge of the exact
variety of fracture. The relation of the bony prominences to each other
should be investigated and the correspondence of such relations with that
on the normal side carefully established. Acupuncture needles may be
employed in obscure cases to determine the location of the bony constitu-
ents of the joint. The surgeon should grasp the head of the humerus
with the fingers of one hand while he rotates the arm by the other hand
applied to the elbow. If a fracture exists between these two points the
motion given to the lower end of the bone will not be transmitted to the
head unless impaction has taken place. The same manipulation will in
most instances of fracture develop crepitus, especially if some extension
be used at the same time to draw the overlapping ends into contact.
In dislocation of the head of the humerus the shoulder will be flattened,
the acromion very prominent and with a depression below it into which
the surgeon's finger-tips can be pushed; the elbow will be abducted from
the chest, the arm roated inward and the head of the humerus noticeable
by palpation in its abnormal location, which is usually the axilla or the
fossa just below the clavicle. In addition to these symptoms voluntary
motion is lost; passive motion greatly restricted; it is impossible to place
the patient's hand on the opposite shoulder while the elbow of the injured
side is pressed close to the breast; the long axis of the humerus is not
directed toward the glenoid cavity but internally to it; the head of the
bone is felt to move when the elbow is rotated; no true fracture crepitus
is developed, though a soft rubbing sensation may be detected, and after
ºtion the deformity does not occur on removing restraint from the
lm O.
When the head of the humerus is in its normal position the upper por-
ºn of a straight rod laid upon the outside of the arm from shoulder to
elbow will be half an inch, an inch, or perhaps more from the edge of
the acromion; but if the head is not in the glenoid cavity the rod will
*gh the acromion unless very great swelling of the soft parts happens
* be present. The following test is given by Hamilton. Grasp the

390 D IS E A SES AND IN J U R IES OF BONES.
top of the shoulder so that the commissure between the forefinger and
thumb will rest upon the acromion just outside its articulation with the
clavicle, and let the finger and thumb fall vertically downward. The
anterior digit will, if the bone be in place, rest upon the centre of the
head as it projects normally in front of the acromion, while the posterior
digit will in a similar manner rest upon its less prominent posterior sur-
face. If the surgeon will now move the patient's elbow forward so as to
carry the head of the humerus backward, he will feel it press strongly
against the posterior digit, thus conclusively proving that the head of the
humerus is in its normal position, for if dislocation exists the humeral
head cannot be so felt by this manipulation.
Fracture of the neck of the scapula with displacement is, according to
Hamilton, the only injury that can simulate dislocation during the appli-
cation of this test. Exclusion of this unusual fracture, therefore, renders
the above tests diagnostic as to the existence or non-existence of disloca-
tion. Fracture of the neck of the scapula is distinguished from disloca-
tion of the head of the humerus by absence of rigidity during passive
movement, which is almost unlimited ; by crepitation, and by the imme-
diate recurrence of deformity when pressure which has pushed the arm
upward is withdrawn.
Fractures of the head and of the anatomical neck of the humerus are
too infrequent and too obscure of diagnosis to require further mention
than has been previously given. Fracture of the greater tuberosity is
unusual also, except as a complication of dislocation.
In epiphyseal separation, which occurs not later than the twentieth
year, the head of the bone can be felt in its normal position though it
does not move with the shaft, the upper end of which lies in front or to
the inner side of the head. Soft crepitation is perceptible when the sepa-
rated surfaces can be placed in apposition, the elbow can readily be
pressed close to the ribs, though the arm is directed somewhat outward
and backward, and voluntary motion is lost, but passive mobility in-
creased.
Fracture of the surgical neck is common, and is therefore the injury in
this region which most frequently requires discrimination from dislocation.
Displacement similar to that found in epiphyseal separation, the easy
demonstration of the head of the bone in its normal position, preternatural
mobility and crepitus unless impaction exists, and immediate recurrence
of deformity upon removal or support, are the usual features. The symp-
toms of fracture of the surgical neck and of epiphyseal separation are
very similar, and differ from those of dislocation in almost every particu-
lar except that in all three injuries voluntary motion is lost. In disloca:
tion this is due to destruction of the articulation and the entanglement of
the humeral head in its abnormal position, which circumstance gives an
appearance of rigidity to the limb. In fracture or epiphyseal separation
loss of active motion results from destruction of the lever through which
the muscles act, hence occurs an appearance of helpless inactivity.
Any of these fractures at the upper end of the humerus may be com-
plicated with dislocation of the scapulo-humeral articulation. The symp-
toms of the two lesions will then be a flat shoulder, prominent acromion;
and abnormal location of the globular head, combined with abnormal
mobility, crepitus, and deformity in the line of the bone. The freedom
of passive motion and the ease with which the hand can be placed upon
the opposite shoulder while the elbow is pressed to the ribs will differen-
tiate the case from uncomplicated dislocation. When the accompanying
F. R A CTU. R. E S OF T H E H U M E R U S. 391
fracture is a mere detachment of the greater tuberosity these last two
symptoms will not be present. When none of the injuries just detailed
have been detected and fracture of the clavicle, acromion, or coracoid
process also have been eliminated, the surgeon is justified in making a
diagnosis of sprain or of contusion, for about the only other described
injury is dislocation of the long tendon of the biceps, the very existence
of which lesion is doubted by many.
TREATMENT OF FRACTURES AT THE UPPER END OF THE HUMERUs.
—The result of these fractures, if of ordinary severity and if displace-
ment is overcome, is usually good; though in rheumatic patients a certain
degree of stiffness often remains for a long time, even when the joint has
not been invaded. The treatment of fractures of the head, anatomical
neck, and tuberosities consists in simple restraint of motion, induced by
carrying a broad strip of adhesive plaster or bandage once around the
arm and chest and placing the hand and wrist in a sling. Violent move-
ments to verify a probable diagnosis should be avoided, as any impaction
existing may thus be destroyed with the unfortunate result of increasing
displacement. In four to six weeks treatment may be discontinued.
Other fractures at the upper end of the humerus are best dressed by
filling up the hollow of the axilla with a folded napkin or thin compress,
and then, after replacing the fragments,
Securing the arm against the chest with FIG. 189.
the elbow carried a little forward. In
this manner the thorax acts as a splint
to which the arm is bound by means of
adhesive plaster or a bandage. The
forearm may be laid across the opposite
mammary region as in treating frac-
tured clavicle, or may be simply sup-
ported in a sling which should preferably
be applied near the wrist in order that
the weight of the elbow may furnish
I
"...
I
i.
\
§,
'. | a
º, Fº
gºss 'A
apparatus of adhesive plaster such as is
used for continuous traction or extension
Some slight extending force. The shoul- sº % ºsy
der-cap splint is usually a useless and sº ſ -
unnecessary complication. When it is Š sº
deemed necessary that greater exten- º º,"
Sion should be exerted a weight may be % º
attached to the elbow by an extension a gº
in fracture of the femur. In the event
of the upper fragment being so rotated
out Ward that coaptation cannot be
'maintained unless the lower fragment is
“arried upward and outward, it becomes
*Cessary to treat the fracture with the
!N
SS-
|º
º
*
a.
*#
ſ
|
ſº
•
…
gº
&%º
ſ
*
f|
ſ
à
à:
y
º
§
|
ºrm strongly abducted. This may be * Nº
* by using a triangular splint, of
º or other firm material, with a Method of applying extension in
unded apex. The apex should be fractures of the humerus. (HAMIL-
Pushed well up into the axilla and the ToN.)
legs of the triangle fixed to the side of
the chest and inner aspect of the arm respectively. Another method is to
P" the patient in bed and by means of an extension apparatus of adhesive




392 D IS E A SES AND IN J U R IES OF B O N E S.
plaster, a pulley and a weight to obtain continuous abduction and exten-
sion of the limb. An elastic cord properly attached to the wall of the
room will answer the same purpose as the weight. Counter-extension
can be exerted by elevating the foot of the bed or by fastening the patient
to the head of the bed by adhesive plaster attached to the chest and shoul-
der. In such instances the arm usually has to be kept at an angle with
the long axis of the trunk of from 30 to 45 degrees.
The dressing may be discontinued in ordinary cases of fracture of the
upper end of the humerus in five or six weeks.
Gunshot and other open fractures involving the shoulder-joint may
demand excision, but conservative antiseptic measures and secondary ex-
cisions have of late years displaced to a great extent primary excisions.
In fractures complicated with dislocation an attempt to reduce the dislo-
cation should be made at once. If this is found impossible, the fracture
should be treated and renewed efforts at reduction made subsequent to
union of the fracture. If there is definite evidence that such late efforts
will be unavailing, even with the advantage of leverage gained by the
united bone, endeavors to prevent union and create a false joint at the
seat of fracture are justifiable. The disability due to old fractures com-
plicated with dislocation may sometimes be lessened by excision of the
head or the upper end of the lower fragment.
FRACTURES OF THE SHAFT OF THE HUMERUS.–Fracture from mus-
cular violence is more common here than in any other part of the skeleton
except the patella and olecranon. Displacement in fractures of the shaft
depends more on the breaking force than the action of muscles. The
usual characteristic symptoms of fracture are present and easily deter-
mined. Involvement of the vessels and nerves in the injury is not so
very uncommon. Wrist-drop from palsy due to pressure upon the mus-
culo-spiral nerve, and gangrene following vascular damage, must not be
hastily referred to improper treatment. Union occurs among children in
three or four weeks, among adults one or two weeks later. Delayed
union and non-union happen more frequently than in other long bones;
and is possibly accounted for by the difficulty of completely immobilizing
the limb when the fracture is treated with the elbow flexed.
FIG. 190.
Internal angular splint with changeable angle.
In treating these lesions the surgeon should be especially on the alert
to overcome rotary displacement. Such deformity can be detected by
observing that a line drawn from the greater tuberosity to the outer con-
dyle is not parallel to the long axis of the bone as it should be. When
much swelling is present, and when a suspicion of complicating injury of
vessels or nerves exists, it is wise to keep the patient in bed a few days and
employ simple support by pillows and cushions, lest the more constricting
dressing be accused of producing gangrene or paralysis. Few fractures of
the shaft require continuous extension by weight from the elbow. Frac-

F. R A C T U R ES OF T H E H U M E R U S. 393
tures in the upper half of the shaft are well treated, as are fractures of the
upper end, by using the lateral thoracic wall as a splint. The thin axillary
pad, described in this manner of dressing, may act better if somewhat
wedge-shaped and placed with its base downward.
In lesions of the lower, and sometimes in those of the upper half, an in-
ternal right-angle splint, with or without an external concave splint of
pasteboard, leather or gutta percha, makes a good dressing. The internal
splint should be well padded at the elbow or have an opening in it to pre-
vent pressure on the internal epicon-
dyle. The elbow should not be drawn FIG. I 91.
upward by the sling used to support
the forearm. Sometimes an external
angular splint, reaching from acromion
to wrist, is preferable. At other
times a straight external splint from
shoulder to wrist may be found more
effective in restraining motion at the
seat of fracture, because it better im-
mobilizes the elbow-joint. The forearm
should be semi-prone when this dress-
ing is employed. The gypsum dressing
is often satisfactory after primary dis-
placement and swelling have been re- a
moved. When adopted it should be Splint for fracture of shaft of humerus.
applied, with the elbow flexed, from the (BRYANT.)
hand to above the shoulder with a few
turns of the saturated bandage passing around the upper part of the chest.
A forearm sling completes the dressing.
FRACTURES OF THE LOWER END OF THE HUMERUs.—The principal
fracture lines which may occur at the lower end of the humerus are shown
in the diagrams. In addition, the small tubercle on the external condyle,
Sometimes called the external epicondyle, may be detached, and in very
rare instances a portion of the articular surface of the bone may be chipped
off. Of course, comminuted fractures following no definite lines may
occur here as elsewhere in the skeleton.
FIG. 192. FIG. 193.
d
Principal fracture lines of lower end of humerus.
In studying injuries about the elbow, it should be remembered that
there is no lateral motion between the humerus and the bones of the fore-
arm. . When the elbow is semi-flexed an apparent lateral motion is ob-
servable. It really takes place at the shoulder and not at the elbow,
which is a hinge joint alone. Flexion and extension of the joint proper
and rotation of the head of the radius are the only possible motions of


394 DISE A SES AND IN J U RIES OF BONES.
the healthy articulation. Lateral mobility at the elbow means fracture
or some other organic change in the constituents of the joint.
Fracture above the condyles may be mistaken for dislocation of the
bones of the forearm, and if complicated with vertical splitting may involve
the elbow-joint. The most frequent displacement is projection of the
FIG, 194.
à%
!fſº a{
|%
§|:
:§\
ſ *s§º
|;t ~§
!.|º
d§*
;:|
&ſºi|º}
n×}
t*ſ-
tW}!
§§|
i
i|-|
:§:*§;#
|*§
ſiº}
ºt
º&;
|
s|
Diagrammatic supra-condyloid fracture of the humerus. (GRAY.)
upper fragment in front of the lower with angular deviation in the line
of the limb. This, if uncorrected, will greatly impair the future utility
of the joint. It is the prominence given the olecranon by this displace-
ment that creates a resemblance to dislocation. The normal relation of
the olecranon to the condyles, the natural character of the joint motions,
the crepitus developed when extension is exerted on the limb, and the
recurrence of deformity, establish the diagnosis.
Separation of the main lower epiphysis, which, though small, includes
both condyles, is rare. In deformity, diagnosis and treatment, the injury
differs little from supracondyloid fracture.
FIG. 195. This conjugal cartilage Ossifies about the
sixteenth year. The prominent tubercle on
the internal condyle, called the epitrochlea
or internal epicondyle, may be the subject
of epiphyseal separation or be broken off
with or without a small portion of the bone
at its base. The line of fracture is entirely
without the limits of the joint; hence, the
>--~~~~ escº articular motions are unimpaired unless by
Epiphyseal fracture of lower end Špasm Or fear of pain. Downward and
of the humerus. (Bryant.) ... forward displacement of the fragment OG-
curs when its fascial envelope is sufficiently
disturbed to permit the influence of muscular traction. Simultaneous
injury to the ulnar nerve lying in the groove behind the epicondyle is
possible. Abnormal mobility and crepitation are easily detected by grasp-











F. R A C T U R ES OF T H E H U M E R U S. 395
ing the tubercle in the fingers. This, which is likewise developed by a
distinct ossific centre on the outer condyle, may in rare instances be
detached.
Fractures separating either of the condyles from the shaft necessarily
involve the joint, and hence are very important injuries. Such fractures
FIG. 196. FIG. 197, FIG. 198.
Fracture above condyles of hume- Normal angle of bones of
rus. (STIMson.) forearm. (ALLIs.)
are common. The essential components of the elbow
hinge are the ulnar and the articular surface of the in-
ternal condyle. Hence, fractures of the inner condyle
are especially dangerous to the future integrity of
joint mobility. The ulnar joins the humerus in such {
a Way that the axes of the two bones form a diverg-
ent angle. This outward deflection of the forearm
gives the “carrying function’ to the limb, by which
the hand when hanging by the side is enabled to
carry burdens without striking the thigh. Loss of Outward deflection of
this angle by ascent of the internal condyle or descent forearm. (Stimson.)
ºf the external condyle after fractures, greatly impairs
theusefulness of the limb. Such displacements are very common, because
the line of fracture usually runs obliquely from the margin of the base of
ºne condyle down into the articular surface of the same. The condyloid
fragment in fracture of the inner condyle is usually displaced upward and
backward, and drags the attached ulna with it, thus destroying the
divergent angle at the elbow. It is said that a quarter-inch displace-
*ent upward will destroy this angular deviation. The anterior or pos-
terior right-angle splint often used to dress this fracture is accused, by
Dr. 9. H. Allis, of Philadelphia, of being a frequent cause of this dé-
formity. He probably is right." He says that such a splint bandaged
"Pon the flexed elbow tends to raise the ulna till it lies on the same plane
* the radius, while it normally lies below that bone when the elbow is
bent. The displacement in fractures of the outer condyle is often


396 I) IS E A S E S A N ID IN J U R T E S OF B O N E S.
upward, thus increasing the outward angle at the elbow ; but the radius
with the attached condyloid fragment may, according to Allis, be forced
FIG. 199. FIG, 200.
#ſº
sºs * º
§ſºmſ
ill||
§ º º §j}} Nº.
W §||
º
Fracture of internal condyle. (HAMILTON.) Fracture of extermal condyle. (HAMILTON.)
FIG, 201.
Deformity after fracture at lower end of humerus, “ Gunstock deformity.” (ALLIS.)
FIG. 202. - FIG. 203.
Epiphyseal Separation or fracture above Fracture of external condyle showing
condyle, showing possibility of deformity similar possibility of deformity. (AL-
by tilting the lower fragment. (ALLIs.) LIS.)








F. R A CTU R E S OF T H E H U M E R U S. 397
down by rectangular splints till it reaches the level of the ulna, so as to
cause a loss of the divergent angle at the elbow. Dr. Allis thinks that
FIG. 204. FIG. 205.
FIG. 204.—Differing planes of radius and ulna. (ALLIs).
FIG. 205.-Relation of radius and ulna, to humerus in fracture of internal condyle,
showing ease with which ulna and broken condyle can be forced up by splint and band-
age, and thus destroy carrying function of arm. (ALLIs.)
epiphyseal separation and fractures above the condyles may show similar
distortion from the use of rectangular splints. Condyloid fractures are
occasionally associated with partial or complete dislocation of one or both
forearm bones.
The existence of mobility and crepitus is to be determined by grasping
the lower end of the humerus and the suspected condyle with the fingers
of the two hands and endeavoring to move the condyle alternately back-
ward and forward. In the fully extended
normal articulation a line joining the two FIG. 206.
epicondyles crosses the tip of the olecranon,
but as flexion is made the olecranon sinks
below this line. The position of the head of
the radius, one-half inch below the external
epicondyle, should also be recollected in
order to differentiate dislocation of this bone.
If the surgeon places a finger at this point
and then rotates the patient’s hand, the head
of the radius will be felt rolling under the
integument. The transverse diameter of the
lower end of the humerus is usually increased §
in condyloid fracture, because of the ob- ºW
liquity of the line of fracture and the common gº % º
tendency in both fractures to upward displace- §§º
ment; but it is often difficult to be certain of
this widening. When backward displacement
has occurred after fracture of the internal
gondyle the prominent olecranon during flex-
lºn and the disappearance of this projection Intercondyloid fracture of the
during extension greatly resemble backward humerus. (STIMSON.)
dislocation of the bones of the forearm.
Union of condyloid fractures occurs in four or five weeks, but unreduced
displacements, masses of callus, and the sequences of secondary synovitis
often leave much functional disability.







398 D IS E A S E S A. N. D IN J U R IB S OF B O N E S.
The term intercondyloid is applied to those fractures in which the con-
dyles are split apart and at the same time are separated from the shaft.
The fracture lines may be exceedingly diverse in direction, but in simple
cases assume an irregular T or Y shape. In intercondyloid fractures,
which are, however, not very common, the joint is, of course, implicated;
and very often great damage to the soft parts co-exists. Separation of
the condyles with the olecranon forced up between them is a not unusual
displacement. Great distortion of the joint, increased width of the
lower end of the humerus, and crepitation when the fractured surfaces
are brought into contact render the diagnosis evident.
DIAGNOSIS OF FRACTURES AT THE LOWER END OF THE HUMERUS.—
The points in the diagnosis of fractures of the lower end of the humerus
need recapitulation. Normally, the head of the radius is about half an
inch below the external epicondyle, and unless the shaft of the radius is
broken moves when the hand is rotated. With an extended forearm the
two epicondyles and the tip of the olecranon are on a level, but as the
elbow is flexed the olecranon sinks below this horizontal line.
Supra-condyloid fracture with the ordinary backward displacement of
the lower fragment shows unusual projection of the olecranon and triceps
tendon, increased by straightening the elbow; correction of deformity
when traction is made upon the forearm, with recurrence of the same
when the traction ceases and the elbow is bent; motion and crepitus above
the joint; free mobility at the joint which may, however, be limited by
swelling or spasm; normal relation of olecranon and epicondyles. In
backward dislocation of the bones of the forearm the unusual projection
of the olecranon and triceps tendon is diminished by straightening the
elbow, and the point of the olecranon rises above the level of the epicon-
dyles; when the deformity is reduced there is a distinct snap and recur-
rence of distortion does not readily recur; no motion or crepitus can be
developed above the joint, though joint frictien may simulate fracture
crepitus; the normal articular movements are almost abolished and the
joint is fixed, though some abnormal lateral motion may be possible; the
relative position of the epicondyles and olecranon is altered; the head of
the radius is not in its proper situation; the distance between the epicon-
dyles and the corresponding styloid processes at the wrist is decreased;
and the lower end of the humerus feels smoother and wider than the lower
end of the shaft in case of fracture.
When the lower fragment is displaced forward the question of diagnosis
is easily settled, because forward dislocation of the forearm is exceedingly
rare and the symptoms characteristic.
Fracture of the internal condyle is diagnosticated by crepitus and
independent mobility; lateral mobility at the elbow-joint when the fore-
arm is extended; and in addition, when displacement is present, change
in the divergent angle of the elbow and alteration in the horizontality of
the line drawn across the back of the articulation joining the epicondyles
and olecranon. If dislocation of the head of the radius coexists, the head
of that bone will probably be discovered behind the external condyle,
and the internal condyloid ridge of the humerus will be felt to termi-
nate abruptly at the line of condyloid fracture. In fracture of the
external condyle, crepitation, independent mobility, alteration of the
normal lateral deviation of the axis of the limb at the elbow, change of
relation with the other condyle and olecranon, but normal relation to the
head of the radius, will serve to indicate the nature of the lesion.
F. R A CTU. R. ES OF T H E H U M E R U S. 399
The relation to the head of the radius should be carefully studied when
outward dislocation of the radius and ulna is a question to be determined.
In suspected intercondyloid fractures, great deformity with distortion
of relation of the bony landmarks, increase in width of the lower end of
the humerus, independent mobility of the condyles and between the con-
dyles and shaft, and crepitation, especially noticeable when the olecranon
is drawn down and the condyles pressed together, are the symptoms to be
sought.
ºwest OF FRACTURES AT THE LOWER END OF THE HUMERUS.—
It has been the general custom for the most part to treat these fractures
in the flexed position with anterior or internal angular wooden splints, or
with posterior angular trough-like splints, made of felt, tin, gypsum, or
similar material. This is usually an error. The best results will generally
be obtained by keeping the joint extended or nearly so during the time
that displacement is likely to occur. Ankylosis in the extended posture
FIG. 207.
Anterior angular splint, with changeable angle.
Fig. 208. FIG. 209.
Deviating splint for fractures through the
condyles of the humerus.
is,...I admit, very undesirable, but, unless permanent ankylosis is very cer-
tain to occur, disability from the “gunstock” deformity is to be guarded
against by keeping the joint extended. Fractures of the epicondyles,
Some fractures of the external condyle, fracture of the internal condyle
With backward luxation of the radius and ulna, and bad intercondyloid
fractures, may perhaps give better results when the flexed position is
3dopted, but for the great majority of cases the extended posture is better.
The dressing, then, for fractures at the lower end of the humerus consists
ºf a straight wooden splint, twelve or fourteen inches long, placed upon
the anterior surface of the arm and forearm, with a little extra padding
ºf the bend of the elbow if complete extension of the joint is not desired.
The application of a moulded gypsum splint to the anterior or posterior
surface, or to the entire circumference of the arm, is sometimes preferable.
Four weeks or less is usually long enough to retain the splint upon the
limb. In all cases the Surgeon should see that the outward deflection of



400 D IS E A SES A N D IN J U R I ES OF B O N E S.
the forearm, due to the obtuse angle between the axes of the arm and
forearm, is maintained. It is usually best to have the straight splint cut
so as to make a slight outward deflection between the arcs of the upper
and lower portions. I have often made such splints from a strip of
board with my pocket-knife. It is well to compare the patient's arms, as
the normal outward deflection varies in individuals. If the position of
extension is uncomfortable, or if there is reason to believe that permanent
ankylosis is about to occur, the straight splint may be removed at the
end of two weeks and the elbow carefully flexed to nearly a right angle.
Should the fragments remain in good position and no tendency to recur-
rence of deformity be present, the subsequent treatment may be con-
ducted with an angular splint.
In very bad intercondyloid fractures and fractures involving the radius
and ulna as well as the humerus, ankylosis will almost certainly occur;
hence the flexed position here should be adopted more frequently than in
other cases. Continuous weight-extension may become necessary to keep
the fragments in position. Excision of the joint may be demanded in
such fractures, if open. It is better in such excisions to avoid, if practi-
cable, removal of the upper ends of radius and ulna, because otherwise
the insertions of the great muscles are disturbed. Passive motion should
not be made before the end of three or four weeks, and not then if it
causes pain. The moderate stiffness, usually left even in favorable cases,
will disappear in the course of a few weeks after removal of the splints,
especially if active and passive motions accompanied by friction be
employed. If inflammatory involvement of the joint has taken place
early passive motion will do no good but probably much harm.
Fractures of the Bones of the Forearm.
Fracture of both bones of the forearm near the middle is quite com-
mon, but fracture of the shaft of either bone alone is unusual. When
the radius alone is broken the lesion is nearly always situated near its
lower end, while the ulna when broken alone nearly always suffers such
lesion at the upper end.
The clinical phases and the diagnosis of fractures of the forearm will
be better appreciated if lesions of similar parts of the ulna and radius are
discussed together. ..
FRACTUREs NEAR THE ELBow-JOINT.-Hence I shall speak first of
fractures near the elbow-joint. This is the method adopted by Stimson in
his elaborate work on fractures, from which, I may say in passing, much
of the material used in this section on fractures has been obtained.
FRACTURE OF THE OLECRANON.—Direct violence may cause the ole-
cranon to be broken from the shaft of the ulna, but it is probable that a
great majority of these fractures are due to a leverage action consequent
upon the triceps holding the process firmly against the lower end of the
humerus at the time the impinging force is applied to the forearm. The
bone snaps in such cases as a stick is broken by the hands across one's
knee. Muscular contraction alone seldom causes this fracture. The
location of fracture varies, but most commonly is near the middle of the
process, where there is a narrowing. The epiphyseal cartilage, which
ossifies about the sixteenth year of life, is placed near the middle of the
olecranon; therefore, supposed fractures in young persons may really be
F R A C T U R ES OF B O N ES OF THE FOR E A R M. 401
instances of diastasis or epiphyseal separation. The triceps muscle tends
to displace the upper fragment upward, but the process is sº attached to
the humerus by ligaments, and the tendinous expansion of the muscle so
unsheathes it and the adjacent part of the ulna that not much separation
occurs unless the forearm is flexed. In fact in many instances no marked
displacement takes place even in flexion, because the fragments are bound
together by the untorn aponeurosis. Under the opposite conditions a
separation of as much as two, and a half inches is said to be possible, but
this probably refers to the joint in a flexed, or semiflexed position. The
intra-articular effusion that frequently arises and the tendency of the
biceps and anterior brachial muscles to draw up the forearm, and thus
crowd the humerus into the gap between the ulnar shaft and olecranon,
probably have an influence in causing separation of the fragments.
EIG. 210. FIG. 211.
J)iagrammatic fracture of olecranon. (GRAY.) Fracture of olecranom. (ERICHSEN.)
The symptoms are localized pain and swelling, lateral mobility and
crepitus, combined with more or less loss of power to extend the fore-
arm, and with, in some cases, a noticeable depression at the seat of fracture.
The last two symptoms vary greatly with the degree of laceration of the
fibrous envelope of the bone. The development of crepitus may require
the fully extended position of the joint in order to obtain contact of the
bony surfaces. If local pain and impaired extension power alone are
present, the case should be treated as an instance of fracture until the
subsequent history disproves the suspicion. -
Union may be bony, but is generally fibrous. A comparatively long
fibrous bond gives but a moderate disability, if there coexist no adhesions
of the olecranon to the humerus and no intra-articular fibrous obstruc-
tion. This is due to the fact that powerful and extensive flexion is a
imore important function of the elbow than complete extension. Ununited
racture is not very infrequent.
. In ordinary cases cure takes place in about four weeks, and though the
. is necessarily involved, there is no tendency to ankylosis of the
€l OOW.
When separation of the fragments is present the injury should be
treated with a splint to keep the elbow extended to that degree which is
*en when the arm hangs passively at the side. As ankylosis is not to

26
402 DISE AS ES A N D IN J U R IES OF BON ES.
be anticipated, the most accurate coaptation possible is to be sought. This
is obtainable only by the extended posture; but the extension must not
be so excessive as to bend the joint backward, which is possible when the
normal check to such motion given by the olecranon is destroyed by frac.
Adhesive strip applied to steady olecranon. (AGNEw.)
ture. The upper fragment may be steadied or pulled down if necessary
by a strip of adhesive plaster so applied above it that the ends cross each
other upon the forearm. An anterior straight splint of wood or metal or
a circular gypsum dressing, leaving the elbow uncovered, is then applied
from the upper third of the arm to the lower third of the forearm. If
e º º |
Fracture of olecranon treated in extended position. (AGNEw.)
it is impossible to bring the fragments, together by extension alone, the
upper fragment, may be drawn down by a single steel hook, similar to
Malgaigne's double patella hooks, inserted into the tendon just above the
olecranon and attached below to the skin and fascia covering the ulna,
or to the gypsum dressing which is applied to keep the elbow extended.
Tenotomy of the triceps tendon would be justifiable to overcome upward
displacement. The hook should not be applied for three or four days
until the inflammation immediately following the injury has subsided,
but should be retained in position for four weeks. If there is much pri-
mary synovial effusion into the joint, increasing displacement, aspiration
is proper. When violent reaction occurs and ankylosis seems probable,
passive motion may be cautiously made after three weeks, but is to be
omitted if it causes inflammatory reaction. When there is little tendency
to separation and flexion does not increase the displacement, the limb
may be treated in a semi-flexed position if extension causes discomfort.
When great disability has resulted from long fibrous union, great im-
provement has been obtained by exposing the bone, freshening the ends,
and fastening the fragments together by wire sutures introduced so as
not to penetrate the joint. This procedure is justifiable under exceptional
circumstances if done antiseptically.



F R A CTU. R. ES OF B O N E S OF T H E F O R. E. A. R. M. 403
Fracture of the coronoid process is very rare except as a complication of
backward luxation of the ulna or of radius and ulna together; when the
process is liable to be broken off by being driven against
the articular surface of the humerus. The symptoms
are the presence of a small movable body in the line
of the tendon of the anterior brachial muscle, crepita-
tion, and usually the symptoms of dislocation of the
forearm. Displacement from muscular contraction is
impossible, unless the line of fracture be below the
base of the process, for the tendon is not inserted upon
the apex of the coronoid process. A similar reason
proves the supposed detachment of this apophysis by
muscular contraction an error. Treatment consists in
immobilization with a splint or the gypsum bandage -
for a couple of weeks with the elbow flexed at a right Fracture of coro-
angle or less. A sling should then be worn for ten noid process, and
days or two weeks longer. head of radius.
FRACTURES OF THE HEAD AND NECK OF THE (BRYANT.)
RADIUS.—Of these rare injuries little is known. A
splitting off of a part of the articular surface of the head with the line
of fracture running down the neck is perhaps the most common form,
and is observed in connection with coronoid fracture of the ulna. The
fracture may be entirely within the joint; hence synovitis and defect in
bony union might be expected. Loss of power of rotation, crepitation,
the presence of a movable fragment, and an apparent widening of the
head of the radius are the symptoms likely to aid in the diagnosis. The
radius may also be broken at the neck just above the bicipital tubercle.
Immobilization for three or four weeks in the flexed and supine position,
which relaxes the biceps, should be the treatment.
FRACTURES NEAR THE MIDDLE of THE FOREARM. Fracture of the
Shaft of Both Bones.—When the radius and ulna sustain simultaneous
Union, with slight lateral displacement, of fracture of radius and ulna.
fracture of the shaft it is usually found that direct violence has caused
the injury; and as a rule the radial fracture is nearer the elbow than is
the ulnar fracture. Fractures from muscular contraction are occasionally
seen. Green-stick fracture is not uncommon. Angular displacement
toward the interosseous space, overriding and rotary displacement of the
*adius are sources of deformity. The overriding may shorten the limb
*Wo or three inches. When the radial fracture is above the insertion of
the round pronator muscle, the short supinator and the biceps, which is
also * Supinator, have unopposed action; hence the upper part of the
bone is supinated, and the lower portion, if it is kept pronated by the
Splints will unite with rotary deviation. To avoid this the hand should
be kept supine by the splints. -


404 D IS E A SES AN ID IN J U R IB S OF B O N ES.
The loss of rigidity of the limb, crepitus, and abnormal mobility render
the diagnosis easy. Union occurs in about four weeks, but a high grade
of inflammation is not an infrequent complication. Gangrene from con-
stricting dressings must be remembered as a possible danger, to which
attention may not be called by any discomfort felt by the patient. The
comparative frequency of these complications probably arises from the
usual causation of the fracture by direct violence. The primary bandage
under the splints is to be especially avoided in these injuries. When the
two fractures are directly opposite each other, when great laceration or
irritation of the interosseous membrane and fibrous tissue has occurred,
and particularly when inward angular deformity is permitted to remain
uncorrected, mormal pronation and supination are liable to be diminished
or destroyed by an osseous bridge soldering the radius and ulna together,
or by a protuberance of one or both bones. The prognosis in uncompli-
cated cases is good, though delay or failure in
FIG. 216. union is not very infrequent. After replacement
of the fragments has been obtained by extension
and counter-extension and by pressure of the fin-
gers in the space between the two bones, the limb
should be placed in the supine position, that is,
with the palm of the hand upward, and so main-
tained by splints until consolidation has occurred.
The semi-supine position is often adopted, but as full
supination is required to prevent rotary deformity
of the radius when it is broken above the insertion
of the round pronator, it is safer to teach the
adoption of complete supination for all cases of
fracture of the shaft. Such a position gives be-
tween the radius and ulna almost, if not quite, as
much space as the semi-supine position, and hence
is as efficient in preventing loss of rotation by
bridges of callus.
The supine position is most conveniently main-
tained by the use of either a right angle wooden
or metal splint applied to the flexor surface of the
limb from the middle of the upper arm to the root
of the fingers, or a right angle trough similarly
fitted to the extensor surface of the arm and fore-
and jo, between bones arm. A straight palmar and dorsal splint applied
in facture of radius and together and extending from elbow to fingers will
ulma. (STIMson.) scarcely prevent the limb assuming the semi-supine
position, which is more convenient and comfortable
to the patient than complete supination. After partial consolidation has
occurred, say at the end of two weeks, the two straight splints may be
substituted for the angular one, since at that time the risk of rotary dis.
tortion is no longer great. In fractures below the insertion of the round
pronator such splints may be used from the beginning of the treatment,
but must be wider than the arm so that the bandage shall not press
the bones together at the site of fracture. The palmar splint is made
more comfortable by having the distal end cut off obliquely and well
padded for the fingers to close over it.
In all these fractures the sling should be broad enough to support both
hand and forearm. A narrow sling supporting one part only is liable to
permit sagging and angular deformity. This is especially so when the
Angular displacement

F. R A CT U R ES OF B O N E S OF T H E FO R. E. A. R. M. 405
palmar and dorsal splints are employed. The use of a narrow compress
under the splint to prevent encroachment of the fragments upon the inter-
osseous space is either unnecessary or inefficient. The circular gypsum
dressing is not well adapted to these fractures, though the moulded gyp-
Sll Iſl it. are not objectionable. º
Daily examination is a wise precaution for the first week, since exces-
sive inflammatory swelling and a tendency to displacement are frequent
accompaniments of these injuries, The splints may be removed in four
weeks. Extreme overriding may require the adjustment of continued
extension. In cases kept in bed this may be effected by a weight and
pulley; in walking cases by elastic bands attached to a splint prolonged
beyond the hand. Shortening is not a matter of much moment except
when due to such overriding as may impair rotary motion by encroaching
upon the interosseous space.
TIG. 217.
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Scott’s splint for extension in fracture of forearm. (STIMson.)
FRACTURE OF SHAFT OF ULNA.—If the radius is neither broken nor
dislocated, shortening is not possible in fracture of the ulnar shaft.
Lateral or angular displacement is readily discovered because of the sub-
Qutaneous position of the ulna. Alternating pressure above and below
the supposed fracture, or grasping the two portions of bone firmly with
the fingers and endeavoring to move them in opposite directions will
usually prove or disprove the existence of crepitus and mobility. If the
tip of the olecranon be quickly tapped with the fingers of one hand while
the lower end of the normal ulna is grasped with the fingers of the other
hand, the transmission of the vibration along the entire length of the
bone will be readily felt. In a broken bone this transmission will be
much less perfect. Attempts to twist the arm may develop crepitus
otherwise not easily elicited. Forward dislocation of the head of the
radius is said to be a not unusual complication of ulnar fractures, and
may be overlooked.
Moulding by digital pressure is the only efficient agent for correcting
splacement, and must be so exerted as to avert infringement of the
*9sseous space by angular deviation of the fragments. The same
*ēsing as that described for fracture of the shafts of both bonesis appli-
cable, though complete supination is not demanded as in the former case.
he prone position is not allowable, but the semi-supine will often do as
*. *the supine. In most cases the elbow joint had better be controlled.
he circular gypsum dressing is often very convenient and efficient. If
di

406 ID IS E A S E S A N I) I N J U R I ES OF B O N E S.
the posterior gutter of felt or metal is used, it is important that it should
support the ulna along its entire shaft as well as at its ends, lest sagging
occur at the seat of fracture. The splints should be kept on about three
weeks.
FRACTURES OF THE SHAFT OF THE RADIUS.—The function of the radius
as the movable segment of the forearm, to which the hand is attached,
gives great importance to this fracture and warrants a guarded prognosis.
Displacement is liable to be angular, forward and toward the ulna, and
the supinating muscles have a tendency to supinate fully
FIG. 218. the upper fragment if the solution of continuity occurs
§ N above the round pronator's insertion; while the hand
* } and lower fragment tend to take the prone position.
$º Marked displacement of the lower fragment at its upper
\},\, \'ºſº, end toward the ulna alters the plane of the lower articular
\ } face of the bone and gives the hand an abnormal devia-
W | tion toward the radial side. Power of voluntary supina-
º tion and pronation is gone, and the hand and forearm
º º when grasped seem to be loose and flaccid. Overlap-
#| WA ping is impossible unless the splint-like ulna be broken
\ } or dislocated.

§ {
! | The diagnosis is established by mobility, crepitus, and
\ occurrence of the deformities just mentioned. Absence
W.A of rotation of the radial head when the hand is grasped
| | and twisted backward and forward is a certain indication
| of fracture. In making this examination the surgeon
should grasp the elbow and place his thumb on the head
| |
# | | of the radius as it lies just below the outer condyle of the
º | | humerus. A rubbing sensation similar to fracture-crepi-
º tus is here quite often developed when no fracture exists.
º This is due to friction of the joint surfaces or to inflam-
matory exudation among the muscles and tendons. The
Fracture of shaft treatment should be the same as in fracture of both
ofradius. (HAMIL- bones, with the limb kept in the supine posture. This is
Ton.) especially demanded in fractures of the upper part of
the shaft. If the hand is much displaced extension of
the ulnar side may be valuable in obtaining and maintaining correct
apposition. In accompanying dislocation of the lower end of the ulna
extension by some such device as that figured under fracture of both bones
may be necessary. Motion of the hand and elbow had better be controlled
in most cases. At the end of three weeks the splints may be discontinued
and a simple bandage used. º
Fractures near the Wrist-joint.
FRACTURE OF THE Low ER END OF THE RADIUS.—This exceedingly
common fracture was long misunderstood and is still very often improperly
treated. It is frequently designated by the name of one or other of those
writers who have discussed it, but I shall not mention the names, Since
such momenclature serves to confuse the student and to perpetuate erroº
neous teaching. The usual fracture line is situated from one-third, tº
three-quarters of an inch above the articular surface of the bone; and is
generally more or less transverse in direction, though some tendency *
lateral or antero-posterior obliquity is not infrequent.
F R A CT U R E S N E A R T H E W 13 IST J O IN T. 407
Displacement of the lower fragment backward upon the lower end of
the upper fragment is the ordinary deformity and is due to the fracturing
force, not to muscular contraction. Some impaction is quite frequent
from driving of the dorsal wall of the upper into the cancellated struc-
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Vertical Section showing epiphyseal separation and backward displacement of lower
end of radius. (BRY ANT.)
ture of the lower fragment; and actual loss of substance from crushing
the bony tissue is not unusual. At times there is little displacement; at
others it occurs at the radial but not at the ulnar side of the lower frag-
ment, which is tilted obliquely backward. The styloid process of the
FIG. 22().
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Deformity in fracture of lower end of radius (diagrammatic). (LEVIs.)
radius is carried upward and backward by this displacement; and, there-
fore, in fracture of the lower end of the radius the radial styloid process
is often on the same level as, or even higher than, the ulnar styloid
process.
FIG. 221.
Diagram of displacement in fracture of lower end of radius. (LEVIs.)
This angular displacement tends to throw the articular surface with the
attached garpus upward, backward, and to the radial side. Hence occur
the peculiar deviation of the hand and the under prominence of the lower
end of the ulna, which gives such a characteristic appearance to the limb





408 I) IS E A S E S A N ID IN J U R IB S OF B O N E S.
after this injury. The hand is, as it were, carried away from the ulna by
the force which breaks the radius and displaces the lower fragment.
Sometimes the ulna is actually forced through the integument by the vio-
lence with which the hand is forced away from it, on account of the forc-
ible shortening of the radius. Such a wound, however, does not necessarily
create an open or compound fracture, for the wound does not always com-
municate with the fracture. Prepared specimens of united fractures give
perhaps a false notion of the amount of impaction originally existing,
because the formation of callus beneath the stripped-up periosteum or
the dorsal surface is misleading.
FIG. 222.
An old fracture of lower end of radius united with deformity uncorrected. (ERICHSEN.)
The wrist joint is not involved unless, as often happens, longitudinal
lines of comminution divide the lower fragment or base of the bone into
more than one piece. Fracture of the lower end of the ulna, or of its
styloid process alone, and rupture of the radio-ulnar ligaments and carti-
laginous attachments are occasional associated lesions; but, as a rule,
fracture of the base of the radius is uncomplicated except by commi-
nution.
In young persons epiphyseal separation, with a causation and deformity
similar to that which pertains to fracture, may occur. The treatment of
the two injuries is identical.
FIG. 223.
Vertical section of fracture of lower end of radius, showing usual backward
displacement. (R. W. SMITH.)
The fracture just described is practically the only one that occurs at
the lower extremity of the radius; though in rare cases irregular fracture
lines splitting off the radial or ulnar side of the base by lines more or
less vertical running into the joint have been described. Displacement
forward of the lower fragment, that is, displacement toward the palmar
surface, has been described as occurring after transverse fracture above
the joint when the force has been received upon the back instead of, as
usually, upon the palm of the hand.
The uniformity of the lesion produced when the radius is broken at the
wrist shows that the mechanical conditions causing the fracture are usually


F. R A CT U R E S N E A R T H E W R IS T J O IN T. 409
the same. When a man falls either forward or backward his arms are ex-
tended to protect himself, and the violence consequently is received on the
palms of the outstretched but not completely pronated hands. The force
is thence transmitted to the radius which is concave on its palmar surface.
Fracture occurs across this concave portion of the bone: 1. Because the
arch has strain brought upon it, and is by nature a weak part of the bone.
2. Because there is a cross-breaking force exerted here, when the hand is
violently extended backward, by the ligaments on the palmar aspect of
the joint; the end of the bone is thus torn off. 3. Because penetration
and crushing of the cancellated osseous tissue is caused by the lower end
of the bone being driven against the shaft.
Stimson thinks that the first theory is a better explanation of the usual
mechanism of the fracture than the others, though he admits that the
lesion may be caused in all three ways. I am inclined to believe in the
truth of his argument.
The symptoms of the fracture are so marked that, in a typical case,
error in diagnosis is impossible, if it is only recollected that dislocation of
the radio-carpal joint is exceedingly rare. The deformity of the fracture
so resembles that of backward dislocation of the carpus that the fracture
has at times been called a dislocation. This error has received apparent
confirmation from the fact that after the displaced lower fragment is
|pushed into position, there is little tendency except in comminuted
fractures, to reproduction of the deformity. The transverse character of
the break, and the absence of muscular displacing causes render secondary
displacement almost impossible unless the wrist is subjected to consider-
able violence. Let the student recollect that injuries of the wrist sug-
gesting dislocation of the carpus are nearly always fractures of the lower
extremity of the radius.
SYMPTOMS.—The characteristic distortion has given the name “silver
fork fracture” to the injury. The hand is apt to be held semi-prone.
Voluntary movements of the wrist are painful, and hence are lost,
though finger motions are but slightly impaired. On the radial side of
the back of the wrist there is a prominence, the upper margin of which
Can sometimes be felt as a sharp bony edge. The radial extensor tendons
may sometimes be felt stretched across the space between the shaft and
the upper portion of this prominence, which is, of course, the displaced
lower fragment. Forced flexion of the hand will render these tendons
more tense and therefore more easily perceived. On the palmar surface
of the wrist there is a transverse furrow behind the ball of the thumb,
and behind that a prominence due to the lower end of the upper fragment
and the inflammatory effusion which takes place into the sheaths and
tendons of the flexor mass of muscles. The hand usually deviates some-
What to the radial side, the ulna is unduly prominent on the posterior and
ulnar aspect of the wrist, and the styloid process of the radius is on a
level or even higher than that of the ulna. Mobility and crepitus are
often absent because of impaction; though both may be developed by
*ong pressure upon the dorsal prominence, which at the same time
forces the displaced portion of the radius into position with a sensation of
*PPing or grating. In comminuted or unimpacted cases motion and
99pitºls are often easily detected. Motion at the wrist joint or in the
Ҽpal articulations may be mistaken for fracture mobility. When no
displacement occurs there may be no distinctive symptoms except a tender
*P* upon the bone, which cannot be attributed to arthritis as it is a little
above the known location of the joint.
410 I) I S E A SES A N D IN J U R I ES OF B O N E S.
DIAGNOSIS.–The diagnosis must be made between sprain of the wrist,
fracture of the lower end of the radius, and dislocation of the carpus. If
no deformity such as described above exists, it nevertheless may be a
fracture with little laceration of the periosteum and no appreciable dis-
placement. The diagnosis then hangs upon the character of the vul-
merating force, the age of the patient, and the position of the tenderness
on pressure. If the patient is beyond middle age, has fallen heavily on
his palm and complains of localized tenderness about half an inch above the
joint, fracture is the probable lesion. If the point of tenderness is over
the wrist-joint, if the patient is young, or if the fall was a slight one, a
sprain with subsequent arthritis is the most likely injury. When the
usual displacement backward of the lower fragment has taken place, an
error is impossible after a careful examination, though it is true that the
swelling of severe sprain does sometimes simulate the deformity of
fracture.
Backward dislocation of the carpus is the only luxation resembling
fracture, and any dislocation about the wrist is exceeding rare. Backward
dislocation would show no change in the relative position of the styloid
processes to each other, would give a smooth, laterally convex upper
border to the dorsal prominence, and would be reduced with a smooth
snap rather than with a rough grating. Deformity would probably be
more easily reproduced than in the usual non-comminuted fracture. Dis-
location of the radio-ulnar joint would give a very different distortion
from that of fracture of the base of the radius.
In a person of fifteen to twenty years, epiphyseal separation is to be
expected rather than fracture. The exact diagnosis is, however, unim-
portant, for the treatment is identical with that of fracture. Inter-
ference with the future growth of the bone may perhaps follow epiphyseal
separation.
TREATMENT.-The essential point in the treatment of this fracture is
early and complete replacement of the lower fragment. The protracted
convalescence and frequent stiffness of the wrist and fingers seen after
this injury are due to imperfect reduction of the fracture and the confine-
ment of the fingers during the use of the fracture dressing. When there
is neither comminution nor loss of tissue by crushing, the fracture can
usually be cured in three to five weeks with little or no deformity, and
without stiffness of the fingers. When comminution and crushing exist,
cure without impairment of motion, though perhaps with more or less
persistent deformity, is nearly always possible, and in the same time.
When I say “cured,” I do not mean that every vestige of swelling and of
osseous thickening disappears so soon, but that the limb is capable of per-
forming its ordinary functions. Old and rheumatic patients may perhaps
exhibit a greater tendency than others to rigidity of the joints; but I
cannot insist too strongly on my belief that stiff fingers are usually an
indication of imperfect reduction of the fragments, which by their pro-
jection interfere with the extensor and flexor tendons and cause adhesive
inflammation. No apparatus should be applied that restricts, at any
period of the treatment, full and free motion of the fingers. In uncompli-
cated cases the splint need not be worn more than about ten days; pl.0-
vided that the patient is sufficiently intelligent to avoid submitting. the
arm to unexpected strains and blows. This is because of the slight
tendency to reproduction of deformity in the properly reduced fracture.
In careless patients, and in comminuted or otherwise complicated fracturº
support by the splint should be continued for three weeks. Uncompli.
FRACTURES N E A R T H E W RIST J O INT 411
cated cases in intelligent persons may be treated without any splint
whatever. A band of adhesive plaster, or a roller bandage applied
firmly around the wrist at the seat of injury, is all that is necessary after
perfect reduction has been accomplished. Passive motion is probably
never necessary if the fracture is properly replaced, and the play of the
fingers not restricted during the use of the splint.
Reduction is always painful, but is usually so quickly accomplished
that an anaesthetic is seldom needed. Ether or nitrous oxide should be
employed, however, if there is likelihood of the pain preventing perfect
coaptation of the parts. The surgeon must apply force directly to the frag-
ments. Let him put the patient's hand in the prone position, grasp the
middle of the forearm with one hand, and take hold of the patient’s palm
with the other hand in such a manner that his thumb can make strong
pressure upon the apex of the dorsal prominence. By making traction
on the hand of the patient and then suddenly flexing the patient's wrist,
while at the same time he presses with his thumb strongly upon the pro-
jection at the back of the wrist, he can nearly always force the lower
fragment into its proper position without difficulty. A repetition of this
manoeuvre is sometimes requisite before accurate replacement is obtained.
The grating produced as the fragment, which may have been impacted,
is driven into its normal position, can at times be distinctly heard by
bystanders. The limb at once assumes its normal contour. The disap-
pearance of the bony edge or shoulder previously perceptible to the touch
where the upper margin of the lower fragment was elevated above the
level of the shaft of the radius, is an indication that reduction of the
backward displacement has been accomplished. Still further manipula-
tion may occasionally be necessary to reconstruct the normal outline of
the radius, which has at the wrist, it will be remembered, a concave
palmar surface,
If great comminution or crushing has been incidental to the fracture,
Perfect restoration of shape may be impossible, although the deformity can
be greatly diminished. In such cases, also, retention of the fragments in
good position may be somewhat difficult. Firm impaction or entangle-
ment of the fragments in the tendons or dorsal periosteal bands may
require that the hand and attached lower fragment be first bent strongly
backward, in order to release the interlocking before making traction,
flexion, and pressure. This preliminary measure is not often necessary.
After reduction has been accomplished any form of dressing is allowable
provided it immobilizes the limb, does not tend to obliterate the normal
Qºrve of the palmar face of the radius, and permits the patient to move
his fingers. It was formerly thought that splints deflecting the hand to
the ulnar side exerted traction on the radial side of the wrist, and were
therefore indicated. This is incorrect teaching. Such splints are unneces.
Šary, as the deflection only causes the carpus to roll in the articular sur-
face of the radius. The hand should be placed in the prone or semi-prone
Pºsition, and a single splint, extending from below the elbow-joint to the
*iddle of the metacarpus, applied either to the dorsal or palmar aspect of
the forearm. It is essential that the palmar splint, if it be chosen, should
°99nvex on its upper surface at its carpal extremity, so as to preserve
the integrity of the radial concavity and not to make the palmar surface
of the radius flat, by forcing upward the lower fragment which has just
been pushed down into proper position by the surgeon's manipulations.
his Cºnvexity may be obtained by using the moulded splint of Levis,
** splint of wood with a hard convex pad to fit into the palmar concavity
412 ID IS E A SES AN ID IN J U R IES OF B O N E S.
of the radius. It should be seen that the pad properly fits. The surgeon
can readily make a pad out of soft wood and fasten it with screws to
a straight splint. No dorsal splint is needed with either of these splints,
FIG. 224.
Normal centre of bone.
Lower fragment pushed by splint,
É Splint.
Showing injurious effect of straight palmar splint in fracture of lower end of radius.
If it is inconvenient to obtain a proper form of curved palmar splint
a flat splint may be applied to the dorsal surface of the radius, which
presents no curve but is straight. Bond's splint, so frequently employed,
is dangerous to the future contour and utility of the limb, and should
never be used. After the splint has been employed for from a week to
ten days, varying, as above stated, with the kind of fracture and disposi-
tion of the patient, it is well to substitute it by a strip of adhesive plaster,
two inches wide, applied circularly around the wrist so as to give moderate
support to the partially consolidated fracture.
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Levis’s metal radius splint.
If union has already occurred in a fracture treated without proper
reduction the surgeon should attempt refracture and adjustment even
after the lapse of several months, provided that the fingers were very
rigid or the deformity very great. It is not likely that as much can be
accomplished in such cases as was possible immediately after the receipt
of injury, but proper reduction should be undertaken even at late periods.
















F. R A CT U R ES OF T H E M ET A C A R P U.S. 413
Good use of the hand is often obtained finally even where there exists a
considerable degree of deformity. Rigidity of the fingers if permitted to
occur remains, however, for many months. Refracture for correction of
deformity is readily accomplished if the surgeon will bend the bone
across his knee. Osteotomy need not be undertaken.
OTHER FRACTUREs NEAR THE WRIST-JOINT.-Fracture of the styloid
process of either the ulna or radius occurs, though rarely. The diagnosis
is not difficult. All that is needed for treatment is such a dorsal or
palmar splint as will prevent motion, at the wrist and fix the hand in a
deflected position; toward the ulnar side in fracture of the ulnar styloid
process, toward the radial side in fracture of the styloid process of the
radius. A circular gypsum dressing will probably best meet the indica-
tions. Fracture of the lower end of the radius, with displacement for-
ward—that is, toward the palmar surface has been mentioned as a rare
form of injury, due to receipt of violence on the back of the hand. It
should be treated with the same form of splints as is the common fracture
at the lower end of the bone; but of course the primary reduction is to
be made by pressure in an opposite direction.
Fracture of both the radius and ulna just above the joint occasionally
happens. It, in appearance, much resembles backward luxation of the
carpus, but is distinguished therefrom by crepitus, mobility and the
preservation of the normal relation of the styloid processes to the bony
landmarks of the hand. The treatment is similar to that of fracture of
the lower end of the radius, but this injury must not be treated without
a splint, as some forms of the latter injury may be. In instances, how-
ever, where the line of fracture is some distance above the joint, the lesion
partakes of the characteristics of fracture of the shafts of the two bones
and should be treated as such, in order to preciude the possibility of
callus interfering with future supination and pronation.
Fractures of the Carpus, Metacarpus, and Phalanges.
FRACTURES OF THE CARPUs.-Uncomplicated fractures of the carpal
bones are rare, though it is probable that they occur at times in connec-
tion with radial fractures and other injuries, but are unrecognized. The
diagnosis must be made by the presence of crepitus or deformity. Pre-
ternatural mobility, unless very marked, could be determined only with
difficulty in a region containing so many movable bony components.
Ankylosis of some of the intracarpal articulations seems a probable con-
sequence of carpal fractures, but it would cause little disability. Crush-
ing injuries, due to direct violence, and causing extensive lesions of the
soft parts, quite often produce open and comminuted carpal fractures.
Such cases, however, do not derive their importance from the broken
carpal bones.
FRACTURES OF THE METACARPUs.-The so-called metacarpal bone of
the thumb is not included in this discussion because it is anatomically a
phalanx. Its fractures are included, therefore, under fractures of the
Phalanges. Metacarpal fractures are generally caused by direct violence
received on the dorsal or palmar aspect of the hand; or by force so applied
to the anterior extremity of one of the bones as to exaggerate its normal
*Ye. To the latter mechanism is due the occasional breaking of a
ºnetacarpal bone when a man strikes a violent blow with his fist, receiv-
*g, of course, the impact on his knuckles. The common displacement is
414 D IS E A SES A N D IN J U R IB S OF B O N E S.
angular with the projection of the angle toward the back of the hand
and the anterior end, or head, of the bone prominent in the palm. Lateral
overriding is not an unusual feature. The single epiphysis of the bone
which is at the anterior extremity, may be torn off in patients not over
twenty years of age, and give the symptoms of true fracture.
When firm pressure is made in the palm, pain, yielding, and the occur-
rence of a prominence on the back of the hand will, as a rule, be de-
veloped in those cases of metacarpal fracture that are not at once clearly
demonstrated by the ordinary symptoms. A sharp pain at the seat of
fracture can often be produced by taking hold of the finger, attached to
the metacarpal bone supposed to be injured, and suddenly pushing it
toward the wrist. Actual shortening of the broken bone is often quite as
characteristic as motion and crepitus. Union takes place in about three
weeks.
Traction of the finger and pressure, upon the dorsal prominence are
sufficient to overcome the displacement in the majority of cases. If no
tendency to recurrence of deformity exists, a layer of cotton in the palm
and another on the back of the hand, held in position by a circular
bandage, constitute an efficient retentive apparatus, though care must be
observed lest lateral displacement be caused by the bandage. In other
cases support to the fragments and the adjoining bones, and prevention of
deformity is best obtained by placing a cylinder of wood, a roller bandage,
or a spherical object, such as a billiard ball, in the palm, and keeping the
flexed fingers closed upon it by strips of adhesive plaster carried from
the back of the wrist, over the knuckles, around to the palmar surface of
the wrist.
Longitudinal splints applied to the palm or dorsum, or both, and con-
trolling the wrist and fingers, may be preferable in some cases. In other
instances short transverse splints placed across the back and front of the
hand may be found more efficient in meeting the indications. When the
tendency to overlapping is marked, no method is as good as continuous
extension. This can be done by the use of adhesive plaster strips applied
to the back and front of the finger, and a rubber cord extending from the
loop of plaster to a nail or screw in the end of a long palmar splint firmly
adjusted to the forearm and hand and extending beyond the finger-tips.
This method is identical with that used in fractures of the thigh-bone.
FRACTURES OF THE PHALANGES.—As these injuries are generally
caused by direct violence, they are frequently complicated by comminu-
tion, dislocation, and great laceration of the soft parts. The phalanges
and the so-called metacarpal bone of the thumb, which, properly con-
sidered, is a phalanx, are developed from two Ossific centres; one for the
shaft and one for the posterior extremity, or base. Epiphyseal fracture
is, therefore, a possible lesion in persons not over twenty years of age.
The swelling after phalangeal fracture often conceals the deformity to
such an extent that mobility and crepitus are the chief diagnostic features.
The prognosis is good except when great comminution or the occurrence
of suppuration renders necrosis probable. Quite firm union may be ex-
pected in about two weeks if the fracture is uncomplicated. e
Lateral and rotary deviation is to be corrected with especial care in
phalangeal fractures, for a crooked finger is not only unsightly, but may
interfere with the manual dexterity of an artisan. Bowing of the middle
of the phalanx toward the palm tends to prevent the patient grasping ob:
jects firmly and must be avoided. If ankylosis is apprehended the finger
should be slightly flexed during treatment, for stiffness in the partially-
F. R A CT U R E S OF THE FE M U R . - 415
bent position is the least inconvenient and least noticeable. A splint of
gutta percha, pasteboard, felt, copper, or zinc moulded to the palmar sur-
face of the member and to the finger-tip is a neat and effective fracture
apparatus. If the proximal phalanx is the seat of lesion, such a splint
should include the palm and wrist. A cylindrical pad in the palm, with
the fingers closed over it, and kept so fixed by adhesive plaster, as de-
scribed under fractures of the metacarpus, is often a good dressing. A
FIG. 226.
Gutta percha splint for finger. (HAMILTON.)
straight palmar splint, the circular gypsum dressing, or continued exten-
sion by a rubber band may, in certain circumstances, be more advanta-
geous. If necessary, the finger or fingers adjoining the broken one may
be used for giving lateral support, or two or three fingers may have to
be kept motionless by a wide splint in order to immobilize the injured
member.
Amputation is frequently demanded in fractures of a complicated
character. Conservatism, however, should be the rule, for a portion of a
finger or a stiff one is often better than none. Especially is preserva-
tion of the smallest apology for a thumb desirable in order that the patient
may have something to oppose to the other fingers when grasping objects.
While it is true that in certain mechanical operations a deformed or im-
movable finger may be an annoyance and disability, and while recovery
will in many cases be sooner attained by amputation than by conserva-
tive attemps; still the latter course is to be advocated in doubtful cases.
Unexpectedly good results are often secured, even when joints are in-
Volved, and the patient learns to manipulate with the disabled hand,
Which moreover preserves its complete integrity. The risks of prolonged
Suppuration and of other secondary troubles which may follow conserva-
tism, are practically annihilated by antiseptic methods. After cure is
complete the mechanic can test the utility of the hand for a few months,
and then, if the deformed finger is a detriment to bread-winning, it may
be removed by amputation with little risk.
Fractures of the Femur.
FRACTURES AT THE UPPER END OF THE FEMUR.—Of these there
*e fractures of the neck which may involve the greater trochanter or
head, fractures detaching the greater trochanter, and fracture through
the base of the trochanter and upper end of the shaft. The first variety
* 90mmon. The others are exceedingly rare, and may be dismissed with
a few words at this time. e

416 I) IS E A S E S A N D IN J U R I ES OF B O N E S.
Fracture of the trochanter is the result of direct violence, and is to be
diagnosticated by displacement of the fragment, character of the injury,
local pain, and absence of the symptoms found with fracture of the neck
of the femur. Epiphyseal detachment may be suspected in such cases if
the patient is not over eighteen years of age. A bandage or strips of ad-
hesive plaster around the hips, with an appropriate compress, would seem
FIG. 227.
<>
* . Appears at end off :yr
É4 % 'Joins Shaft affout 18°y r
Appears/S-14 * ye
Joins Shaft about 78th y:
ºw
ſº rºll, W.
º ſ
º ºffº % |
ſ º ſ”/)
ºtſº.; %
Ně *
//, \º * Joany Shaftaz20%f.
Appeare at 9%mo Wº WNº.
4. Aſ (Žež24)4, - * ss=- l
*e, Extremiº
Posterior surface of femur showing epiphyses. The three upper epiphyses unite about
the eighteenth year; the lower one about the twentieth year. (GRAY.)
to be the proper method of treatment. Hooks similar to those employed
for fracture of the patella would not be improper if the displacement
was very marked.
Fracture more or less transverse through the base of the trochanter and
upper part of the shaft is said to occur. Its diagnosis is uncertain, but
its treatment is the same as for fractures of the neck.
Fractures of the femoral neck are very common and very important
surgical lesions. The classification of Stimson seems to be the best. He
divides them into fractures of the small part of the neck, and fractures
at the base of the neck. The former is identical with the class often
called intracapsular fractures, and includes the rare condition, separa:
tion of the epiphysis of the head; the latter includes both the so-called
extracapsular fractures and those which are partially intracapsular. The
reasons for rejecting the old classification are: that the neck is entirely
covered by the capsular ligaments in front and below, while behind and



F. R A C T U R ES OF THE FEM U R . 417
above only about three-fourths of its length is so covered, and that the
extent of capsular envelopment varies in different persons; that the
synovial membrane does not extend as far out upon the neck as does the
the capsule, hence a part of the neck is extra-articular
though really intra-capsular; that the line of fracture FIG. 228.
is frequently not confined to either the intra- or extra-
capsular portion of bone, and that the clinical diagnosis
between intra- and extra-capsular lines is often impos-
sible; as can readily be understood by what has pre-
ceded. Even at the autopsy the fact of a given fracture
being intra-capsular, or rather intra-articular, for it is
the relation to the joint that is important, can only
be known by accurate examination of the synovial
membrane. This is further complicated by the fact
that, after fracture, the outer portion of the cavity of
the joint may, it is said, be obliterated by adhesion of
the capsule to the periosteum.
Impaction and fixation of fragments at the first
receipt of injury is very frequent in fractures at the
base of the neck, and not infrequent in those of the
small part of the neck. Attempts at walking, im-
proper surgical manipulation, and other secondary
violence often cause undesirable separation of the inter-
locked fragments. Cervical fractures of the femur are Fragºre of epi-
often due to slight injuries, as a twist from catching physis of great tro-
the foot in a fold of carpet, missteps, and insignificant chanter and frac-
falls on the knee, buttocks, and side of thigh. It is ture of condyles.
possible that in certain positions muscular efforts to (Agnew.)
avoid falling may be a factor in causing the fracture.
An important element in their production is weakening of the osseous
tissue by senile degeneration which begins at about the fiftieth year of
life, and is said to be more marked in women than •
in men. This degenerative change is the predis- FIG. 229.
posing cause which permits slight injuries to have -
such a disastrous effect. It is not a relative in-
crease of earthy constituents that renders the bone
more friable; but an actual thinning of the wall
of the femur, and also an increase in size of the
Spages found in the bone for vessels and fat. The
radiating and arched lines of compact bone which
Cross the cancellous portion of the bone, and
Which are so readily demonstrated by section of
he upper end of the femur, are thus absorbed. Fracture of epiphysis of
This rarefaction of osseous tissue, and consequent great trochanter. (Bry-
loss of resisting power to strains, is a much more ANT.)
Potent factor in the frequent occurrence of frac-
*śs of the femoral neck than the change of angle between the shaft
ºnd neck which has been said to occur with advancing age. Fractures
ºn Very slight kinds of violence are very apt to be at the small part
of the neck. Fractures of the small part, or constriction of the neck
9f the femur, seldom occur before the age of fifty years. The line, which
**pt to be nearly transverse, may be oblique or irregular, and even run
"PWºrd into the head of the bone. Impaction, with fixation of frag-
*ts, and comminution are not unusual features. A portion of the


27 t
4.18 D IS E A S E S A N D IN J U R IB S OF B O N E S.
-
periosteum may remain untorn, and assist in keeping the fragments in
juxtaposition. In other cases not only is the periosteum completely torn
and the fragments separated, but the capsule itself rent by the violence
FIG. 230.
N.W. §§ {T/|\º
W W t *-w" º º §
\ \\ º
\ º \\ º:
º ū ºW \º ſº
\\ \º %
§§ §
§
§ \\ º º
\ Nº
§
§
§
º
|
§.
Fracture of narrow part of neck.
(HAMILTON.)
and by displacement of the fragments.
The displacement is usually of the shaft
upward. In impacted fractures some
degree of twisting deformity may exist.
The shortening of the limb from dis-
placement is apt to increase gradually
during the first week, but rarely exceeds
one inch, except when, after weeks have
elapsed, absorption of the neck has taken
place.
When these fractures are repaired it
is usually accomplished by fibrous tissue.
Indeed, it has been asserted that bony
union never occurs. Such statements
are erroneous, though it is true that
failure of union or fibrous union is the
most common result of the reparative
attempts. Bony union does occur, though
rarely. The question is of little clinical
importance, since a short fibrous bond
gives as useful a limb as an Osseous one;
and union should always be sought by treatment, if the patient's condiition
will permit the necessary confinement.
Examination of specimens, with or without a history of fracture, does
not throw as much light on the question as would be supposed, because
the arthritic changes of old age and interstitial absorption of the neck of
FIG. 231.
FIG. 232.
Fracture of small part of neck united by Femur of opposite side, showing amount
bone, fibrous tissue, and cartilage, showing
absorption of neck. (BRYANT.)
of bone absorbed on injured side.
(BRY ANT.)
the femur which occur subsequent to cervical fractures, obliterate,9*
simulate lines of fracture. Simple contusion of the hip is supposed. by
some writers to be a cause sufficient to induce in the aged interstitial
absorption of the neck of the femur.




















F R A CT U R ES OF T H E FE M U R . 419
The cause of such frequent defective union appears to be want of
contact between the fragments, imperfect immobilization, and some consti-
tutional peculiarity. The difficulty of obtaining perfect contact and
immobilization when the small upper fragment is so inaccessible and floats
in such a cup-like cavity as the acetabulum, will
be easily understood. The error of rude manipu- FIG. 233.
lation, by which impacted fragments may be sep- ãº.
o o ºğ º
arated, is a useful lesson taught by this statement. £º, §
It would seem that the constitutional tendency,
already mentioned as a cause of the extreme
fragility of this part of the skeleton in aged per-
sons, would tend to interfere with the occurrence
of Osseous repair. These reasons for defective
union seem to be sufficient without recourse to
those often given : namely, deficient blood supply
to the upper fragment, and contact of the frac-
tured surfaces with the synovial fluid. These §§§
agencies, however, possibly exert some influence. º;
The symptoms and diagnosis of fractures of the # §§
small part of the neck will be discussed with simi- ſº
lar topics relative to fractures at the base of the Upper fragment driven
neck. The usual result after fractures of the into the trochanter frag-
small part of the femoral neck is disability with ment. (Gross.)
eversion, and some shortening of the limb. The
patient in some cases can walk without crutch or cane, but such a slight
degree of lameness is uncommon. Occasionally, feebleness from pain,
confinement, and age, renders the unfortunate patient bedridden.
In fractures at the base of the neck the line of fracture shows a ten-
dency to separate the neck from the shaft in the vicinity of the inter-
trochanteric line, but may be varied or complicated by lines running
downward into the shaft, splitting off the lesser trochanter, extending along
the neck toward the head, or involving the upper portion of the great
trochanter. Bending the neck backward, with crushing or penetration
near the posterior part of the greater trochanter, is said to be a very
Common form of the injury. Various degrees and forms of penetration
and impaction of the cervical into the trochanteric fragment have been
described. The trochanteric fragment or shaft is seldom forced into the
cancellated structure of the neck. These fractures usually unite by bone,
and in six or seven weeks; showing, therefore, much better reparative
effort than fractures of the narrow part of the neck.
SYMPTOMS.–The distinctive symptoms of fracture of the neck of the
femur are motor disability, eversion, shortening, and crepitation. To these
may be added certain incidental symptoms that occasionally assist in the
diagnosis.
The limb is usually so helpless that no voluntary effort can lift it from
the bed, nor can the weight of the body be borne upon it in the erect
Pºsition. Sometimes slight elevation of the thigh is possible, especially
if the patient can get a purchase on the bed for his heel. In very excep-
*onal gases walking on the injured limb has been possible. Here firm
*P*ction has almost certainly existed. In making a differential diagnosis
ºpenes following severe sprain or contusion must not be for-
gotten.
The posture assumed by the limb is almost pathognomonic. It lies, as
the patient rests on his back, upon its outer side with the little toe almost

420 D IS E A S E S A N D IN J U R I E S OF B O N E S.
or quite touching the mattress, and the heel on a level with the space
between the inner malleolus and point of the calcaneum of the other foot.
A slight degree of flexion and abduction at the hip is quite usual. This
eversion is probably, in the main, the result of gravity being unresisted
by the normal supporting agencies of the limb rather than due to the
action of the external rotators or other muscles. In some cases the ever-
sion is slight, at other times the toes point directly upward, while in rare
instances actual inversion exists. Angular deformity at the seat of frac-
ture, crushing, impaction, and interlocking of fragments and entanglement
in capsular rents have probably an agency in the production of the vary-
ing degrees of eversion and inversion. Eversion is the usual position and
is very suggestive of fracture, though it has been observed in simple
injuries of the hip. The normal position of the limb, indeed, when the
recumbent posture on the back is assumed, is eversion, and especially so
when the knee is flexed even slightly. It is well to compare the injured
limb with the uninjured one to determine whether eversion is apparent or
real, whether the extent of possible eversion at the surgeon's hands is
greater or less on the injured side, and whether the supposed fracture
interferes with or increases inward rotation, such as is possible in the
sound limb. Inversion has been described as occurring in some cases
only after the lapse of a day or two from the time of injury. Violent
manipulation to determine these points is not justifiable, since other symp-
toms are available for diagnostic purposes.
Shortening occurs in cervical fractures of the femur from overriding,
and from alteration of the angle between the shaft and the neck. It
varies from a mere fraction of an inch, to two, three or even four inches.
It may exist to its greatest degree immediately after the injury, or may
gradually increase with the lapse of a few days. It has been noticed to
occur suddenly, when little or no alteration in length was apparent at
the first examination.
Great shortening (13 to 3 inches) occurring immediately is rather in-
dicative of fracture at the base of the neck, while slight immediate
shortening followed by increased shortening is more characteristic of frac-
ture at the small part of the neck.
The now well-established fact that femurs and tibias are often of un-
equal length in persons who have never sustained injuries to the bones of
either limb greatly lessens the diagnostic importance of shortening. If a
limb which is a half-inch or one inch longer than its fellow is fractured,
and a half-inch or one inch shortening occurs, the two limbs when
examined by the surgeon will measure exactly the same, and no evidence
will be derivable from such attempts at estimation of shortening. If the
shorter limb is subjected to traumatism, shortening may seem to exist
when such is not the case; or the traumatic diminution in length which
actually exists will appear to be greater than it is. Fortunately the
normal difference of length rarely exceeds a quarter- or half-inch. .
The most practical method of measuring the length of the limbs is to
carry a tape measure from the lower edge of each anterior superior Spinº
of the ilium to the tip of the corresponding internal malleolus. It is
well, perhaps, to verify the differential measurement by placing the upper
end of the tape at the lower margin of the umbilicus, and holding it theº
while the lower end is successively carried to the two internal malleoli.
During the measuring the pelvis must be horizontal—that is, at a right
angle with the median line of the body—and the two limbs in the Saº
condition of abduction and extension. The difficulty of obtaining exactly
F. R A C T U R ES OF T H E FE M U R . 421
the same point of measurement on the two sides, because of the mobility
of the skin and the want of definite outline in the prominences, together
with the fallacy above mentioned, have made me place little confidence
in the accurate estimation of fracture shortening.
The determination of the relative position of the two greater trochanters
by means of Nélaton's line or Bryant's rectangle is of great value in
proving elevation or absence of eleva-
tion of the trochanter on the injured FIG. 234.
side. The method is useful in sup-
posed dislocations as well as fractures,
but will be discussed here. Nélaton's
test line is applied by carrying a string
% tº
t #º §: § SSS § §
tº
WN
Nº
£º-Essº -
from the tip of the anterior superior * sº §§§
e f the ilium to the tip of the *4% Yº º
spine o tº © p © &#% ($ N ăş sº º
tuberosity of the ischium. The line #ſº º;.....º.
so indicated touches the upper border § W. fºss &
of the greater trochanter, and this re- ºl
lation is not disturbed by flexion and º W Ø
extension of the limb. Displacement kº Mºsséſ;
of the trochanter upward, from short- §§Nº.
ening due to cervical fracture, and dis-
placement downward or upward, as a
result of dislocation, are indicated by
comparing the two hips. The two
limbs must be examined when neither
abducted nor adducted, since in normal
limbs the former position brings the
trochanter above the line and the latter
below it. Bryant's rectangle consists Nélaton's line, dark. Bryant's rect-
of two lines drawn while the patient angle, dotted. (ERICHSEN.)
lies upon his back. A vertical line is
dropped from the anterior superior spine of the ilium to the bed; toward
this line, at a right angle to it, a second line is drawn from the upper
border of the trochanter. The last drawn line determines the fact and
degree of elevation of the trochanter as compared with the sound side.
The fallacy due to abduction or adduction must be remembered here, as
in using Nélaton's line.
Stimson uses Bryant's method by placing a small stick or pencil verti-
cally against the pelvis in a line with the process and tuberosity, and meas-
\ring from it to the trochanter. Morris estimates changes in distance
between the joint and the trochanter by measuring from the outer surface
of the trochanter on each side to the median line of the body. This is
Readily done by means of a graduated rod placed across the pelvis at the
lºvel of the two anterior superior lines of the ilium, with its centre over
the linea alba, and having upon each end a sliding vertical bar, which
°ºn be moved till it just touches the outside of the corresponding tro-
chanter. These are the simplest and most available plans for determining
shºrtening of the neck or displacement of the trochanter. More compli-
*dgeometrical methods introduce more sources of possible error.
...Allis has called attention to relaxation of the fascia lata between the
iliac crest and trochanter, and above the outer condyle of the femur in
fractures accompanied by shortening. Cleeman has directed the profes-
** ſo ºbserve a wrinkle in the skin over the ligament of the patella,
which will be obliterated when the shortening is corrected by extension.




422 I) I S E A S E S A N D IN J U R IES OF B O N E S.
If shortening has been detected, its correction may be attempted for diag-
nostic and therapeutic purposes by gentle traction and slight internal rota-
tion. Marked rotary movements,
IFIG. 235. however, and absence of support to
the limb are liable to cause sepa-
ration of fragments which may be
impacted, and should therefore be
avoided. The shortening corrected
by traction will usually recur when
the traction is intermitted, and thus
confirm the diagnosis of fracture.
Crepitation is a symptom of cer-
vical fractures of great diagnostic
value when elicited, but is often
unobtainable. It should seldom
be sought for with avidity be-
cause of the risk of separating im-
pacted fragments. Pressure behind
the trochanter or traction, with or
without rotation, will often make
it evident; but impaction, great
splintering, wide separation of the
fractured surfaces, or the impossi-
bility of keeping the small upper
i. fragment steady in the acetabulum,
! often prevents its production. Cases
\\ showing from other symptoms un-
%d. doubted evidence of fracture should
º i. not be submitted to persistent ma-
t mipulation for the production of cre-
| pitus. In obscure cases its develop-
ment will not usually afford evidence
Allis's method of testing relation of fascia of sufficient value to warrant the
lata. risk of detaching impacted frag-
ments. Rubbing of the outer frag-
ment or of a dislocated head upon the ilium sometimes simulates crepitus
between two broken surfaces. The character of the grating is softer than
in fracture crepitus. Crepitus is more frequently detected with ease in
fracture of the base of the neck than in those of the constriction of the
neck, especially if the fracture line runs into the trochanter. *
The other symptoms liable to be found in cervical fractures are pain
referred to the trochanter, groin, or thigh, tenderness on pressure in the
groin outside the femoral vessels, swelling or diminished depressibility at
the upper part of thigh, ecchymosis appearing only after two or three
days have elapsed, spasm of muscles, flattening in the trochanterić
region, or enlargement of the trochanter due to splitting or comminution.
The outer surface of the trochanter may be further than normal from
the middle line of the body, nearer to it, or may present no change in
this respect, according as angular deformity, crushing, and separation exist
alone or are combined. Morris's method of investigating this symptom
has been discussed.
It is evident that, if the normal limb is rotated, the trochanter must
move in the are of a circle whose radius is the distance between the
articular surface of the head and the outer surface of the trochanter;

F. R A C T U R E S OF T H E FE M U R . 423
but, when the neck is broken and unimpacted, such rotation will be in the
arc of a circle whose radius is the distance from the line of fracture to
the trochanteric surface. The second radius will be shorter, and hence
the arc of rotation traversed by the trochanter more curved. Such
change may be estimated by placing the hand on the outside of the
trochanter while an assistant rotates the limb. This test has often been
recommended as worthy of diagnostic credence, but it has at my hands
been of little service. If thickening of the soft parts and a large amount
of callus is detected in the groin, or about the trochanter at the end of
one or two weeks, fracture of the base of the neck is of course the prob-
able lesion.
DIAGNOSIS.—The diagnosis that fracture of the neck of the femur
exists can usually be made with comparative ease, but whether the lesion
is at the constriction or at the base of the neck is a problem much more
difficult to solve. It is not a question worth attempting to answer, except
in those cases where it is almost self-evident. The treatment of both
injuries is the same, the elaborate tables of supposed diagnostic differences
between fractures of the constriction and of the base have been proved
unreliable, and the endeavor to make an accurate diagnosis is fraught with
great danger to the future usefulness of the limb by reason of breaking
up impaction and severing untorn periosteal attachments. When there
is doubt as to the kind of fracture, or as to whether fracture, contusion,
or sprain exists, always treat the lesion as fracture of the base of the
. and the result will clear up the doubts in the course of a few
WeekS.
The symptoms which have just been discussed at length will, when taken
in connection with the history of a fall and the non-existence of any former
arthritis, fracture, or other pathological conditions, seldom fail to indicate
that fracture of some portion of the neck has occurred.
The differential diagnosis of fractures of the neck and dislocations of
the head of the bone is important. Inversion is so rare in fracture that
its existence should at once suggest posterior dislocation. Fracture with
inversion would not show a flexed, adducted, and such a fixed hip as the
posterior luxations; nor would the presence of the head of the bone over
the iliac dorsum or sciatic notch, and its absence from the acetabular
region be demonstrable. In fracture with inversion, traction may convert
the inversion into eversion and correct the shortening, but not so in dis-
lºcation. The anterior dislocations are rare injuries; present flattening of
the trochanteric region, abduction, and flexion of the hip, and the unusual
fulness or prominence at the abnormal site of the head of the bone.
The pubic dislocation is accompanied by shortening, the thyroid not by
shortening but by apparent lengthening. In dislocation there is a marked
limitation of passive motion, and the limit of possible mobility is reached
by a sort of sudden stopping or check felt by the surgeon’s hands. In a
normal femur the inner condyle and the head of the bone always have
the same direction: therefore, the position of the head can be determined
in dislocations by observing the direction of the inner condyle. This is
*9t true of fractures of the femur. If there is anterior spinal curvature
the hip may be somewhat flexed, and still appear extended. This pos-
sible source of error is eliminated by placing the man on his back and
flexing the opposite thigh completely on the abdomen, when the second
thigh Will be raised from the bed, if it be in a state of flexion concealed
by the spinal curve.
424 DIS E A SES A N D IN J U R IES OF B.O N ES.
PROGNOSIS.—Patients with fractures of the femoral neck have died not
infrequently from rapid debility, severe arthritis, or other inflammation
about the injury, or hypostatic pneumonia. Especially has this been the
case in the aged. The unfortunate tendency was possibly dependent in
some measure upon fat embolism, but more probably upon the rigid
confinement to bed with cumbersome and uncomfortable fracture dressings,
which used to be enforced for long periods. Our present methods of
treatment with continuous traction and less absolute immobility in bed
seem to permit a much better prognosis. The unfavorable outlook so often
spoken of in hip fractures is possibly scarcely warranted by our present
experience. A certain amount of shortening, eversion, stiffness, and pain
often persists even in fractures that have recovered with fibrous or osseous
Runion; but fair, or even very good, use of the limb is not unusual, even in
old persons who have apparently or certainly sustained fracture of the
constriction of the neck. Even when the fracture remains ununited fair
walking is possible, because hypertrophied muscular and tendinous bands
may support the pelvis as by a sling attached to the greater trochanter.
TREATMENT.—In treating fractures of the lower extremity, the firm,
level mattress is much more important than in similar lesions of the upper
limb. A plain mattress made of hair, and a bed-pan for receiving the
dejections, is often preferable to any one of the various forms of fracture
bed sold by manufacturers. Careful nursing will prevent injurious move-
ment during the use of the bed-pan. Union is to be sought in all cases
of cervical fracture, and its acceptance even in faulty position is more
jº. than the production of non-union or violent arthritis in the aged,
y reason of vigorous and repeated manipulation, for the purpose of
establishing the exact line of fracture or obtaining accurate coaptation. If
the existence of dislocation is eliminated, all doubtful cases should be
treated as fractures of the base of the neck. Continuous extension or
traction, applied by means of a rubber band or weight attached to the
leg with adhesive plaster and lateral support to the limb by means of Sand-
bags, as employed in fractures of the shaft of the femur, is the proper
treatment for all fractures of the neck of the bone. The trochanter may
be supported by a small pad or sand-bag placed under it. This method
of immobilization is to be kept up until consolidation of the fracture
takes place. Proof that union will not occur, or satisfactory evidence that
the injury was a mere sprain or contusion, indicate its discontinuance. It
must also be discontinued if it becomes evident that the patient's life is
endangered by the confinement to bed and to one posture. Then, attempts
at gaining union may have to be discontinued in order to prevent death
from failure of the vital forces. Even when no union occurs, comfort
is usually gained by the rest given to the joint and limb for two or three
weeks by traction. Union, when it occurs, takes place in from five to six
weeks.
The extending force should equal about six to eight pounds, while the
counter-extension is to be gained by elevating the foot of the bed about
six inches, so as to use the weight of the patient's trunk as a counter-force:
The foot should be maintained in a position with the toes pointing upward
and a little outward, which is the normal posture of the limb when a man
lies on his back. Catheterization will be necessary in many patients, and
the occurrence of sacral bedsores must be averted by watchfulness an
cleanliness.
In order to get more complete immobility at the seat of fracture, the
pelvis and both thighs may be encased in gypsum bandages. In addition,
FRACT U R ES OF THE SH A FT OF THE FE MU R. 425
a pad adjusted by a screw, passing through a frame attached to the gypsum
dressing, may be arranged to make pressure upon the outside of the tro-
chanter, and thereby hold the fragments in apposition. This is the char-
acter of Senn's method.
Gunshot fractures of the femoral neck will require provision for free
drainage, and perhaps excision of the head of the bone. Attempts to
fasten the capital fragment to the trochanteric one by Screws and pegs
have been made in the endeavor to avoid non-union, but at the present
time such attempts seem scarcely warrantable.
Fractures of the Shaft of the Femur.
Fractures of the shaft of the femur include those occurring in the shaft
of the bone anywhere except just above the condyles. The latter, being
near the knee-joint and liable to special complications, are discussed
under Fractures at the Lower End of the Femur. Transverse fracture
of the shaft is not rare in children, but in adults such an occurrence is
very unusual. In fractures of the femoral shaft, deformity due to over-
riding and to angular or rotary displacement is apt to be great. When
the fracture is in the upper third, the lower end of the upper fragment is
generally tilted outward and forward by the great psoas, iliac, and ex-
ternal rotator muscles of the hip, and the upper end of the lower fragment
drawn upward and inward by the flexors of the leg and adductors of the
thigh. This special angular distortion is mentioned because it at times
compels the adoption of unusual methods of treatment.
SYMPTOMs.-The symptoms indicative of fracture of the femoral shaft
are: total loss of voluntary power in the limb, eversion of the foot and leg,
and the usual concomitants of fractures, deformity, abnormal mobility,
and crepitus. Rotation of the limb is not accompanied by movement of
the greater trochanter. The deformity and flexibility of the thigh at the
seat of fracture are often entirely sufficient for diagnosis without requir-
ing successive attempts at getting crepitus, which cause pain and may do
harm. The shortening, which is chiefly due to the powerful muscles sur-
rounding the broken bone and to the obliquity of the fracture, may be
Very great, but is overcome partially, if not entirely, during the continu-
ance of strong traction. The estimation of the degree of shortening by
measuring is, as has been mentioned under Eractures Near the Hip, sub-
ject to fallacies. The symptoms may be a good deal modified by impac-
tion or interlocking of fragments. This condition, however, is unusual.
Union occurs in ordinary cases in about six weeks, after which time
the patient may be trusted to use crutches, provided that all possible
Strains upon the repaired fracture are avoided by suitable supporting
ºsings, and that no weight is borne on the injured limb in walking
Pälsion into the knee-joint often occurs after the fracture, sometimes
Within a few days, and occasionally it persists for many months. It has
been attributed to involvement of the synovial membrane; to invasion of
the joint by the blood extravasated at the time of fracture; to coincident
*Pºin of the knee; to interference with venous return, and to the posture
and prolonged immobility of treatment. Fractures at the lower third
should be expected to present this complication most frequently. It needs,
as a rule, no special treatment.
tl sº Permanent shortening is to be expected after every fracture of
**mur; but, if union is obtained with the fragments in good line,
426 D IS E A SES AN ID IN J U R IES OF B O N E S.
without rotary displacement, a shortening of even three-quarters of an
inch will cause little limp in the gait. Rigidity of the knee may remain
for a long time in rheumatic or aged patients. Open fractures of the
femur, especially if also comminuted, are rather dangerous lesions, requir.
ing, in even favorable cases, a protracted convalescence.
In all fractures of the femur, with rare exceptions, permanent horizontal
traction, or extension, as it is often called, by means of adhesive plaster
and attached weights, is the best method of treatment. Counter-extension
is to be obtained by elevating the foot of the bed six inches. This pro-
cedure makes the weight of the trunk act as a counter-extending force.
Any tendency to lateral mobility or deformity of the fragments may be
avoided or corrected by short coaptation splints of wood, metal, or paste.
board, or by long narrow bags, well, but not too tensely, filled with sand
and laid closely along the inner and outer sides of the limb. The outer
bag should extend from below the sole to within a few inches of the
axilla, the inner bag from below the sole to the perineum.
Before the application of the plaster strips the thigh and leg should be
shaved. A piece of thin board, three inches wide and five inches long, is
FIG. 236.
Adhesive plaster and foot-board applied for continuous extension.
fastened lengthwise to the middle of the adhesive side of a strip of rubber
adhesive plaster three inches wide and six feet long. This stirrup-like
apparatus is then smoothly attached to the limb by applying the plaster
up the sides of the leg and thigh to a point just below the seat of fracture.
Its adherence to the skin is further assured by applying narrow bands of
plaster around the limb and side strips at three points—namely, above the
knee, below the knee, and about an inch above the ankle. A bandage is
next applied over the foot and malleoli under the stirrup, and then carried
up the limb over the adhesive plaster attachment until it nearly reaches
the height of the fracture. The terminal ends of the plaster which pro-
ject above the last fold of the bandage are now turned over the bandage,
so that their adhesive surface becomes external. Around these turned
down ends the bandage is applied by a few more folds, until no vestige
of the plaster is seen. The attachment of the plaster to the skin should
extend above the knee, in order to avoid what might prove injurious
traction on its ligaments. The turning over of the ends is additional
security against the traction weights causing the adhesive strips to slip on
the skin. To the foot-piece a cord about three feet long should be attached
so that in the course of an hour, when the plaster has become firmly
adherent to the skin, the traction weights may be tied to the apparatus.
When it is thought that the plaster will bear the weight without slipping,
the surgeon props up the foot of the bed, and, taking hold of the foot and
ankle, makes powerful but steady traction to overcome the muscular
spasm causing the over-riding and shortening. If there is great shortening,

F R A CT U R E S OF T H E S H A FT OF T H E FE M U R . 427
or if the patient is very muscular, it may be well to obtain relaxation of .
the muscles by producing a slight degree of general anaesthesia with ether
or nitrous oxide. When the deformity has been overcome as much as
possible, two or three bricks, or an equivalent weight, are tied to the cord
and suspended over a pulley at the foot of the bed.
The pulley should be placed high enough to lift the
heel a little from the mattress, and in such a posi-
tion laterally as to keep the axis of the limb cor-
rect. The cord should not let the bricks rest on
the floor when the patient slides toward the foot of
the bed, though it should be long enough to let
the patient slide up and down for the distance of a
foot or so. There should be no shelf or obstacle
above the floor upon which the bricks may catch
and suddenly fall off with a jerk. The pulley must
have side-pieces or an arch projecting above the
groove, that the cord may not be pushed off by
persons passing the foot of the bed.
Instead of using the adhesive plaster apparatus
a series of straps may be adopted.
The amount of weight for the first three weeks
should be from fifteen to twenty-five pounds for an
adult, according to the muscular development and
tendency to spasm. At the end of that time the
amount may be decreased one-half, and be discon-
tinued at about the sixth week. Then a circular
gypsum or silicate of sodium dressing is applied
from the ankle to the hip, including the pelvis if
the fracture is in the upper third, and walking with
Crutches is permitted. The patient should not bear
any of his weight on the foot till the tenth or elev-
enth week. If the gypsum or silicate dressing is
not adopted, sufficient lateral support may be ob- !
tained by using coaptation splints of moulded paste- Levis’s pulley for con-
board, provided that the knee and hip are fixed by tinuous traction appa-
them. It is, of course, understood that the patient ratus.
shall, not be permitted to walk even with these
dressings, unless the fracture has lost its mobility. Caution must be
exerted against subjecting the limb to strains or falls, for rupture of the
Gallus readily occurs, even as late as three or four months after the original
Injury.
Usually a slight amount of padding is required on the bed beneath the
Popliteal space, because the absolutely straight position of the knee be-
$omes, painful unless a little support is given at the point mentioned. If
lateral deviation at the site of facture is not prevented by the sand-bags,
* if there is antero-posterior bending, three or four coaptation splints of
Wood eight to ten inches long may be applied over the bandage and kept
* Place by a few turns of another bandage. Pasteboard or other plastic
*ºrial may be moulded to the front or side of the thigh, if the surgeon
Prefers. Care must be taken that pressure of the heel on the bed does
nºt cause a bedsore. A mass of oakum, wool, or cotton, hollowed out like
º bird S nest to receive the heel, or a pad placed beneath the tendon of
f º so as to lift the heel from the mattress, are the simplest devices
**lieving this injurious pressure, The bed-clothes must not rest on the

428 I) IS E A S E S A N D IN J U R IF. S OF B O N E S.
toes, since their weight will press the foot outward and evert the leg.
Any sort of an arched frame, such as can be made from pieces of barrel
hoop placed over the foot, will hold the coverings up.
It is also necessary to see that the patient lies flat on his back, for if he
turns a little on his side, or if the pelvis sinks into the mattress on one
side, while the foot and leg are held motionless by the dressing, rotary
deformity will remain when the fracture is united. The foot should be
kept very slightly everted, as has been stated under the treatment of
Fractures Near the Hip. The patient should not be allowed to sit up in
bed nor have a high pillow or bolster, until at least three weeks have
elapsed. Then he may be propped up in the half-sitting posture, if it
shows no tendency to displace the partially united fracture. The sliding
movements up and down in the bed, which are permissible from the begin-
ning, relieve the monotony of confinement very much, and enable the
nurse to adjust the bed-pan and keep the patient clean.
When, in fractures of the upper third, there is marked tilting forward
of the upper fragment, the straight position just described is not always
satisfactory. It may become necessary to elevate the lower fragment, in
order to meet the displaced upper fragment and preserve the proper axis
of the limb. In order to get proper apposition of the fragments the limb
with the traction apparatus attached should be elevated upon an inclined
!
FIG. 238.
s § - s º § %§
&\lºssº Yºss
* =s* Tºis
†TTm- Titº
Inclined plane and extension apparatus. (AGNEw.)
plane of wood and maintained in that position during the treatment. The
weight extension can readily be continued at the same time. Whether
the inclined plane is such as will keep the knee straight or flexed is a
matter of comparative indifference.
FIG. 239.
Double inclined plane fracture box.
In treating open fractures with much suppuration a long fracture bºx
or the anterior wire splint of Nathan R. Smith are often convenient. The
method of using the anterior splint is shown in the illustration, except











FR A CTU RES OF T H E SH A FT OF THE FE MU R. 429
that the pulley should be placed over the middle of the leg so as to obtain
extension or traction by the weight of the buttock.
FIG. 240.
SN Tº
* }
Smith’s anterior splint.
In infants below five years it is often difficult to prevent soiling of the
traction apparatus by the alvine discharges; hence, vertical extension has
been employed with good results. This is effected by flexing both hips
at a right angle, placing straight splints along the posterior surfaces of
the limbs to prevent flexion of the knee, and attaching the feet to a sup-
port over the bed. The buttocks thus act as a traction weight and the
little patient can be kept clean. If preferred a pulley and a weight of
four or five pounds attached to the leg and foot may be used to increase
the traction power. When the child is over four or five years of age the
ordinary horizontal traction is easily employed. The weight should be
about one pound for every year. Union becomes firm in children in about
four weeks. -
FRACTURES OF THE Low ER END OF THE FEMUR.—These injuries,
occuring so near the knee-joint and having a short lower fragment, which
may be difficult to control, deserve some special consideration. The line
of fracture may be in the shaft just above the condyles, may at the same
time run dowward between the condyles, splitting them apart, or may not
involve the shaft at all but merely separate one of
the condyles or a part of a condyle from the rest of FIG. 24l.
the bone. Sometimes small pieces of the bone are º
torn up by strains on the crucial ligaments. The
last two varieties are very rare.
The epiphysis, which includes the entire condy-
loid portion of the bone, may be detached in per-
sons not over twenty years of age. The line of
fractures just above the condyle is usually oblique,
but a transverse direction is said to be more com-
mon than when the bone is broken at a higher
point. The lower fragment in fractures above or
through the condyles is frequently displaced back- femoral epiphysis. (Bry-
Ward and may, by pressure upon, or laceration of, ANT.)
the popliteal vessels, cause gangrene of the leg.
* Same result may follow similar displacement of the upper fragment.
The usual symptoms of fracture are present. The lateral mobility
possible above the knee, the backward displacement of the lower frag-


430 D ISE AS ES A N D IN J U R IES OF B O N E S.
ment and the leg, and the prominence and unusual mobility of the patella
in supra-condyloid fracture, or its sinking between the separated condyles
in inter-condyloid fractures, are additional aids to diagnosis. A pointed
upper fragment is sometimes driven into the fibres or tendon of the four-
headed extensor muscle or thrust through the integument. Effusion or
hemorrhage into the knee-joint is particularly common in fractures in-
volving the condyles.
Death from suppurative arthritis or gangrene, though not frequent, is
a possibility to be remembered in giving a prognosis; and more or less
ankylosis of the knee is quite usual, especially when the joint is invaded
by the fracture line.
The proper treatment is permanent horizonal traction, as in fracture of
the shaft, with even greater care to keep the knee-joint immovable. This
immobility may be attained by a pasteboard splint adjusted to the back
of the joint. The adhesive strips for traction should extend along the
limb only as far as the knee. If the straight posture does not maintain
the lower fragment in proper position, the knee may be partially flexed by
placing a pillow or a double inclined plane under it, or by using a
Smith's anterior splint. Severe arthritis is an argument for the com-
pletely extended position, since, if ankylosis occurs, a straight knee is
more useful than a slightly flexed one. If the distention of the joint
with fluid is too great to allow the joint to be completely extended, the
fluid may be partially withdrawn with an aseptic aspirator needle.
If spasm of the gastrocnemius muscle prevents adjustment of the lower
fragment, tenotomy of the tendon of Achilles may be justifiable, to
weaken the displacing cause. If the upper fragment is buttonholed and
so tightly held in the substance of the extensor tendon that reduction of
the fracture is impossible, its liberation by subcutaneous or open section
of the muscle is proper. Arthritis, if severe, requires appropriate treat-
ment. The formation of pus in the joint is a demand for immediate in-
cision under antiseptic measures.
Fracture of a single condyle is a very rare injury and, owing to the
slight deformity attending it, may be mistaken for a sprain or arthritis of
the knee. The integrity of the other condyle and the attachment of the
broken piece of bone to the tibia prevent shortening and marked displace-
ment. Suppuration of the joint has followed condyloid fracture. The
diagnosis is to be made from localized pain and ecchymosis, motion and
crepitus. Horizontal traction with care to correct any lateral deviation
at the knee is the treatment; though a long fracture box or a posterior
splint may do equally well. The joint should be kept immovable for
three or four weeks. These fractures, and those in which small splinters
of bone are torn off within the joint, resemble in their symptoms Severe
sprain, and should receive much the same treatment.
Fractures of the Patella.
PATHology.—The patella is broken generally by sudden and forcible
contraction of the four-headed extensor of the leg, and occasionally by
direct violence. The patient usually attributes the fracture to the fall
upon the knee; but the fall in most cases is due to the previous giving
way of the patella from muscular strain exerted upon it, for it is a sesa-
moid bone in the tendon. A slip of the foot occurs, and, as the man tries
to save himself from falling, the violent muscular contraction bends the
F R A C T U R ES OF T H E P A T E L L A. 431
patella across the condyles and fractures it by the cross-breaking strain,
or else tears it asunder simply by the powerful traction upward. A
similar result may occur in efforts at kicking or lifting. This usual causa-
tion of the fracture is proved, in the history of some cases, by the fact
that in falls upon the bent knee the impact is received on the head of the
tibia rather than on the patella, and by the further circumstances that
the line of fracture is usually transverse, that in fractures known to be
caused by direct violence the bone shows vertical, oblique, or comminuted
fractures, and that no bruise is seen over the patella in the ordinary
CàS6S.
The fracture from muscular contraction is usually more or less trans-
verse, is situated near the middle of the bone, and is generally repaired
by fibrous union. Comminuted and oblique fractures usually unite by
bony instead of fibrous tissue.
FIG. 242. FIG. 243. FIG. 244.
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Transverse fracture of Oblique fracture of Bony union of comminuted frac-
patella. patella. ture of patella. (GURLT.)
The transverse fracture, from muscular action, is so much more common
than any other that the subsequent description refers to it, unless other-
wise stated. The lower fragment retains its normal position; but the
upper one is drawn upward by the muscle and pushed upward by the
rapidly occurring intra-articular effusion, until the separation amounts to
half an inch or an inch. If the muscular aponeurosis surrounding the
bone is greatly torn, the displacement may be much greater; and, on the
other hand, if the fibrous envelope is not ruptured, the fragments may
remain in contact. Lateral displacement may at times occur, but in any
marked degree is not common. Some tilting of the fragments due to the
Surgeon's dressing or to the intra-articular effusion is not unusual. The
fragments may thus be tilted so that they are in contact at one side, but
Separated at the other, or may be so everted that the fractured surfaces
are directed in an anterior direction.
SYMPTOMS.–The symptoms are a sudden loss of extending power at
the knee, often accompanied by a sharp snap at the moment the bone
§Wes Way ; pain, difficult progression, though walking is often possible
if care is taken to keep the tibia and femur in a straight line and the
heel to the ground; a well-marked furrow felt with the finger between
the fragments, independent mobility of the upper and lower parts of the
one, with crepitus when they are pressed together and moved laterally;
*nd swelling of the knee from blood and inflammatory products within
the Synovial cavity of the joint and the surrounding structures. The
*thritis accompanying the fracture does not give rise to the intense pain



























432 D IS E A SES A N D IN J U R IES OF B O N ES,
so common in other cases of synovitis of the knee, probably because the
tearing open of the joint prevents intra-articular tension. The patient
is unable to extend the knee after it has been flexed, or to raise the foot
from the surface of the bed upon which he lies. The disability, however,
varies, as would be expected, with the amount of laceration of the tendi-
mous aponeurosis surrounding the patella. The bone has the vastus mus-
cles inserted into its lateral margins and the general aponeurosis spread
over its front. Hence, extension of the knee may be accompanied to a
limited degree by such untorn attachments, even after fracture of the
patella. In vertical and many comminuted fractures the extending
power will be interfered with only by reason of pain. The joint-effusion
will be absent if the case is seen immediately after the injury.
The diagnosis is readily made by palpation and the symptoms above
described. Fractures with little or no separation, and traumatic bursitis
in which the bursa in front of the patella is filled with blood and inflam-
matory products, may need careful consideration before a correct under-
standing of the lesion is obtained. It is said that crepitus and the feeling
of separated bony fragments may be simulated by blood-clots in the bursa.
The filling of the prepatellar bursa with fluid secreted by its own wall, or
with synovia entering it from the joint, with which communication is
mutually established by means of laceration of the bursa and the cleft
in the bone, may prevent accurate determination of the exact line of
fracture. After about ten days have elapsed the swelling of the joint
decreases, and, if the pieces of bone are in close contact, a short fibrous,
in rare cases an Osseous, bond of union is established.
The fibrous union is often a long one, even measuring three to four
inches, and the separation of the fragments may increase on flexion of
the knee if the upper fragment has become adherent to the structures on
the front of the thigh. Sometimes the bond of connection is little more
than a condensation of the fascial structures, and seems not to partake of
the nature of an attempt at repair. Use of a quite well-repaired fracture
of the patella has often caused the fibrous union to stretch, and stretching
may be greater on one side than on the other. Osseous union occasion-
FIG. 245. FIG. 246.
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Bony union of fractured patella. Close ligamentous union resembling bomy union.
y p g £
(BRYANT.) (Levis’s specimen in Mütter Museum.)
ally takes place, but many close fibrous unions have been mistaken during
life for bony repair. Nodules of bone are at times found in the fibro-
ligamentous tissue between the fragments, Rupture of the bond holding
the pieces together, or fracture near the point of union, is not infrequent.






















F. R A CTU. R. ES OF THE PA. T E L L A . 433
Such secondary accidents show at times little attempt at union. When
the tissues have become rigid and adherent about the seat of fracture, and
there still remains some stiffness of the joint, the integument may be
torn and the joint laid open at the time the secondary fracture occurs.
The open fractures so caused or originally open are, of course, very serious
injuries. *.
FIG. 247.
§
§*
*
|§
f
*
Ununited fracture of patella, from cast.
A severe arthritis may leave a very stiff knee; and, even in ordinary
cases, free motion of the limb is not attained for six months or a year.
This is partly due to the fear of tearing or stretching the ligamentous union
by early attempts at motion, which induces the surgeon and the patient
to insist upon protracted wearing of splints and abstinence from strong
passive movements. The fear is a well-grounded one. After freedom of
flexion and extension of the joint has finally been gained, the disability
from fibrous union, even an inch in length, is not very great. The patient
may scarcely limp ; though a rapid gait or the ascending and descending
of stairs will show his imperfect power of control over the knee. Going
down stairs is especially troublesome. Active extension of the joint will
pºly be possible only when the limb is put in an almost straight po-
Sltil Ol).
TREATMENT—In treating fracture of the patella, inflammation of the
joint should be moderated and a short bond of union secured. These
at least are the objects to be sought. Usually rest is all that is required
to effect the first result. Cooling lotions may be employed if the arthritis
Prºmises to be severe. When there is very great intra-articular effusion,
ºšting as late as ten days or two weeks after the receipt of injury, aspi-
...tion of the joint with an aseptic aspiration needle may be performed.
The small size and irregular margins of the fragments, their being imbedded
* a tendinous aponeurosis which is attached to the bone at the anterior
ºdge of its margins, and the convex surface of the condyles on which the
fºgments rest, all make accurate adjustment by encircling dressings
difficult and unsatisfactory. -
fe The best treatment for the majority of cases is obtained by drawing the
*&^ents together by means of steel hooks thrust through the skin and






28
434 D IS E A SES AN ID IN J U R IES OF B O N E S.
imbedded in the tendon above and below the upper and lower fragments
respectively. The hooks devised by Malgaigne are effective, but on
account of the irregular shape of the bone do not permit as accurate co-
aptation as do those devised by Levis. These latter are separated pairs
and can, therefore, be introduced parallel to each other or at an angle;
Varying with the line of fracture and tendency to irregularity in the dis.
placement. Each pair of hooks has its points held together, after coap.
tation of the fragments, by a screw or by a lateral clamp.
FIG. 248. FIG. 249.
i Rºs
;
zº
Levis’s modification of Malgaigne's patella hook.
To get rid of the muscular displacing cause the leg should be kept
fully extended on the thigh, and the thigh perhaps slightly flexed on the
pelvis. This is readily done by elevating the limb on an inclined plane;
or by supporting it with pillows after placing any form of rigid splint
behind the knee. This position relaxes the three muscular masses arising
from the femur and also the rectus, which has its origin from the pelvis.
Absolute rest in this position for about a week, with perhaps the applica-
tion of cooling lotions, will cause absorption of the articular effusion which
aids in separating the fragments. If it does not, aspiration is justifiable.
At the end of this time the fragments can usually be pressed together
by the surgeon's fingers and held while the hooks are inserted, so as to
keep them closely approximated. It is best to put the lower hook of the
pair in position first; and then the upper fragment, which is the displaced
one, can be controlled by the insertion of the second hook.
The points of the hooks must be sharp, and should be thrust as deeply
as possible into the tendon close to the margin of the bone. There is no
danger of entering the joint, for the tendon is very thick and tough. After
one pair has been inserted the other is to be placed where it will best
hold the fragments firmly together. The skin should be drawn tightly
over the knee-pan before the hooks are inserted, and both the surface of
the skin and the hooks cleaned and made aseptic. Ether may be required




F. R. A. CT U R ES OF T H E PA. T E I, L.A . 435
in some patients, since the operation is rather painful, though not a tedious
one. The points of puncture and the surrounding skin should be dusted
with boric acid or iodoform, and the parts surrounded with a dressing of
dry antiseptic cotton or gauze.
The hooks should be kept in place for six weeks; and, when removed,
the patient, though using crutches, should wear a posterior splint for five
or six weeks longer, in order not to tear the broken bone asunder by Sud-
denly flexing the joint. Sometimes the hooks may need tightening once
or twice as the swelling subsides, but usually no change is required. Their
removal from the first punctures is not to be expected until they are
finally taken out. The irritation produced by the hooks is inconsiderable.
If a tendency to erysipelas or abscess about the punctures is feared because
of the unhealthy condition of the patient or for any other reason, the
hooks should not be applied; or, if already applied, they should be re-
moved. Under such circumstances the adhesive plaster dressing is proba-
bly as simple and efficient as any. -
The adhesive plaster dressing is applied as follows: After the knee has
been extended and the entire limb elevated, the middle of a strip of adhe-
sive plaster about two feet long is placed on the skin beneath the lower
patellar fragment, and its ends carried upward and crossed upon the back
of the thigh. By two or more strips applied in a similar manner, but
not exactly corresponding with the first, the lower fragment is steadied.
Then similar overlying strips are placed above the upper fragment and
used to draw it down toward the lower one. The ends are crossed on the
back of the calf of the leg. Over the whole a roller bandage is applied
from foot to hip, and the limb kept extended and elevated by an inclined
plane. Renewal of the adhesive plaster will be required about once a
week, during the six weeks that the dressing is used before permitting the
patient to be up on crutches. In applying this and similar constricting
dressings there is a great tendency to tilt the fragments so that the ante-
rior edges of the broken surfaces are further apart than the posterior.
Perhaps this may be avoided by one or two strips carried directly around
the front of the knee-joint. -
For a long time after discarding all apparatus and crutches the patient
should support the patella by wearing a knee-cap of elastic webbing.
Open fractures of the patella should be treated by free incision into
the joint, washing out the synovial sac with a five per cent. solution of
carbolic acid, a sublimate solution (1:2000), or beta-naphthol solution
(1 : 2500), and free drainage by tubes. If the opening is very small
and the injury just received, the attempt to convert the fracture into a
glºsed one without free incision may be proper; but the first sign of joint
inflammation is a signal for free incision, antiseptic washing, and drainage.
The use of the hooks or the adoption of a simple posterior splint to main-
tain the extended position will necessarily be the treatment in all such
$ºses, since the adhesive plaster dressing and similar devices can scarcely
* ºpplied The drainage-tube need not, as a rule, be retained over a
Wee •
Rupture of the bond of union or refracture of the patella should be
*ated as the original fracture. Sometimes the tendon of the great
$ºnsor mass of muscles is torn from the upper edge of the patella by
the same mechanism that usually breaks the bone. The treatment, as
well as the Symptoms, is similar.
The treatment of fractured patella by wiring the fragments, and the
*gement of cases with long fibrous union by resection and wiring are
436 I) IS E A S E S A N D IN J U R I ES OF B O N ES.
not justifiable. The disability resulting from imperfect connection of
the fragments is not great enough to warrant the additional though slight
risk to life assumed. Such, at least, is my opinion. I am prepared to
have the fracture in my own person treated by the hooks, but not by
wiring. Therefore, I recommend one and condemn the other.
Fractures of the Tibia and Fibula.
The tibia and fibula are each developed by three ossific centres, one for
the shaft and one for each extremity. The upper epiphyses unite at about
twenty-five years of age, the lower at about twenty years. Occasionally
the tubercle and malleolus of the tibia develop from separate centres.
The possibility of epiphyseal separations occurring when the bones of the
legs are subjected to violence should be recollected. Such diastases are,
however, very rare. t
FRACTURES NEAR THE KNEE.–Fractures at the upper end of the
tibia, which usually are accompanied by fibular fracture, are frequently
transverse, and may, by more or less vertical lines, invade the knee-joint.
If the fibula is neither broken nor dislocated, it aids in preventing dis-
placement. Epiphyseal separation here, as elsewhere, is liable to inter-
fere with growth of the bone in length. Hence the uninjured fibula as
it grows must either become bowed or dislocated at one of its ends.
The usual symptoms of fracture may be associated with those of syno-
vitis of the knee, or of injury to popliteal vessels and nerves. The prog-
nosis is serious because of the possibility of ankylosis, suppurative arthritis,
and other complications. The fibula is seldom broken at its upper end,
except when the tibia also is fractured.
FRACTURES OF THE SHAFT OF THE TIBIA AND FIBULA. PATHOL-
oGY.—The tibia alone is seldom broken except when the fracture is due
to direct violence, such as a kick on the shin. The line of fracture is
then apt to be somewhat transverse. The fibula, being the smaller bone,
may readily be broken while the tibia remains intact. If both bones are
involved, the fibula is likely to give way at a higher point than the tibia.
The most common point of fracture of the bones of the leg is near the
junction of the middle and lower thirds, and a frequent displacement is
projection of the upper fragment forward and inward while the lower
fragment is drawn upward, behind the upper fragment, by the great
muscles of the calf. The subcutaneous situation of the tibia makes per-
foration of the integument and the conversion of the fracture into an open
one quite frequent.
SYMPTOMS.–The symptoms of fracture are easily discernible, especially
when both bones are broken, since mobility and deformity are then pres:
ent to a greater extent than under the opposite condition. The tibial
crest and inner surface are so easily felt through the thin overlaying tis-
sues that deviation in outlines here can scarcely be missed unless sufficient
time has elapsed for the development of the great swelling which so often
happens. Patients have occasionally the ability to walk upon a broken
tibia, and even when both bones are fractured such a feat is not impossible.
Walking after fracture of the fragile fibula is neither surprising nor
uncommon. If it has been ascertained that the tibia is broken, fracture
of the fibula may usually be assumed, unless the history is that of an
injury of a localized character received in the tibial region. If the fact
is not evident from the general deformity and preternatural mobility of
F. R A CTU. R. ES OF THE TIBIA. A N D FIBU L A. 437
the limb, pressure along the fibula may perhaps elicit pain, crepitus, or
yielding sufficient to establish the fact of its fracture.
When such evidence is not at once obtained, repeated and vigorous
attempts at developing symptoms of fracture of the fibula are not wise
or justifiable, unless the treatment is to be influenced by such knowledge,
which is rarely the case. The formation of blebs on the surface of the
leg, great swelling, violent cellulitis, and fat embolism are not unusual
accompaniments of the severe injuries that give rise to fractures of the
leg bones.
Union in uncomplicated cases of tibial fracture is firm in five or six
weeks; in fibular fracture in from three to four. The bridge of callus
occasionally uniting the bones after cure is of no evil consequence, since
rotation is not a function of the leg and foot, as it is in the upper extrem-
ity. Non-union is not so very infrequent, and when occurring is probably
often occasioned by imperfect immobilization due to faulty dressings.
Comminuted and very oblique fractures require more time for consolida-
tion. Neuralgic and rheumatic pains, persistent oadema, rigidity of the
ankle, and chronic ulcers from defective restoration of circulation are not
unusual sequences of fractures in the leg.
FRACTURES OF THE TIBIA AND FIBULA NEAR THE ANKLE.
PATHOLOGY..—These injuries are frequent and often very serious injuries
FIG. 250. FIG. 251.
2
!
(
\
w
\
Vertical section of bones at ankle-
joint. (TILLAUX.)
Both bones. may be broken without complication, they may be greatly
shattered with the ankle-joint involved, the fibula alone may be fractured,
Deformity after a bad fracture
at the ankle. (STIMsoN.)


438 D IS E A SES A N ID IN J U R IES OF B O N E S.
or one or both malleoli may be separated from the corresponding shaft.
The lower end of the tibia is scarcely ever broken without the fibula
being similarly injured, though the fracture of the latter bone may be
two or three inches above its tip. In making this statement I refer to
the base of the tibia and not to its malleolus, which can readily be
chipped off without the fibula sustaining any fracture.
On account of the mortise-like manner in which the astragalus fits
between the malleoli, lateral mobility of the normal ankle-joint is impos-
sible, though it is simulated during the extended position of the foot by
the slight rotation about a vertical axis which is possible. Lateral motion
between the tarsal bones is sometimes mistaken for lateral movement in
the ankle-joint. The impossibility of other motions than flexion and
extension renders the occurrence of bad fractures common when falls,
twists, or direct violence tend to forcibly evert or invert the foot at the
ankle-joint. By such mechanism one bone may be fractured, or one
malleolus may be torn off by avulsion through the lateral ligament; while
the other is broken from the shaft by the astragalus within the joint being
driven against its inner surface. Instead of involving the malleoli only,
the force may fracture the tibia and fibula above the malleoli, rupture the
ligaments holding the lower ends of these two bones together, and even so
displace the foot laterally as to drive one of the bones through the skin.
The dissolution of integrity of the inferior tibio-fibular ligamentous
bond allows, by widening the mortise in which the astragalus lies, lateral
mobility in the joint, and suggests severe damage to the articulation,
unless examination shows that the line of fracture has been limited to one
of the malleoli or to the fibula above its malleolar extremity. Occa-
sionally the astragalus has been actually driven up between the tibia and
fibula.
FIG. 252. FIG. 253.
Diagram showing frequent fracture-lines Fracture of tibia and fibula at ankle.
from forcible eversion and abduction of foot. (GRoss.)
(STIMson.)
SYMPTOMs.-The symptoms in the majority of cases are characteristić
of fracture, though occasionally it is necessary to examine the malleoli
and fibula carefully in order to avoid calling the injury a sprain. Local-
ized tenderness and ecchymosis will often be determining symptoms in
obscure fracture of these parts. “Sprain-fracture,” or sprain with detach-
ment of a small piece of bone from the end of the malleolus, is not un-

F. R A CT U R ES OF THE TIB I A. A. N. D F IBU L.A . 439
common at the inner malleolus. The fracture of the fibula may be two
and a half inches above its tip. #
In the form of injury depicted in Fig. 253, which is quite common,
the foot is displaced to the outer side, the inner malleolus prominent, the
sole of the foot everted, and the heel apparently elongated. There is
sometimes a groove on the outside of the ankle at the point where the
fibula has given way. Pain and ecchymosis will probably be found in
both malleolar regions, and lateral mobility at the ankle-joint will be
detected if the calcaneum and astragalus are seized with one hand while
the lower end of the leg is grasped with the other. Motion in the tarsal
joints must not be mistaken for ankle motion.
Fracture of the lower part of the fibula can often be detected by
placing the fingers behind the upper third of its shaft and endeavoring to
lift it forward. If this causes pain about the lower portion of the bone,
it is evident that the fibula is fractured and movable at the point of pain.
This test has often been very serviceable to me in obscure injuries about
the ankle. *
Uncomplicated fractures about the ankle, without much displacement
or with easily corrected displacement, give good results and do not leave
any very great final stiffness. The period of union is about five weeks,
but it requires many weeks to restore the mobility of the ankle. Where
there is great deformity and the eversion or inversion of the foot cannot
be overcome, permanent disability results from the weight of the body
being carried on a foot out of proper line. The strain on ligaments and
bones in the unusual relations creates lameness and a tendency to increased
deviation from the normal axis. Open fractures in which suppuration
occurs are of serious prognosis, because, when restitution of position is
made, the external wound frequently does not correspond with the point
of fracture, and decomposing secretions are retained. Free incisions and
the introduction of drainage-tubes may not only avert amputation but
save life. Ankylosis is common in bad fractures entering the joint.
Such fractures, especially, should be treated with the foot at a right angle
to the leg.
&º
3.3%
ſºº
º
Method of adjusting the leg in fracture-box.
*ATMENT-There are few fractures of the bones of the leg that
cannot be properly treated in a fracture-box, with hinged sides and foot-
i. and appropriate compresses. Continuous horizontal traction can
**dded to the box, if the case is such as to demand it. Unless traction
* simultaneously used, and it is seldom required, the box should be sus-
º because thus the patient can have greater freedom of motion in
ed withont danger of displacing the fragments.



440 D IS E A SES A N D IN J U R I ES OF B O N E S.
The fracture-box is prepared by opening its hinged sides and laying
within it a small feather pillow just large enough to fill the space which
ºw ºn
- ºn tº -
|||ſº ºùù
º Sº v.
tº
FIG. 255.
- º |, | }. — sº-> (« º 32% sº --- -
tº Tºsºs
Tº s: ºil
º sº Tsº
G **º sº tº
\ *º-> |Pilllllllll."
Suspended fracture-box, with slide on cord by which box can be raised or
lowered. (AGNEw.)
would exist between the leg and the inner surface of the box when the
sides are closed. Upon the pillow, close to the footboard, should be placed
FIG. 256.
t
§
§
D
º
|(Nº
Slide by which fracture-box is
raised and lowered. (AGNEw.)
a ring of oakum, tow, or cotton to receive the
point of the patient's heel; and over the ring
a strip of bandage two feet long should be
laid. The leg is to be placed upon the middle
of the pillow, with the ankle bent at a right
angle and the foot close to the footboard,
from which it is separated by only a soft com:
º The foot is affixed to the footboard
y the ends of the piece of bandage men-
tioned being carried over the top of the foot,
where they are crossed, carried through the
slots in the footboard and tied on its outside.
The next step is to raise the sides of the box,
by which means the edges of the pillow are
pressed against the broken limb, and to hold
them in position by pieces of bandage drawn
underneath the box and tied over the top.
The amount of pressure exerted by the sides
of the box, which act as lateral splints, call


















































F R A CT U R ES OF THE TI BIA AND FIBU L.A. 441
be regulated or changed by tightening or loosening the encircling strips of
bandage or altering the thickness of the pillow. If any lateral deviation
in the line of the leg is observed by running the finger-tip along the crest
of the tibia, it can be corrected by compresses slipped between the sides
of the box and the pillow at the appropriate places. Anterior or posterior
displacement can usually be overcome by elevating or depressing the heel,
which is done by increasing or diminishing the size of the ring used to
prevent a bedsore on its tip.
F1 G. 257
Elevated fracture-box. (STIMsoN.)
No primary bandage should ever be applied to the leg from the toes to
the knee, as the danger of gangrene produced thereby is too great. In
suspending the fracture-box, which should always be done except in some
fractures close to the knee-joint, and in those which require horizontal
traction from the foot, cords should pass through openings in the upper
part of the sides of the box and be attached to a single cord carried to a
pulley fastened above the bed. It is easy to devise methods by which the
height of the box from the bed may be changed to suit the patient. The
posterior end of the box must not be allowed to drag on the bed, nor
should any position be assumed which tends to permit motion or displace-
ment at the site of fracture. Rotary displacement is a particularly un-
fortunate deformity, as permanent inversion or eversion of the toes is
unsightly and interferes with walking. The surgeon should see to it that
the ball of the great toe, the inner malleolus, and the inner condyle of
the femur are in the same vertical plane, or that the great toe is on a line
With the inner edge of the malleolus. When muscular contraction pre-
Vents complete reduction at the first dressing, flexing the knee and ex-
tending the foot will relax the calf muscles. Stimson says that compres-
Sion of the femoral artery for a few minutes has induced for him
relaxation of the muscular spasm. Subcutaneous section of the tendon
of Achilles is rarely necessary.
When the fracture is at the upper part of the leg the knee must be
kept immovable; hence the fracture-box should extend above the knee,
Which is to be kept straight or slightly flexed, according as one or other
Posture favors accurate adjustment of the fragments. If flexion is neces-
*Y, a double inclined fracture-box like that used occasionally for frac-

442 DISE A S E S A N D IN J U R IES OF B O N E S.
tured femur may be needed. It is not easy to suspend this form of box,
nor is it necessary; but, with the knee in a straight box, suspension is
readily accomplished. The synovitis, often complicating, should be
watched, and if purulent must be treated by incisions, antisepsis, and
drainage.
In very oblique fractures of the shaft continuous longitudinal traction
may be needed to correct the over-riding. This can be attained by ele-
vating the foot of the bed as in femoral fractures and attaching a weight
to the footboard of the box, after placing under the box a smooth board
or kind of railroad upon which it can slide up and down. Another
method is to apply a stirrup to the leg, as in fractures of the femur, but
by means of shorter adhesive strips, and to substitute for the fracture-box
lateral coaptation splints or sand-bags. When the fracture is too low to
give sufficient attachment for the plaster, a thin board may be cut in the
shape of the sole and attached to the foot by strips of plaster. To this
footpiece or sandal, cord and weight can be fixed, and the lateral splints
then applied to the leg.
When the fibula alone is broken, when one of the malleoli is split off,
and even when the tibia itself is fractured, if the line is transverse and
the fibula intact, little support is needed. Hence the fracture-box may
be discontinued in a week, and the patient allowed to go on crutches with
the circular gypsum dressing. This should be worn for about three
weeks.
In those cases of severe fracture at the ankle in which the foot is greatly
everted or inverted, it is of primary importance that the correct axis of
the foot should be regained. Hence it is necessary to over-correct the
deformity by inverting the everted foot, or everting the inverted foot, and
keeping it so till some degree of consolidation has occurred, This being
neglected will permit union to occur without reëstablishing the close mor-
tise between the malleoli in which the astragalus fits, and thereby will
leave a want of solidity at the ankle. The projection backward of the
heel must also be corrected by elevating it in the fracture-box. Back:
ward displacements can sometimes be well corrected by passing a piece of
adhesive plaster under the heel or ankle with its adhesive side against the
skin and tacking its ends to the upper and outer part of the sides of the
box. The fracture-box, with the judicious use of compresses and the
other adjuvants mentioned previously, will accomplish these indications
as well, if not better, than more complicated dressings.
In many fractures the great swelling will for some days permit the sides
of the box to be only partially closed, hence the strips of bandage will
need tightening frequently. The box should at first be opened and the
leg examined once or twice daily. Afterward it may remain undisturbed
for a week, if no burning of the heel or discomfort suggests bedsores or
displacement. The blebs frequently seen on the surface, even if contain-
ing bloody serum, are of no importance as a rule, and need no treatment.
If large, they may be evacuated with a sterile needle and afterward be
covered with powdered boric acid. They soon dry up. They are, per-
haps, due at times to the unnecessary swathing of the broken limb in
lead-water and laudanum, or similar lotions, which are often employed
immediately after the fracture. Such applications are often used with
the idea of lessening the inflammation, but their virtue in moderating the
deep inflammation existing is problematical. Time is the element re-
uired.
At the end of a week in uncomplicated fractures and after the lapse of
F. R A CT U R ES OF THE TI BIA. A. N. D FIBU L A. 443
from three to five weeks in more serious cases, the box should be discarded
and the circular gypsum dressing applied from the base of the toes to the
knee or above it. The patient can then go about on crutches. When
the fracture is at the ankle the dressing should be made additionally firm
there by extra turns of the bandage. The foot should in such cases be
held in the correct position for from fifteen to thirty minutes, till the gyp-
sum sets firmly. Care must be observed in order that the tarsus itself
may be pressed over, and not merely the anterior part of the foot. The
gypsum cast should be worn about three weeks in all cases.
Open fractures, not demanding immediate amputation, are well treated
in a fracture box after being made thoroughly aseptic and being Sur-
rounded by a large gauze dressing. Drainage must be well arranged,
even if additional incisions are needed for the purpose. Free drainage
and frequent irrigations are demanded if the fracture cannot be converted
into an aseptic wound. When union has become pretty firm, or earlier
FIG. 258.
r ====<===
+
:*
|
|
YS$$$. - ==- - “sº
Nº. ñº º º
Nº.
N N º º º |
§ sº ſº i º à | º
º
Wºjº. º
Van Wagemen's suspended fenestrated gypsum dressing for open fracture of the leg.
(HAMILTON.)
if profuse discharge has ceased, a fenestrated gypsum dressing may be
Substituted for the fracture-box. The device of Van Wagenen, described
by Hamilton, is especially nice for suspending such gypsum dressings, and
it allows the patient to turn on his side and slide up and down in bed.
Crutches are allowed when the fracture becomes firm.
Fractures of the fibula have been discussed with those of the tibia;
hence little further need be said. Injury of the peroneal nerve is some-
ºmes an accompaniment of fibular fracture, and is shown by paralysis.
Localized pain and crepitus, and pain felt at the seat of tenderness when
the upper part of the shaft is lifted as previously described, are diagnostic
symptoms, but are not always present. When the fracture is low down
and accompanied by spreading apart of the malleoli, lateral motion of the
*agalus becomes possible. The upper end of the fibula has occasionally
been broken from the shaft by violent contraction of the biceps muscle.
* such cases flexion of the knee to relax the muscle will be a judicious
measure during treatment. Union after fibular fracture occurs in three
i. #. Weeks. When the fibula alone is broken the fracture-box can
§ ºpensed with in a day or two and the gypsum dressing applied. In
* cases nothing more than a bandage is needed from the first.





























444 L) IS E A S E S A N ID IN J U R IBS OF BO N E S.
Fracture of the Bones of the Foot.
These lesions are usually the result of severe violence, which is often
direct; hence many cases present, in addition to the fracture, great
damage to the soft parts. Comminuted and open fractures are, there.
fore, common ; and amputation or excision of bone often required.
Very little apparatus is, as a rule, sufficient to immobilize fractures of
the foot, because the size and shape of the bones and the manner of
mutual articulation does not favor a wide range of displacing motion,
Union is to be expected in uncomplicated cases in three or four weeks,
but ankylosis, caries, necrosis and prolonged disability often follow lesions
of comparatively slight significance.
FRACTURES OF THE TARSAL BONES.—The astragalus and calcaneum
are the only tarsal bones whose fractures require special discussion, as
fracture of the astragalus is not infrequently associated with dislocation of
the ankle and fracture of the fibula, or with calcaneal fracture. Marked
displacement is not very common when the bone injury is unaccompanied
by a wound leading to the seat of fracture. The diagnosis is difficult,
because the crepitus, the inability to bear the weight of the trunk on the
foot, the pain and swelling, may be due to fracture of the calcaneum or
other tarsal bones. The treatment consists in reducing any apparent
displacement and immobilizing the ankle and foot by a fracture-box
or circular gypsum dressing. The foot should be at a right angle to the
leg, and its sole neither everted nor inverted. In closed fractures, with
extreme displacement of fragments, which cannot be overcome and which
threaten, by tension on the integument, to produce ulceration, excision of
the fragment may be performed at once under antiseptic methods.
In open fractures free incisions, counter-openings, drainage and anti-
septics are essential elements of success. Febrile reaction and pain are
often the surest indications that putrescent fluids are imprisoned. The
best point for incision is probably between the extensor tendons of the
great and second toes. Ankylosis will result, and hence the foot must be
kept at a right angle to the leg during treatment. The body of the cal-
caneum may be broken by falls, the sustentaculum tali snapped off by
forced inversion of the foot, and the posterior portion of the calcaneum,
where the tendon of Achilles is inserted, pulled off by the calf muscles,
Flatness of the sole, increased breadth of the foot in the calcaneal region,
approximation of the sole to the malleoli, and the limitation of crepitus,
pain and motion to the known location of the calcaneum are the distin-
guishing features of these lesions, which are often obscure in diagnosis.
Fracture of the ledge of bone on the inner and upper aspect, called the
sustentaculum tali, is said to allow sinking of the inner malleolus and
eversion of the foot, and to be attended by shortening of the heel, as shown
by measuring around the back of the heel from one malleolus to the other.
When the posterior part of the os calcis is detached by muscular contracº
tion, the small fragment may be displaced upward two or three inches.
The treatment comprises immobilization in a fracture-box or circular gypt
sum dressing; with care to obtain correct position of the foot when the
sustentaculum tali has been broken, by moderate inversion. In muscular
fracture of the point of the heel, flexion of the knee and extension of the
ankle will usually be required to keep the fragment down in contact with
the rest of the bone. A slipper attached by a cord to a band around the
lower third of the thigh will accomplish this. If preferred, an anterior
F R A CT U R E OF T H E B O N E S OF THE FOOT. 445
splint may be moulded to the anterior surface of the limb and the dorsum
of the extended foot.
Occasionally the force received tears out a little scale of bone at the
point of attachment of one of the ligaments. The astragalus is subject
to this lesion, which may be termed a “sprain-fracture,” on its posterior
aspect, where the external lateral ligament is attached near the groove
for the long flexor tendon of the great toe. A similar lesion may occur
at the point where the external ligament is attached to the calcaneum.
The metatarsal bones most often broken are those of the great toe,
really by development a phalanx, and that belonging to the little toe.
Metatarsal fractures show little deformity unless several contiguous bones
are broken. Displacement, when it occurs, is apt to cause an angular
projection on the dorsum of the foot. Pressure of a toe backward toward
the tarsus will often, after injury, reveal fracture of the corresponding
metatarsal bone by giving rise to pain at the suspicious spot. Immobili-
zation by a circular gypsum dressing applied at once, or by a fracture-
box, soon followed by the gypsum dressing, is the proper treatment.
Open fractures and burrowing of pus must be met by drainage and anti-
septics. If the deformity in either closed or open fractures is irreducible
and of a character to produce lameness or to interfere with wearing a
shoe, excision of the projecting portion of bone is justifiable.
Fractures of the phalanges are often compound, and in such cases
immediate amputation may be done more frequently than in correspond-
ing injuries of the fingers, because the deformity and disability is not as
important in the foot as in the hand. The toe in other cases may be
made immovable by strips of adhesive plaster holding it to the adjoining
toe, by a gypsum dressing, or by a small pasteboard splint bound to the
top of the foot and back of the toe by adhesive plaster. Serious inflam-
mation not infrequently starts from these insignificant fractures.
C H A P T E R XV III.
SURGICAL DISEASES OF THE JOINTS, CARTILAGES AND
LIGAMENTS.
CONG ENITAL DEFORMITIES OF JOINTS (CONGENITAL DISLOCATIONs).
THESE deformities arise either from intra-uterine traumata or from
nervous or other causes, which may arrest development in portions of the
embryo. Fortunately, they are of rare occurrence, taking place prin-
cipally at the hip; although the jaw, shoulder, knee and almost any joint
may be affected. They are frequently found associated with such other
congenital defects as club-foot, spina bifida, exstrophy of the bladder,
ventral hernia or encephalocele.
FIG. 259. FIG. 260.
sº <āś # %
Ş. º sº % ſº Z’ { l,
ſº % *Nº. º º sº sº $.” %2 % / 3.
> || Sº | y * º
f' ' % Å. *
f * ,
%. 2%
%ft /
& 3%
º, º
5%. 3,
Fº
>- § cº- S/ *
_-rººt
--~~~~~ *=-
Unilateral congenital dislocation of the hip. Double congenital dislocation of hip.
(KRöNLEIN.) (STIMSoN.)
Treatment of these dislocations is apt to prove unsatisfactory. Reduc-
tion should always be attempted, but very rarely, if ever, will the effort
be crowned with success, as the joint is more or less defective in construc-
tion or portions may be entirely absent. Most usually merely rudimen-
tary elements of a joint exist; when palliative measures alone are


SY NO WIT I S. 447
permissible. All means calculated to aid in the formation of a false joint
should be employed, even to dividing contracted or constricting tissues,
or the neck of the femur. In case of the hip-joint an apparatus com-
bining a tight band around the loins to force the femoral head against
the ilium, with a perimeal band to relieve upward pressure is to be
recommended.
SYNOVITIS.
Synovitis is an inflammatory affection of the lining membrane of a
joint. It occurs chiefly in adults, and may affect one or more articula-
tions; none are exempt ; but the knee, wrist, ankle and phalanges are
most commonly involved. Certain diatheses, such as the rheumatic,
tuberculous, and syphilitic, predispose, whilst contusions, sprains, disloca-
tions, neighboring disease, and wounds act as exciting causes. A rigor,
with slight elevation of local and general temperature, pain, and creak-
ing upon motion, fixation, moderate swelling, and, a little later, effusion
and fluctuation, mark its advent. The synovial membrane becomes
blood-red in color and swollen, sheds its superficial cell layers and exudes
serum, at first limpid or, perhaps, tinged with blood, which speedily
becomes turbid, or, in the most intense varieties, purulent.
When located in the knee-joint, the patella is floated from contact with
the femoral condyles when the leg is extended, and when pressed upon
displaces the underlying fluid and comes into palpable contact with the
bones beneath. Simple acute synovitis is to be treated by absolute rest
in an extended position, by cold applications, local abstraction of blood
by leeches or cups, counter-irritation by blisters, and, in some cases, by
the application of firm bandages over wadding. Rest may be secured
either by splint or extension apparatus, but it must not be persisted in
longer than the more acute stage, when cautious passive motion and
massage should be instituted to prevent adhesions.
|FIG. 261.
A
i
*
-->
w 4-
.*-
º
*
Chronic symovitis of knee showing dilatation of synovial cavity by effusion. (DRUITT.)
Should the affection, nevertheless, become sub-acute or chronic, these
*Sures should be coupled with more decided counter-irritation, diu-
* Cathartics, and later, should effusion persist, with aseptic aspiration
or Washing-out of the cavity. -

448 DISE AS ES OF JOINTS, CARTILA GES AND LIGA MENTS.
Purulent synovitis is a serious complication, recognizable by recurring
rigors, persistent high (103°) temperature locally, constitutional disturb-
ance, and by hypodermic aspiration.
It is to be treated, first, by aspiration and washing-out of the joint,
and, this failing, by incision and drainage, or by excision of the membrane
if that alone is involved.
Septic synovitis is extremely resistant to treatment, often requiring in
addition to the usual constitutional and local measures such operative
procedures as will be described under
FIG. 262. arthritis, and as frequently resulting in
ankylosis or destruction of the joint. Its
cause, pathology, diagnosis, and treatment
are practically identical with the septic
form of the latter affection, as the process
occurring in the synovial membrane in-
variably extends quickly to other struc-
tures of the joint.
Syphilitic synovitis much resembles
simple acute and subacute synovitis, but
is dependent upon and intercurrent with
the constitutional disease, and promptly
yields to anti-syphilitic treatment. It
may be acute or chronic ; is limited to
adults; is symmetrical, and usually occurs
in the knees. Some swelling and effusion
accompanies it, but scarcely any pain.
Occasionally synovial membranes undergo
a fibroid change of probably rheumatic
nature, and minute sessile or pedunculated
whitish fibroid bodies are developed
throughout the membrane. These, during
movements of the joint, may become separ-
ated from their attachments and form a
Fibroid hyperplasia of synovial variety of “loose bodies” in joints. A
membrane of knee. (DRUITT.) second variety of this same process exists
where the fibroid masses are developed in
the deeper layers of the membrane. Here they become flattened by joint
motion, and bear great resemblance to melon seeds, by which appellation
they are commonly known. These and other fibroid changes of the
synovial membrane occur in rheumatic arthritis.
Nothing short of excision of the affected membrane can afford any
relief from these affections.
Primary and metastatic neoplasms of the synovial membranes rarely
occur, but cannot, as a rule, be accurately diagnosed save by opening the
joint. Effusion will usually be present.
* § º | bº
º
º
§
HAEMARTHROSIS.
Haemarthrosis results from laceration of the bloodvessels of the synovial
membrane. It may occur in conjunction with synovitis, or exist sepa-
rately. Blood quickly distends the cavity of a joint, but does not clot
unless it has communication with a fracture. Marked fluctuation is

A R T H R ITIS. 449
frequent, but there is usually no pain or increase of heat, and upon hypo:
dermic aspiration pure blood is withdrawn. Small quantities of blood
thus effused into healthy joints is rapidly absorbed under pressure, but
otherwise must be withdrawn by aspiration. Persistent effusion after
injury, without pain, will almost invariably prove sanguineous. Haemar-
throsis followed by degenerative joint change is common in haemato-
philics, when it should not be interfered with surgically, unless its causa-
tive condition has first been effectively cured.
Hydr.ARTHROSIs, or simple non-inflammatory infiltration of joints, is
usually a part of a general oedematous condition of an extremity having
origin in heart, liver, or kidney disease, or in venous obstruction or dis-
tention. It can only be relieved by removal of the ulterior cause, together
with elevation and elastic pressure by bandages.
ARTHRITIS.
When an inflammatory process has originated in or been engrafted
upon other portions of a joint than the synovial membrane, it is termed
arthritis. Practically, however, the distinction between synovitis and
arthritis is frequently impossible and as often immaterial as regards
treatment; the synovial membrane being invariably involved, either
primarily, secondarily, or synchronously with other portions of the articu-
lation. Arthritis may involve a whole joint or be limited to any portion
of its extent. Identical varieties are apt to present at once more severe
constitutional and local phenomena than do the corresponding forms of
synovitis, but its development, on the contrary, occasionally is most
insidious.
Simple acute or chronic arthritis takes place as a rarity. Almost all
cases of arthritis are to be included in the chronic, septic, specific, and
neurotic varieties.
Acute suppurative arthritis is a purulent inflammation of the entire
contents of a joint. It may involve one or many articulations at once or
consecutively. The causes are either contusions or wounds of the
joints, contiguous inflammation as in epiphysitis, by burrowing of pus
from periostitis beneath the periosteum into the joint, or rupture of an
abscess of the bone head into the articulation. The pathology of the
affection is simply that of acute suppurative inflammation of all the
elements of the joint; the cartilages erode or necrose, purulent or sanio-
purulent effusion takes place, producing abscess of the joint, which subse-
quently may rupture externally or penetrate into the surrounding tissues.
Finally, the joint may return to a non-inflammatory ankylosed condi-
tion, or necrosis of the adjacent bones may take place. Taking the
knee, for example, pain increased by motion, chill, temperature rising
to 102° to 104°, and swelling will be the initial symptoms. Fluc-
tuation, great swelling and oedema, and severe constitutional depression
With high pulse, will, together with aseptic hypodermic aspiration, render
the diagnosis certain. Before the diagnosis of pus can positively be made,
the jºint must be put at rest by splints, and evaporative lotions, ice-bag,
or irrigations applied. When pus is recognizable (sometimes when only
suspected) the joint should be tapped and washed out, or, especially if
Plls recur, be laid open and drained. Constitutional support and stim-
ºlation, antiperiodics, and concentrated diet are of prime importance.
Such treatment will sometimes save a joint and preserve fair motion, but
29
450 DISE ASES OF JOINTS, CARTILA GES AND LIG AM ENTs
ankylosis is usual. Later stages will probably require excision or ampu-
tation. Except in pyaemic cases, these latter measures should, when
indicated, never be delayed if the patient can withstand the shock, for
the rule is constant loss of strength without recuperation whilst the sup:
purative process lasts, and the danger of further constitutional contami.
nation is great.
Gomon'rhoeal Arthritis.
Gonorrhoeal arthritis is caused by metastasis of gonorrhoeal pus from
the urethra, is almost limited to the male sex, and involves as a rule a
single large articulation, but may be symmetrical, or attack any, even
phalangeal joints. All parts of the joint are involved. There is great
pain, worse at night, Swelling and Oedema; pressure and motion are ex-
tremely painful, and grating may be present. Plastic exudation, rather
than effusion, takes place, which exudate commonly organizes into fibrous
material which more or less completely obliterates and ankyloses the
joint. The urethral discharge, which may be either from acute gonor-
rhoea or chronic gleet, is not usually in any way affected by joint involve-
ment; but on the other hand, treatment of the discharge often has a
marked beneficial effect upon the diseased joint and will prevent other
articular involvement. Gonorrhoeal arthritis is extremely resistant to
treatment and very apt to pursue a long chronic course. Absolute rest,
leeches, counter-irritation by a series of small blisters, morphia for pain,
and a liberal use of belladonna and mercurial ointments upon the joints,
in conjunction with good diet and hygienic surroundings, are the most
beneficial remedies.
Tubercular Arthritis.
Tubercular arthritis usually takes origin from extension of tuberculous
disease from the contiguous bone extremities, but may also arise primarily
in the synovial membrane. The tubercle bacillus is invariably present,
actively causative, and diagnostic. This form of arthritis is most common
in childhood or youth, but may arise at any age. In aged persons the
process is apt to run a rapidly destructive, almost irremediable, course,
speedily breaking down the joint and involving adjacent bones. The
strumous or tubercular diathesis invariably precedes and predisposes to
joint infection, whilst depraved physical condition or slight traumata serve
as exciting causes. It frequently follows such diseases as measles, Scarla:
tina, and typhoid fever. The malady may be limited to one or several
joints, or be concomitant with or consecutive to tuberculous lesions else-
where. *
PATHOLOGY..—Primarily tubercles are deposited in the articular ex-
tremities or membranes of the joint. Then follow irritative inflamma-
tion, serous succeeded by purulent effusion, distention and progressive
softening of the joint capsule and ligaments, ending in their rupture or
disappearance. The membranes and cartilages are replaced by a fibrouš,
gelatinoid, yellowish or brownish substance; the bone-ends are invaded,
abscesses form and discharge, leaving sinuses from which sequestræ 0"
granular portions of bone may be discharged. Finally, by continuous
reflex muscular contraction, the bones forming the articulation are drawn
asunder, giving rise to great deformity and disability. The process may
be arrested in the earlier stages, when the parts may return to the normal
TUBER CU Lo Ús ARTH RITIS OF SPECIAL J OINTS 451
previous condition, or the inflammatory products may organize and pro-
duce intra-articular adhesions and more or less ankylosis.
Symptoms.-Slight impairment of function is earlier or later followed
by pain and swelling. Pain may be absent until later; it is not essential,
or at all characteristic. No impaired function even may be discernible
at first, save on close examination. The temperature of the body or part
may or may not be raised. Soon the articulation assumes a white swollen
appearance; blue veins are apt to course over its surface, and upon palpa-
tion a sensation of “doughy” fluctuation is apt to be observed, which,
later, will probably be succeeded by true fluctuation, lateral move-
ment, grating, abscesses, sinuses, and discharge of disintegrated bone
and cartilage, spiculae or sequestra, and dislocation. Hectic will be
present if the joints have become infected through the sinuses, but not if
that accident has been prevented by proper treatment. If purulent dis-
charge has been of long duration, amyloid disease may complicate the
case and interfere with treatment.
TREATMENT.-Absolute rest of the joint for a long period, with good
food, tonics, iron, cod liver oil, and such measures as have been sug-
gested for synovitis and simple arthritis, such as cold applications, leeches,
blisters over points of greatest pain, applications of iodine, and pressure
by bandages, is the treatment for all but the later stages. Should the
process still continue, excision of the joint membranes and other tubercu-
lous foci in the cavity (erasion) is called for. Next in order comes
excision, and, lastly, if the joint is utterly destroyed or the bones hope-
lessly involved, amputation of the extremity.
PROGNOSIS.–Many cases appear to recover perfectly when the disease
yields to minor measures; others preserve simply a stiff or ankylosed
joint. Excision and erasion are very successful, if not left too late.
But many live for years with discharging sinuses without much discom-
fort other than more or less loss of function. Constitutional infection is
supposed to occur frequently, if the disease is not eradicated. Tubercular
meningitis is not rare at any period. Amyloid degeneration of the kid-
neys and other organs sometimes results from continued purulent dis-
charge. Joints cured by minor measures are liable to recurrence upon
even trivial aggravation or injury.
TUBERCULOUS ARTHRITIs OF SPECIAL Joints.
Tuberculosis of Vertebral Articulations (Spondylitis, Pott's Disease).
Tuberculosis of the vertebral articulations conforms, with modifications
due to location, to the general description of joint tuberculosis. Thus
situated the affection is most apt to develop between the third and six-
*enth years, but no period of life, from a few days up to about the
*Ventieth year, is entirely exempt. Any joint or joints of the spine,
from the occipito-atloid to the lumbo-sacral or even inter-coccygeal, may
be affected. The lower dorsal region is most usually involved; then, in
Order of frequency, come the dorso-lumbar, cervico-dorsal, cervical,
lumbar, lumbo-sacrai, atlo-axoid, occipito-atloid, and inter-coccygeal. The
disease may develop simultaneously or secondarily in two or more distinct
º or travel through a considerable number of contiguous ver-
*...ither upward or downward. It may be an entirely local disorder,
**nifestation of general tuberculosis, or itself may originate the latter.
452 DISE A SES OF JOINTS, C A RTILA GES AND LIG AMENTs.
The course of vertebral tuberculosis is, as a rule, slow and chronic, but
exceptional cases and those which become infected through abscess open-
ings may run a very acute and rapid course.
A history of traumatic cause or origin is almost always presented with
the case. Slight direct or indirect traumata are probably determining
and exciting causes, but the tuberculous constitution must be present to
render them efficient. Violent injuries of these, as of other joints, are
mot likely to be followed by tuberculosis. It may arise from infected
spinal wounds.
PATHOLOGY..—As the medulla and epiphyses of the vertebrae remain
soft and embryonic until long after other cancellar tissues have undergone
the permanent changes of adult bone, they are more predisposed to inflam-
matory affections than other bones. Hence, tubercle bacilli find a more
congenial bone location in the pulpy Osteo-cartilaginous or epiphyseal
junctions of the vertebrae than elsewhere. At these points the disease in
almost every case begins, although it is possible that some few originate in
the inter-vertebral fibro-cartilages or synovial membrane, except in the
occipito-atloid, atlo-axoid, and inter-coccygeal varieties, when the disorder
commences as a tubercular synovitis or in the odontoid process. In every
case the joints are quickly involved and adjacent cartilages and bone are
broken down. The destructive process is always confined to the bodies of
the vertebrae, while the laminae and spinous processes escape. At this stage,
before deformity takes place, the disease may naturally, or responding to
treatment, cease, the products organize or casefy, and no special harm be
done. But much more usually it progresses; the bodies of the vertebrae on
either side of the first affected joint become carious and crumble down, or
necrose and throw off sequestrae; the super-imposed portions of the spine
are drawn forward and downward by gravity and action of the abdominal
muscles, deformity results, abscesses may form and burrow in the peri-spinal
sheaths and perhaps infect new portions of the column. If unretarded, the
process may continue until many separate or contiguous vertebral bodies
are destroyed, great deformity has supervened, and the patient finally
succumbs to suppuration and exhaustion. Unless the case is complicated
by old lateral curvature, the deformity is always directly antero-posterior,
because the spinal arches, articular spinous processes, and the lateral sup:
ports of the column are not interfered with. The projecting portions of
the deformity are due to the pushed-out spinous processes. Where the
seat of the disease is situated in the lumbar region, deformity does not
appear or comes very late, because the natural anterior curvature of the
spine at this point must first be overcome before angulation can become
evident, as well as because of the rigidity and broad articular surfaces of
this region.
Suppuration is not a good index of the disease; it (abscess) may present
in advance of other symptoms, or not appear until destruction is great.
Some worst cases are never complicated by its presence. Abscess is dis-
covered in about twenty-five per cent. of all cases, but it occurs without
being fully demonstrable in as many more. At post-mortems they are
usually found concealed or sacculated, and if the case recover the suppurº
tive products may have organized, caseated, or have formed residual abº
scesses. A variety of vertebral tuberculosis has been recorded in which
the bodies of the bones become honey-combed, but do not suppurate,
break down, or produce deformity. g
Contrary to conventional belief, angular deformity does not give rise tº
direct pressure upon the cord, except in rarest of instances, and when the
TU BERCULO Us A RTH RITIS OF SPECIAL J O INTs, 453
disease is located at the atlo-axoid junction. Actually, there is much
more than the usual space for the cord to pass through when angular
deformity exists, as then the anterior wall of the canal is replaced by an
excavation. But such deformity by approximating the ribs may give rise
to pressure symptoms or destruction of the nerves emerging laterally from
the spinal column. In alto-axoid disease the atlas is displaced forward
upon the axis, the posterior arch of the former compresses the cord more
and more against the odontoid process of the latter, and gradual or Sud-
den extinction of the functions of the cord, and death, may result. The
paralysis of the more ordinary forms of the disease is due to secondary
inflammatory affections of the cord and membranes, and to pressure
from pent-up pus, hemorrhage, as from ulceration into the vertebral
artery or other vessel, or from a displaced sequestrum. If the displace-
ment or pressure be gradual in onset the cord will often accommodate
itself to it, and can carry on its varied functions through a very much
narrowed spinal canal. Therefore, it is not strange that many palsies of
tubercular spondylitis are often erratic, anomalous, and, on occasion, the
first symptom of trouble. Angular deformity in the cervical region
forces the chin upon the chest and may produce dyspnoea, while in the
dorsal region the same effect follows compression of the thoracic viscera,
whence mechanical dyspepsia and intercostal neuralgia may result.
The paralysis of vertebral disease is essentially motor, and always com-
mences as such. Sensory function is last to appear and first to return
where improvement takes place, because the motor tracks being anterior
bear the brunt of the pressure, while the sensory are posterior and more
protected. Owing to sympathetic connections, however, entire control of
the bladder and rectum sensations and functions is never entirely lost.
By continuity, or by abscesses opening into the spinal meninges, tuber-
culous spinal or cerebro-spinal meningitis may be produced, but more
frequently the latter arises from general miliary tuberculosis—both rare
Complications of vertebral tuberculosis.
When spinal abscesses form pus collects in front of the affected vertebrae;
upward progress is shut off by the overhanging, displaced vertebrae, and
in other directions the anterior ligament, periosteum, and pleura or peri-
toneum thicken and form an abscess wall so that the pus, to make its way
Out, must find exit on one or other side of the spine and enter one or both
of the sheaths of the psoi muscles, and destroying the contained muscle
present in the iliac fossa, groin, or thigh as a psoas abscess, or pass back-
Ward through or external to the quadratus lumborum, and give rise to a
loin or lumbar abscess.
Cervical spinal abscesses by much the same process point either in the
pharynx or find their way along the fasciae and muscles to some point upon
the neck. When cure is established, after deformity has taken place,
true or Osseous ankylosis of the affected vertebrae takes place, inflamma-
tºry, products are organized, absorbed, or encysted, the muscles relax their
Vigil, and the cord becomes accommodated to its altered position. Firm
*nkylosis is to be desired in any part of the spine. This desideratum usually
involves great deformity if much bone destruction has taken place, but
* Preferable to less deformity with the vertebral bodies separated and held
*Pºrt by slender bridges of bone which are liable to fracture and danger-
* relapse upon slight provocation.
SYMPTOMs are frequently obscure at first and extremely palpable after-
Ward. The appearance of a boss of unnaturally prominent spinous pro-
* may appear without prodromata and constitute the first sign. It is
454 DISE A SES OF JOINTS, CARTILA GES AND LIG AMENTs.
at this stage that most of the cases amongst the poorer people are brought
to the surgeon. , Stiffening of the spine and nerve symptoms usually long
precede recognizable deformity. Pain will usually attract the person's
attention and may be mistaken for colic, muscular cramps, dyspepsia,
rheumatism, neuralgia, or “growing pains.” It is aggravated by motion
or concussion of the spine, as in riding in a carriage, over crossings in a
street car, or by missing a step; is always referred to the same locations
and is relieved by rest. It is usually complained of as intercostal, sub-
sternal, sciatic, or as headache of the occipital distribution when the dis-
ease is located in the cervical spine. Some local pain or tenderness may
be present, but this is usually dull, whilst the referred pains are apt to be
sharp. Before actual pain develops various minor sensations, as tingling,
burning, formication and itching, may be present. It may be referred to
the hip, which, accompanied with spine lameness or alteration of gait, may
cause error in diagnosis. The sensation as of a cord tied tight around
the chest or abdomen, and spasmodic abdominal attacks with accompany-
ing or subsequent flatulent distention, are not uncommon symptoms. Pain
and muscular tension can usually be relieved at once by longitudinal ex-
tension or by bending the spine in a direction contrary to the angle of
deformity, as by a hand placed under the back and the patient thereby
partially raised. In rare instances, however, they may thus be aggravated.
Elevated temperature may be a prominent or an absent feature of the
case. When acute it rises to 101° or 102°. If abscesses become infected
it may rise higher, and then become of hectic type. A high temperature,
except at first, or upon abscess infection, will indicate grave complications,
Paralysis or other severe nerve symptoms may occur at any stage, as also
may those of spinal inflammation, cerebro-spinal meningitis, general miliary
tuberculosis, phthisis, hip disease, empyema, and peritonitis.
At once, or after a lapse of months, or even years, prominence of the
spines of the affected vertebræ and angular deformity appear in varying
degree. So, also, is it the case with abscesses; they may present early,
late, not at all. Anaesthesia may be required for their diagnosis if deeply
situated. Very late loss of motion, then sensation, and finally contrac-
tion of leg-muscles, bedsores, or amyloid degeneration of viscera may
supervene; the muscles waste, and the patient becomes excessively blood-
less, pallid, and of aged appearance, even if very young. g
Certain special symptoms pertain to atlo-axoid and occipito-atloid dis-
ease. There may be spasm of the sterno-mastoid or choreic movements
of the neck muscles or neuralgia or paralysis of the brachial plexus, all
of which are increased by nodding rather than by rotation, and relieved
by occipital extension. Laryngeal cough, or stridor, difficulty in respi-
ration, deglutition, or phonation may be present. Sometimes grating or
crepitus can be developed by motion. The head is stiff, thrown forward
or to either side, the chin forced upon the sternum, the neck appears
shortened, and the spine of the axis is extremely prominent. Rarely the
head in addition to being thrown forward is turned upward by spasm of
the posterior neck muscles. The head is held in the hands when the
disease is extensive; there is danger in any movement; the patient is
apprehensive of sudden death and cannot lie down or lean forward.
There is constant danger, in extreme cases, of sudden dislocation 9."
fracture, pressure upon the cord and instant death. Abscesses of this
region usually point in the pharynx or upon the neck.
DIAGNOSIS.–With this end in view the patient should be stripped naked
in a warm room and stood before, or laid across the knees of the surgeon.
TU BER C U L O U S A RTH RIT IS OF SPECIAL J OINT S. 455
All cases wherein there is any possibility that disease of the spine may be
present, to account for distant or obscure symptoms, should be thus
examined.
Spinal pains can best be elicited by motion of the column and pressure
in its axial direction. Percussion, applications of electricity, heat or
cold, are most unreliable.
Muscular symptoms are, perhaps, most important. Almost as soon as
disease commences the erector-spinae muscles involuntarily assume the Sup-
port of the column to prevent movement of, or pressure upon, the diseased
part. This gives rise to characteristic postures and modified movements,
recognition of which is most to be desired, for treatment instituted at this
stage is highly successful and prophylactic.
No skill is required to diagnose later stages when deformity has taken
place, nor will treatment then avail for much. The characteristic posture
is one of caution and apprehension.
The child tires of play, lies about, or FIG. 263.
seeks support; is easily fatigued. Com-
plains, perhaps, of local or referred
pains or other sensations, is clumsy in
walking, or struts or shuffles along
without elasticity. He is afraid of **,
jarring, does not jump ; turns rather
than look around, and in every way,
quite involuntary, as a rule, at first,
Saves the spine from motion or con- ... }
cussion. The head is thrown back, &
the shoulders elevated by the trapezii,
the arms hang at the sides, and the
toes turn out. All movements are
guarded. If asked to pick up an ob-
ject from the floor he rests a hand
upon the corresponding thigh and
bends, the knees until the free hand
reaches the object, or he may kneel
outright. He may continually hold
his head in his hands, and phonation, Early dorsal vertebral tuberculosis;
respiration, or deglutition may be in- typical posture in stooping; child cannot
terfered with if the affection be cer bend spine in picking up object, and sup-
vical. ports her weight by hand on knee.
Even slight stiffness of the spine (Swith.)
can be made evident by the above
º ther gymnastic performances, which the surgeon's ingenuity will
pply.
, Vertebral tuberculosis must be differentially diagnosed from rheuma-
*m; neuralgia; affections of the cord and membranes, as myelitis, and
*ngitis; sprains; tuberculosis of the hip; abscess, and other affections
9f the liver and kidney; perityphlitis, aneurism, and tumors of, or press-
*8 upon, the vertebrae. The last-mentioned diseases may exactly present
the usual symptoms of spinal disease, even to the characteristic deformity
Y. Pºsure absorption of the vertebral bodies, and cannot be positively
º therefrom until late. Happily, these conditions are very uncom-
Il. s ºf
al Tuberculosis of the vertebral joints may become engrafted upon a spine
*dy affected with lateral curvature, when some symptoms may be


456 DISE ASES OF JOINTS, C A RTI I, A GES AND LIGA MENTS.
decidedly modified. I concede the possibility, indeed the belief, that
other than tuberculous forms of inflammation of the spinal joints and
bones take place, but think (as treatment would, in all cases, be identical
and so little is known of the other varieties) to prevent confusion by omit.
ting their description.
TREATMENT is of greatest value in the earlier stages, when the disease
may often be entirely checked. The great indications are to build up the
vital powers and to secure local rest. The former is to be attained by
attention to the hygienic surroundings and diet of the patient, and by the
administration of such agents as cod-liver oil, iron, iodide of potassium
or mercury, hypophosphites, Strychnia, and, perhaps, phosphorus. A little
brandy can often be added to the diet with advantage. Removal to sea
or country air will usually make marvellous changes for the better. Even
if it is necessary for the patient to remain in bed, he should be placed upon
a hard hair mattress cot, which can be carried into the yard, to the roof,
or to another room. Massage, electricity, and douching must not be
neglected. From the first appearance of symptoms until consolidation
has well advanced (most certainly while any acute symptoms last) the
patient should be kept in bed, and, as much as possible, motionless upon
his back. While symptoms are very acute sand-bags may be placed
upon each side of his body. Even greater repose can be secured when
FIG. 264.
# th: .
T ºuliſſil III; tº “
*
|.
*mºmºmºmºmºsºm
Extension in the recumbent posture. (WYETH, after REEVES.)
indicated by applying extension to the neck and elevating the head of
the bed; by its application to the legs and elevating the foot of the bed,
or by the conjoint application of both methods. It is also well to place
a small pillow under the angle of deformity, or to sustain that portion of
the body in a sort of sling, after the manner of Reeves. I do not wish,
however, by this advice to be construed as endorsing methods which tend
to correct forcibly the deformity, which, in my opinion, are ill-advised and
contrary to the teachings of pathology. Neck extension is especially
called for in cervical disease. The object of treatment by posture and
moderate extension is to relieve muscle tension, and pressure upon the
affected vertebrae; by which are secured consolidation with least deformity,
and comfort to the patient meanwhile. Desperate cases, where bedsores
are threatened, must be placed upon an air- or water-bed.
When acute symptoms have subsided, the patient may be allowed tº
get up and go about in a brace. Where limited circumstances prohibit
more expensive apparatus, the plaster jacket, while not so light, conve.
nient, or comfortable as other apparatus, yet answers every purpose of
treatment.


TU BER C U LO U S A R T H RIT IS OF SPECIA. L J O IN TS. 457
For its application the patient should be stripped to beneath the hips,
or entirely, and a close-fitting woollen shirt, extending below the trochanters
and provided with shoulder-straps, put on. He is then raised in a sus-
pension apparatus until he is comfortably resting upon the great toes.
Fſ G. 265.
Suspension by means of tripod for application of jacket for spinal disease.
N OWs while he grasps the suspension rod with his hands, moistened crino-
line bandages, well impregnated with plaster-of-Paris, are evenly wound
about the trunk from just below the trochanters to the axillae. Any
inequalities are smoothed over by the hand or a little moist plaster rubbed
*o them. A folded towel should be placed over the lower abdomen to
allow for subsequent distention of the stomach by food, but this can be
dispensed with if the patient has recently partaken of a meal. If the
Patient is a female, that portion of the jacket in the interval between the
breasts should be well moulded in before the plaster sets. As soon as the
Plaster has become firm, it is cut vertically in the median line in front and
*refully sprung off. It is then trimmed along the borders with chamois

458 DISE As Es OF JOINTs, CARTIL AGES AND LIG AMENTS.
skin, somewhat padded in the axillae, and lacing eyelets placed along the
cut edges.
FIG. 266.
Shears for cutting gypsum bandages and iackets.
82 ºn © J
If the vertebral prominence is sharp or irritable, a ring of wool should
be placed about it before the bandages are applied, or a fenestrum may be
cut in the jacket and its edges padded. Or, when even this much cannot
be afforded, jackets may be applied every few weeks and allowed to re.
main uncut until it is time to apply a new one; but, in so doing, great
care must be observed in young children to see that pressure Sores do not
(!, FIG. 26'7.
@2.
l
|
º
W : ©
O
W. Rºo
W
gº - º
fºssº zº: º
Fº Šº
a. Leather jacket with jury-mast. b. Same, applied.
develop and that vermin do not find lodgement. Where circumstances
permit, it is much preferable to use the plaster jacket simply as a mould
in which is cast a plaster model of the body, around which is accurately
fitted a leather or felt jacket, which is subsequently trimmed, fitted with
eyelets, and extensively perforated. º







TU BERCULO U S A R T H RIT IS OF SPECIAL J O IN T S. 459
The above will answer perfectly for all diseases located below the upper
dorsal region. Otherwise a supporting head-gear must be fitted to the
jacket. This is done by either fastening the head-piece between the folds
of bandages or by subsequently riveting it upon the completed brace.
For disease of the cervical spine and of the
º
º
ſº
|tº
* º
|
occipito-atloid region, the “jury-mast” head-
gear will not always afford sufficient security.
Then some such device as the leather collar is
more appropriate, and the jacket is dispensed
with, but such cases had best remain in bed
until firm ankylosis has taken place. Remov-
able jackets need not be worn in bed. If the
spine straightens out, or if the proportions of
FIG. 269.
§ | º | g *
#|| t º
Head support for spinal Breast-plate and collar for cervical or high dorsal
tuberculosis.
caries. (OWEN.)
the patient materially change, a new apparatus must be, in the same
manner, applied. Nothing but the shirt, or shirt and chemise, must be
Worm beneath the jacket, and it is well
for each patient to have a suspension
apparatus and put on his brace while
the spine is extended. If the child is
continually kept in the admirable sus-
pension chair of Dr. Meigs-Case when
out of bed, no jacket will be required.
Operations intended to remove the
diseased portions of the diseased ver-
tebræ, or to afford direct drainage, have
been performed, but enough is not yet
known of these measures to justify either
Criticism or endorsement.
TREATMENT OF ABScEsses.—When-
*Ver a palpable abscess is accompanied
With pain, fever, or other marked local
91 Constitutional signs, it should be
9pened forthwith. But if it do not
*90mmode the patient, it need not be
interfered with until it shows some ten-
dency to point or open. Abscesses should
*Ver be allowed to open spontaneously,
FIG. 270.
º
Rºmsæº-Eſsº
º
e-8
#
i
L
. Suspension chair of Dr. Meigs-Case







460 DISE ASES OF JOINTS, C A RTIL AGES AND LIG AM ENTs.
for fear of infection. Such infection usually gives tenfold impetus to the
disease, and may cause speedy death by suppurative exhaustion. In
opening abscesses, absolute antiseptic precautions should be taken. Free
incision is made, the sac washed out with 1:1000 bichloride solution,
freely curetted as far as possible, again washed out and the incision
sutured, leaving in a large drain. A large dressing should then be ap-
plied and renewed, and the sac re-washed upon the slightest indication
therefor. Thus treated, their opening causes none but beneficial results.
Psoas abscesses, if detected in time, can be more easily dealt with by
cutting down upon the sac above Poupart's ligament.
PROGNOSIS.—Tubercular spondylitis is rarely fatal under ordinary cir-
cumstances. Prognosis depends upon the age of the patient, the duration
and location of the disease, and whether abscesses have formed or have
become infected. High cervical disease is always dangerous, occasionally
suddenly fatal.
TUBERCULOSIS OF THE SACRO-ILIAC ARTICULATION.
This seat of tuberculosis is not uncommon, and often, especially during
early stages, is confounded with sciatica and hip-joint disease. It occurs
rarely in children; between the ages of fifteen and thirty-five it is most
common. The causes are either local traumata or extension from the
acetabulum or from iliac or hip-joint abscesses burrowing into the articu-
lation.
The symptoms are pain, local and radiating, tenderness upon pressure
or motion, especially when pressure is made upon the iliac crests, perhaps
interference with or painful defecation or urination, and, rarely, oadema of
the corresponding limb from swelling pressure upon the iliac vein. The
body is inclined to the sound side to secure absence of pressure, and exten-
sion by weight of the sound limb. Swelling occurs early, but does not
shift from over the line of articulation or obliterate the gluteal fold, but
later, especially when abscess forms, the tumefaction may extend to and
change the buttock contour. Always there is wasting of the gluteal
muscles and loss of power in the limb. Apparent lengthening of the
limb is due to dropping the pelvis to secure ease; the foot is everted.
Abscess may subsequently form and point locally, or discharge into the
pelvis or its contained organs, through the sciatic foramen into the but-
tock, via the levator ani and obturator fascia into the ischio-rectal fossa,
or upon the inside aspect of the thigh. &
The affection must be differentiated from spinal or innominate caries,
hip disease, and sciatica. &
Treatment of the early stages should comprise strict rest, extension,
proper diet; plus blisters, cautery, or iodine paintings locally. Later, if
all goes well, a hip case or splint, or crutches may be allowed. If by
these means progress of the disease is not quickly arrested, and more pºlº
ticularly if abscess supervene, the joint must at once be laid open by in-
cision of its own direction and length, and the diseased portions of the
membrane or bone scraped or chiselled away. Following this the wound
should be kept well packed with antiseptic materials until it heals. Often
all that we can do will not prevent the patient finally dying from exhaus'
tion.
TU B E R C U L OSIS OF HIP - J O IN T. 461
Tuberculosis of Hip-joint.
Tuberculosis of the hip-joint is a disease very frequently met with.
Two-thirds of all cases are under sixteen years of age ; males are most
often affected. It may attack one hip or both either synchronously or at
different times.
CAUSEs are, in order of frequency : injury, spontaneous, and auto-
infection from other organs or tissues.
PATHOLOGY..—The inflammation may begin as a tubercular epiphysitis
of the head of the femur, and, the epiphyseal junction being entirely within
the joint-capsule, thence quickly spread to the other articular structures.
Or it may take onset upon the acetabulum floor in the lines of union
of the three segments of the ilium ; in the synovial membrane; or, possibly,
in the ligamentum teres. But most usually the disorder is supposed to
originate in the Osteo-cartilaginous junction of the femoral head.
According to the constitution of the patient the case will run either
an acute or chronic course. If acute, profuse suppuration and breaking
down of the contents of the joint and necrosis of the neighboring bones
take place. Or, if epiphysitis has taken place, the head of the femur may
become entirely detached into the joint. The worst forms are those where
the tuberculous process is transmitted along the bone shafts, through the
bottom of the cotyloid cavity into the pelvic bones or their neighboring
organs, or into the blood current as miliary tuberculosis.
In the chronic variety, on the other hand, the disease is persistent; pus
is not formed, or only slowly, the effused materials are plastic, become
firm and, in time, give rise to fibrous, rarely osseous, ankylosis.
In either case, but especially the former, destruction of the joint plus
continuous muscular action may dislocate the altered head or neck of the
femur upon the dorsum ilii and give rise to great deformity.
SYMPTOMS.—Often before positive symptoms develop, the child is noticed
to exhibit lassitude, to tire easily of play, become pallid, sleep uneasily,
lose strength, and, perhaps, be feverish. He eases the affected limb in
exercise, play or standing, and, possibly, may complain of what are vul-
garly taken for “growing pains” in the knee, thigh, or hip. Great atten-
tion should be paid to these conditions, as diagnosis at this stage is of vital
importance. Yet, no one sign can be depended upon more than to centre
attention upon the parts, and, perhaps, indicate precautionary treatment
until others develop.
Stiffening will be the first positive symptom and give rise to lameness
and a characteristic standing posture, where, leaning a little forward, all
Weight is thrown upon the sound limb, while the other is advanced, slightly
flexed, abducted, and rotated outward. Stiffening of the joint in varying
egrees of flexion, at first by muscle tension to prevent motion, and later
by joint changes, is present in all stages of the disease. Even in the
slightest amount it can be recognized by placing the child flat upon a
table, and upon attempting to straighten out the affected leg, the vertebrae
become arched forward by tension upon the psoas and iliac muscles and
the hand can readily be carried beneath. When the sound limb, which,
to gain the confidence of the child, should first be examined, is so manipu-
lated, no change in the back takes place. This involuntary muscular
tension, which is shared in by all the anterior muscles of the thigh, is to
Protect the joint from motion and consequent production of pain. The
degrees 9f flexion, abduction, and rotation, indicate that position of the
Joint which gives most room to accommodate the effusion always present
462 DISE ASES OF JOINTS, C A RTIL AGES AND LIG AM ENTS,
in the joint; later, flexion may depend upon excessive muscle contrae.
tion. Impaired motion of the joint is amongst the most valuable of early
signs. If motion is unimpaired, it is almost conclusive evidence that no
hip disease is present. Interference with extension and flexion may be
FIG. 271.
N
SN
sº
*s-,
*. * Sº w
-- - - - ** NS % -
-- ^ -, -, * --~~2: $.” CŞSN %;
*g --~~~~ ~~ jº º
§ s º -i.
~ Sił,
. ...;3%02 2% bºxº zººi
...&#3%iº,4&^*
º £ºfflº
ºº:: ==#2
sº a
º.º.,
º &º.º.º.
§º º
& ššč
Curvature of spine when leg is extended. (SMITH,)
caused by spinal disease, but rotation (the crucial test) is only impeded
by hip-joint involvement. To apply the test, flex the thigh to an angle
of 120 degrees and then attempt rotation.
All manipulations should be most gentle, cause little or no pain, and,
except to diagnose very late complications, anaesthesia should never be
employed, as it will relax all muscles and thus defeat our object.
Pain, while usually present in some degree locally, yet is most com-
plained of about the knee, over the patella, or upon the inner side of the
thigh. Especially is it referred to these parts when the disease is located
in the femoral head. The mechanism of this referred pain is not clearly
understood, but, undoubtedly, the proximity of branches of the obturator
distribution in part explains it. There are no referred pains at first, when
the process primarily involves the synovial membrane, but local pain
from capsule tension is severe and constant. When the capsule is tense
there is much tenderness in the groin and above the great trochanter.
Sudden ceasing of long-continued severe pain indicates that the capsule
has given away and the fluid joint contents have escaped into the sur:
rounding tissues. Night starting and sudden cryings out (ostitic cry)
during sleep or waking moments are common, being due to the muscles
having, during sleep, relaxed their vigil only to assume rigidity again
suddenly and painfully as the child awakens. Pain, both locally and
referred, is increased by inward pressure upon the great trochanter;
Pounding the heel or flexed knee is a very crude and valueless method
of developing hip tenderness. Patients suffering acutely from hip-joint
distention occasionally can gain more relaxation of capsule and quietude,
hence comfort, by crossing the knee over the sound thigh or by hugging
it upon the abdomen or chest. e
Swelling is early and most noticeably developed in the synovial variety.



TU B E R C U L OSIS OF HIP - J O IN T. 463
Great heat and redness do not, as a rule, accompany it, except in acute
tuberculous abscesses of the joint or surroundings, but more or less local
rise of temperature is present... Swelling is most apparent in the groin,
where the inguinal glands will be very prominent, about the great tro-
chanter, and, in a minor degree, in the buttock, and about the joint
generally. *
Muscular Wasting or Atrophy early sets in and involves the joint sur-
roundings and the entire limb. The proportions (even length, as the
bones participate) of an affected limb will never
again equal those of its fellow. Comparative meas- FIG. 273.
urements of the calves and thighs will demonstrate
the presence and amount of atrophy, Wasting of
the gluteal muscles, together with the swelling in
that region, flattens and broadens the buttock, shal-
lows or obliterates the natural crease or fold and
creates a deviation of the internatal line toward the
sound side. To observe gluteal changes the patient
is stood naked on a table, his back to the surgeon.
Compensating Postures.—Continued hip disease
from muscular tension in time gives rise to a lateral
curvature of the lumbar spine and compensating
curve in the dorsal region. This, with abduction of
the thigh, makes the leg appear lengthened. But Diagram showing
until great bony destruction, or actual dislocation flattening of buttoº
of the joint occurs, changes in length of the limbs and lowered position
do not occur, except rarely, when great distention of gluteal crease on
of the capsule forces the femur away from the ace- diseased side.
tabulum and produces moderate lengthening. Care-
ful measurements of the position of the trochanter will prove its position
to be unchanged in most cases. Apparent changes in the length of the
limb are simply the result of compensatory postures, which permit loco-
motion without motion of the affected joint.
Déſormity, up to the later stages, is purely muscular. But when the
capsular and other ligaments are destroyed, and especially when, in addi-
tion, the head of the femur has been shed into the joint, or both head,
neck, and the margins of the cotyloid cavity have been eaten away, dis-
19eation of the femur upon the dorsum ilii is very apt to take place
through influence of continued muscular action. Pain then ceases and
the limb becomes, from spasm or inflammation of the adductor muscles,
adducted and inverted. When both hip joints become thus dislocated
the legs are crossed in adduction, and produce what is called “scissor leg”
deformity. . Dislocation is determined by the position of the trochanter,
gharacteristic deformity, and actual shortening. Accidental force applied
in the length of the limb may drive the femoral head or neck through
the floor of the acetabulum if the latter is much diseased and eroded.
Occasionally it becomes entirely destroyed, and the femur slips into the
pelvic cavity without aid of outside force.
4bscess is a very frequent, generally inevitable, symptom and compli-
Sºtion. Neglected cases almost invariably suppurate. It may, or may
* Produce constitutional disturbance unless septic infection take place,
When hectic and some degree of exhaustion are certain to follow. Ab-
*ses may slowly develop and be circumscribed by the capsule. Or it
*Y Supervene with rapidity and give rise to great suffering until the
*Psule ulcerates or ruptures. Then the abscess contents escape into sur-

464 DISE ASES OF JOINTS, CA RTIL AGES AND LIG AMENTS.
rounding structures and, perhaps, give rise to multiple foci of suppura-
tion or a diffused abscess. In either case the pus, earlier or later, finds
its way to the surface. It is supposed that certain abscesses may form in
the inflamed joint surroundings without rupture of the capsule. Abscesses
which point below Poupart's ligament are most common and come directly
from the joint. Those which appear above that ligament find their way
through the acetabular floor into the pelvis, and thence to the surface, or
into the rectum, bladder, or intestines. Either variety, however, may
point in the gluteal or ischio-rectal regions. The latter must not be mis-
taken for simple ischio-rectal abscess or fistula.
DIAGNOSIS.—By application of the above given diagnostic signs of hip
tuberculosis, and of those of the respective diseases which follow, it may
be distinguished from rheumatism, spinal or sacro-iliac disease, psoas or
iliac abscess, periostitis of the upper femur, simple extra-articular abscess,
spastic paralysis, and injuries or displacements of the femur.
TREATMENT should be begun when disease is but suspected, and before
unequivocal signs are present. The fundamental principles of treatment
are: to build up the general health by such measures as have elsewhere
been indicated, and to secure absolute rest for the joint until all acute
symptoms have vanished. Great deformity and suppuration will occur
unless treatment is thorough and early.
To secure the necessary repose, the patient must be kept strictly upon
his back in bed, with pulley extension and lateral sand-bags. He must
not be allowed to sit up in bed. If necessary, a sheet across the chest or
FIG. 274.
# º
* #
Hºſſ
# sº------- * *------. §º-º-º-º-º-º:
Pxtension of the limb in a flexed and adducted position. (MARSIT.)
under the arm-pits, and tied to the sides or head of the bed, must be em-
ployed. If extension with the limb flat upon the bed produces pain or
spine-aching, then the direction must be in the line of the flexion over a
wedge-shaped pillow. Extension in the usual manner, in these latter
cases, produces great intra-articular pressure by dragging upon the psoas
and iliacus muscles, which act as the fulcrum of a lever.
After this extension at the angle of deformity has been kept up some
time the limb can, from day to day, without pain or resistance, be
brought to better position and, finally, into the axis of the body. During
extension the foot must be supported laterally and vertically to prevent













T U BE R C U L OS IS OF HIP- JOINT. 465
consecutive deformity; to the same end and to prevent atrophy, massage
of the limb, without motion of the joint, should be employed. A cradle
to hold the bedclothes from the limb is also
desirable. Counter-irritation about the hip FIG, 2.75.
by blisters is of value in acute stages, and
will often relieve pain. Excessive pain from
joint distention can be at once stopped by
aspirating the joint. The needle should
be introduced through the gluteal, not the
inguinal region, becaue of proximity of
vessels in the latter locality. Pain can often
be moderated by simple change of position,
or of the direction of extension.
Extension, as above described, must be
kept up, perhaps for many months, until
all acute symptoms have vanished and the
thigh is in the body axis. Then the patient
may gradually be allowed to get up, but
must constantly wear a Thomas's, or other
immobilizing apparatus, and still sleep with
the extension apparatus applied.
The removable extension apparatus of
Morton (Fig. 276) is the most convenient for
the latter purpose. When the disease has still
further progressed toward cure, night exten-
sion may be omitted; and when motion has
become normal, or when consolidation of
the hip is complete, the splint can be ten-
tatively left off. Six to ten weeks will be
consumed in the cure of even the most
favorable cases. Non-use of the joint, alone,
will never produce stiffening which cannot
afterward be readily overcome. |
Late stages of the disease may also de-
mand extension or splints to prevent or = }
reduce the shortening, dislocation, or other º
deformity. Forcible reduction of deformity * ||
is not justifiable at any stage, nor should Thomas' hip splint.
tendons or muscles be divided except in
º * where they impede function or have become hopelessly com-
l'a,CLéCl.
Abscesses need not be interfered with unless they produce pain or con-
stitutional disturbance, or show tendency to open spontaneously. Then
they should be freely incised, curetted, irrigated, drained, sutured, and
Protected from septic infection by proper dressings. Abscesses which open
themselves, or are surgically infected, at once set up hectic, and are very
ºpt to lead to such changes in or about the joint as to necessitate sub-
$9%uent excision or amputation. Abscesses which open above Poupart's
ligament, or into the pelvic contents, are almost hopeless affairs, as they
indicate pelvic bone involvement, which is practically unamenable to
known treatment.
Pxhaustion from continued suppuration may demand excision of the
head of the femur and extirpation of the joint and infected surroundings.
This may effect cure if all, or almost all, disease can be eradicated.




30
466 DISE ASES OF JOINTS, C A RTIL AGES AND LIGA MENTS,
Otherwise, the patient will probably succumb to the effects of prolonged
suppuration, or die of systemic tubercular complications. In suppurating
cases, consolidation (usually inseparable from great deformity) is all that
we can hope for; under the circumstances even that result must be con-
sidered good, though years may be consumed in its attainment. If the
disease has travelled along the shaft of the femur, or osteomyelitis has
developed, amputation will be the patient's only chance for life. If the
joint has become ankylosed in an awkward position, no treatment for its
correction should be undertaken until the last traces of disease have long
since disappeared. Then one of several operations may be employed:
FIG. 276.
Morton’s extension apparatus.
The neck of the femur may be divided by introducing an Adams saw
through a small incision immediately above the great trochanter and
carried down until the neck is touched. After division of the bone and
any resisting muscles or fascia, the extremity is brought into the axis of
the body, and either in that position treated as a fracture of the same
region, or, as soon as the wound has firmly healed, at once starting active
and passive movements that a false joint may be established. Very fair
position and function result from the latter procedure, or, if dislocation
does not exist, the osseous material interposed between the acetabulum and
femur may be divided similarly. A chisel should never be used for these
purposes on account of the inevitable traumatism and splintering which
are thereby produced. Excision of the head of the femur and division of
resisting structures will also give equally good position, but with greater
shortening and more uncertain function.
Dislocations resulting from hip disease can never be permanently re-
duced. Attempts thereat are very dangerous, and should not be considered.
When a patient does not rally under treatment, but continues to lose
ground, and especially when from continued suppuration, excision of the
joint is clearly indicated; but, as operation in these stages is excessively
dangerous, the chances of life with or without surgical interference must
be most carefully balanced. Whenever large sequestrae or the separated
femoral head can, by probe or finger, be felt, they should be removed by
incision and the surroundings within reach curetted and washed out as
thoroughly as possible.

SY PHILITIC A R T H R ITIS. 467
PROGNOSIS.—Even in cases cured with good function some atrophy and
consequent shortening will remain and the limb will never quite catch up
to the other. Interference with the upper epiphysis makes this more
marked. Cure with stiffening and deformity should be considered a good
result in more advanced cases. The joint may suppurate, apparently
hopelessly, for even years and then consolidate. It is never safe to say that
any case cannot recover without operation. Amputation can sometimes
be done with comparative safety when the risks of excision would be too
great. Excision is often necessary in advanced stages. Months and years
are often necessary to cure completely a well-marked case; eighteen
months may be called the average duration of disease. Relapses are
frequent, particularly should the patient be subjected to exhaustive con-
ditions, or bad diet or hygiene. Other joints may become involved.
Many cases succumb to intercurrent tuberculosis or other complications.
Prognosis should always be most guarded.
Syphilitic Arthritis.
Syphilitic arthritis is a frequently overlooked disease, which is almost
limited to adults suffering from tertiary syphilis, but may be developed in
congenitally syphilitic children.
During the later manifestations of syphilis the deep layers of the
synovial membrane of one or more joints becomes infiltrated and swollen.
This thickening extends to the sub- and superjacent structures, usually
taking the form of innumerable vari-sized gummata. The endothelial
layers of the synovial membrane are never primarily involved, but are
FIG. 277.
N.
gº tº
§: A \,{} ...Y *WS
#lºº
w ſ.ſº, ºgº
ſº g § % * & º:42
º º 7| • • { 2 tº,
Žnº ſiſ? J. f. r.
º ſº
Alſº 4 § § . 3.3 §:
ſ # |! ºf '...}. * § • ?
|
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Syphilitic arthritis of the knee-joint, showing thickened sub-synovial tissue and
inflamed bone. (MARSH.)
bulged intº the joint cavity by the new growths pressing from beneath.
º fusion, if present, is always slight. The disease in its earlier stages much
*mbles other subacute affections of like situations, when gummata
º developed, however, the diagnosis is evident, for they can often be
* Which, with the general Spongy feeling of the joint, symmetry of the















468 DISEASE S OF JOINTS, CARTILA GES AND LIG AM ENTS,
joint involvement, perhaps slight pain, creaking, and effusion, makes the
real nature of the case plain. Extension, rest, counter-irritants, and anti-
syphilitic remedies embrace the necessary treatment, to all of which, how-
ever, the disease will often prove most obdurate. Firm, fibrous adhesions
may remain after absorption of the gummata and more or less cripple
the articulation, or, more rarely, the modules may soften, suppurate, and
discharge into the joint cavity, giving rise to purulent arthritis.
Syphilitic arthritis also as frequently invades a joint from the bone
ends. Specific arthritis enlarges the bone extremities, giving rise to all
the symptoms of syphilitic ostitis elsewhere, and the joint is speedily in-
volved in suppurative destruction, which proves rebellious to all save
heroic surgical measures such as excision, or even amputation.
Osteo-arthritis (Arthritis Deformans).
Osteo-arthritis is a form of chronic arthritis which is almost limited to
later life, being disposed to by constitutional depravity and excited by
diseased conditions of the proximal bone-ends or synovial membranes, and
traumata.
FIG. 278.
º, y
g º jº | }º
ºğ. §
§§ ºft |
º 7 º’ ºffº.
º
| - º º ºf ſº -
§
it.
-
Changes in hip-joint dependent upon osteo-arthritis. (MARSH.)
The disease commences in the articular cartilages, which rapidly lose
their smoothness and pearly color, become of a yellowish tint, and
wear away at the points of pressure contact, even into the cancellated
structure of the subjacent bones, whilst at places, such as ligament and
muscle attachments, where no pressure is brought to bear, cartilage hy:
pertrophy and thickening occur and give to the joint a characteristic
deformed appearance. One or more of these nodules may subsequently
become isolated and become “loose bodies” in the joint. Later the
synovial membrane becomes thickened and exceedingly vascular. At
this stage effusion may appear, but is not inevitable: marked distention
is always transitory; occasionally slight effusion may last throughout, but
as often it will entirely disappear. Now the cartilaginous outgrowth;

A T R O PHIC A R T H R ITIS. 469
begin to ossify, and from the wearing down of the bone the joint surface
becomes broad and at the same time extremely mobile by the consequent
relaxation of the surrounding ligaments and other tissues, which them-
selves at this stage have become softened, atrophied, or even destroyed.
Displacements of the bones composing the joint usually, at this stage,
takes place, and great deformity results. Such displacements constitute a
variety of so-called “pathological dislocations,” and are due to the con-
tinual activity or spastic contraction of the neighboring muscles after the
joint structures have been so weakened as not to be able to resist their
displacing action. Ankylosis in any position may finally end the altera-
tive process.
The first symptoms of osteo-arthritis are dull, aching pains in the joints
shortly followed by pain and creaking upon motion. Subsequent symp-
toms depend greatly upon the rapidity with which the particular case
may progress. The disease may run its full course in a few months or
continue indefinitely. Frequently it has had origin in some form of in-
jury, and without the exercise of great care in diagnosis deformities pro-
duced by the arthritis may readily be mistaken for neglected fracture,
dislocations, or other injuries. Treatment of this form of arthritis, un-
fortunately, will almost always prove unavailing. Those measures which
are best calculated to improve the general physical condition are always
to be applied, together with massage, hot and cold douches, and perhaps
counter-irritation locally. Excessive deformity can usually be prevented
by splints, extension, plaster bandages, and division of tendons.
Atrophic Arthritis (Charcot's Disease).
Atrophic arthritis is a retrograde arthropathy which may develop in
the later stages of locomotor ataxia. Etiologically, it is directly de-
pendent upon those changes in the central nervous system which are
present in ataxia, and most likely due to interference with trophic
nerves. In its early manifestations the disease much resembles osteo-
arthritis, but later runs a very distinctive course. The presence of a group
of ataxic symptoms would always settle the diagnosis in favor of atrophic
arthritis.
Beginning in any joint or number of joints, but usually in the knee,
the synovial membrane is thickened, and some effusion is poured out;
grating with some pain and disability supervene and ostitic thickenings
begin to form, Later, pain almost disappears, great absorption of contact
points of the bones takes place, and wide separation of articulating
surfaces with great resultant deformity occurs. The ligaments have by
this time become greatly stretched and disintegrated; but a most sur.
Prising and diagnostic symptom is the preservation of more or less loco-
inotive function of the joint until a very late stage of the disease. Ostitic
fºrmations are much less marked in atrophic arthritis than in osteo-arthri-
tis, but erosion of the bones is markedly greater in the former.
Months and years are usually required for the joint symptoms of ataxia
2 run their course, but occasionally instances are met with where but a
few months are necessary to carry the process to its utmost limit. No spe-
°ial local treatment can be recommended ; our efforts should be toward
removal of the cause.
470 DISE ASES OF JOINTs, C A RTIL AGES AND LIGA MENTs.
HYSTERICAL AND NEURALGIC JoſNT AFFECTIONS.
These may be classed together, as both are purely subjective disorders.
Though not identical they are frequently exceeding difficult to differenti-
ate. Females more often than males are affected. In the hysteroid affec-
tion pain may be complained of out of all proportion to other symptoms,
perhaps combined with voluntary or involuntary fixation. Slight swell-
ing of the joint may supervene, owing to increased vascular tension there-
about, but more often the peculiar avascular condition of hysteria will
render the joint pale and bloodless.
Hyperaesthesia, either local or general, will be present; pain may be
definitely located or shift its position.
The joint can always be freely moved under ether, often also when the
patient's attention is diverted or under application of extension when
long continued; false ankylosis and muscular wasting may take place.
Symptoms are mostly anomalous, varying, and inconsistent, and apt to be
but a single group in an hysterical aggregate.
Great caution must be observed, and close watching and repeated ex-
aminations resorted to before positive opinion of these cases is expressed.
Treatment of these neurotic joint affections should include special
attention to the general health as well as the judicious use of massage,
electricity, anti-neuralgics, and anti-periodics; possibly counter-irritation,
prolonged extension, and occasional movements under anaesthesia.
ANKYLOSIS.
By ankylosis is meant that condition of a joint free from active disease
in which motion has become restricted or abolished.
When all motion is impossible ankylosis is complete; when partial mo-
tion remains or can be developed, incomplete.
Ankylosis may be true or false; true when the bones of the articulation
have grown together by cancellated bone structure; and false when the joint
is impeded by fibrous adhesions, situated within or surrounding its capsule.
True ankylosis or osseous consolidation is also called synostosis. The con:
dition is not in itself a disease, but is the result of prečxistent disease, and
the term ankylosis should not be applied to the usual coincident stiffness
of inflammation.
In true ankylosis the joint as a joint is destroyed, the cartilages have
disappeared over more or less of its area and the cancellated tissue of bone
ends has grown together. True ankylosis, therefore, cannot take place
until cartilage and its subjacent bone layer have been destroyed upon the
surface of the joint. This may be accomplished by disease or by the Sur-
geon, as in the complete bony ankylosis which follows a successful excision
of the knee.
The uniting bony substance may be extra- as well as intra-capsular, but
the extra-capsular portion is usually nothing more than a calcification of
ligaments or other surroundings, which is common to either variety. The
joint cavity is generally totally obliterated before any bony union takes
place. The true variety of stiffening always is caused by either fractures
or long-continued destructive inflammatory disorder.
False or fibrous complete ankylosis may be due to either of the above
causes, to trophic changes, to organization of tuberculous or other dis-
ease products, or to non-use of the articulation for a long period of time
A N K Y LOSIS. 471
after injury or disease. The greater proportion of all joint restriction
results from injury, when insertions of tendons are stretched or torn, the
capsule lacerated, and blood or lymph effused. These products subse-
quently organize and bind folds of the capsule as well as surrounding
parts together and motion, becomes impeded and painful or impossible.
Fibrous bands may also form connecting the joint surfaces. If these
adhesions are not early interfered with they will firmly organize and
contract or may even become calcareous. But again ankylosis of the
false variety may be complete and yet every structure of the joint remain
almost unchanged, all adhesions being extra-articular.
Impeded joint-motion from outside cause, such as muscular spasm,
hysteria, burns, cicatrices, etc., is termed “spurious ankylosis,” but may
result in false ankylosis through contraction of and wasting of the joint-
structures from long-continued inactivity. Nerve injury also may thus
give rise to spurious ankylosis, especially when small joints are concerned.
DIAGNOSIs of the variety of ankylosis can usually be made from the
history of the case, but sometimes differentiation will be found impossible.
Except in trivial cases, all manipulations should be made with anaesthesia.
If the slightest motion remains the case is not one of bony consolidation.
If judicious force under ether fails to produce movement, the case had
better be considered one of bone variety rather than subject the part to
dangerous manipulation, for with such firm adhesion the exact diagnosis
would be of little aid in treatment.
TREATMENT of ankylosis is extremely important and successful if
properly apprehended and applied. It 'should always be instituted as
early as possible, but never while the slightest heat or redness of the part
persists, but a moderate degree of swelling may be ignored. Manipulation
is of what treatment mainly consists. If this is productive of pain (and it
practically always is) nitrous oxide or ether anaesthesia should first be in-
duced. No great force is ever justifiable,
FIG. 279. nor should a known case of true ankylosis
ever be subjected to manipulation. If, with
moderate force, adhesions are felt to break,
the joint should gradually and gently be put
through its range of motions, but manipula-
*
2*
ºv.
==== :2:
Modified Stromeyer splint for Modified Stromeyer splint for ankylosis of elbow.
amkylosis of knee.
* ~
§§§ºss->
º
3%
- º
* never be kept up more than five or ten minutes at one sitting.
**quires considerable force and the adhesions seem very tough and





472 DISE A SES OF JOINTS, CA. RTILA GES AND LIGA MENTs.
strong, the outlook is not favorable, and after a few unsuccessful seances
this form of treatment should be abandoned, as also should it be given
up if after each manipulation there is a return of inflammation. This
latter complication, however, is liable to follow once or twice in any
case and should be prohibitory only when frequently repeated or severe.
When it does occur, no further manipulation should be attempted until
the parts are again free from abnormal heat.
Certain varieties of stiffness can be manipulated every day or two,
others may require a longer interval. Between times motion may be pre-
served by means of extension, splints, or the Stromeyer screw. (Figs. 279,
280.) Movements should be kept up until the joint regains its former
motions, or until no further improvement can, by this means, be obtained.
Without securing motion, a fibrous ankylosis at an inconvenient angle
may, by manipulation, be changed to one of more comfort or utility.
Where tendons have contracted, or are in unrelieved spasm, they should
be divided as a preliminary to passive motion; their division alone will
accomplish little or nothing.
When a joint has been extensively diseased, as in tuberculosis, manipu-
lation is useless and dangerous, but where adhesions are recent it is most
successful, and especially so when the trouble is mainly resident in the
peri-articular structures.
Where fibrous ankylosis has become very resistant and firm, nothing
except the knife or chisel should be used to separate the adhesions.
Bony ankylosis, if it is thought expedient or necessary, may like.
wise be treated by driving a chisel or saw through the line of union if
the connecting and surrounding tissues are healthy; otherwise, or when
there is great displacement or deformity, excision of the joint or osteotomy of
one or the other, or both of the proximate bone shafts would be preferable;
more especially at the elbow, knee, and hip.
Recurring ankylosis, if troublesome, may demand either division of
tendons or excision of the joint. Many cases will require a brace for
Some time after practical recovery, plus, perhaps, extension at night,
(See Osteotomy; Excision of Joints.)
LOOSE BoDIES IN JOINTs.
These are not of uncommon occurrence, and consist of entirely loose or
pediculated masses of varying size, which only demand attention when
they impede function or cause pain.
FIG. 281. They arise from : 1, condensed fibrous
exudate; 2, organized blood-clot: 3,
broken osteophytes, as in Osteo-arthri-
tis; 4, actual foreign bodies, as bullets
or needles, either encrusted or not :
5, pieces of articular cartilages, with:
perhaps, sub-adjacent bone, broken of
or exfoliated into the joint cavity; 6,
hypertrophied and hardened portions
of the synovial membrane; 7, irritative
development of cartilaginous cells em.
*>Nº. V) bedded in the deep layers of synovial
Trochlea of humerus, showing for. membrane. º
mation and connection of loose bodies The first four classes are never pedi-
developing from synovial membrane, culated; the last three frequently are:
(MILLER.) the seventh is always so at first. In the

I N J U RIES OF J O IN T S. 473
latter class, owing to severe irritation, one or more of the depots of in-
active cartilage cells, which are to be found studding the deep layers of
articular cartilages, take on active growth, press forward the layers of
membrane between them and the joint cavity, and become prominent as
minute nodules. Combined growth and the movements of the joint Soon
stretch their attachments and they become pediculated, which connec-
tion is apt to be snapped during some motion of the joint, and the now
unattached bodies float free.
Loose bodies almost never are found in other than hinge joints, and
nearly always in the knee. They may be single or in great numbers,
according to their mode of origin.
SYMPTOMs arise when the bodies get caught between articulating sur-
faces. Commonly they become so caught for a second, and at once slip
out again. In either case the symptoms only vary in degree and duration.
When the accident takes place the joint surfaces are forced apart and
bruised or scratched, and the ligaments are put upon a severe stretch, the
joint locks, and if it be the knee, the person is thrown to the ground in
great agony, sick and faint. If the body slips out again, pain and other
symptoms instantly cease, until the accident again takes place. Other-
wise symptoms persist until relieved by the surgeon. Very rarely, a joint
becomes locked in this way without pain. Any variety may be followed
by synovitis, but this is not common or serious except in joints already
diseased or predisposed thereto. Frequently recurring entanglement is
apt, in time, to originate chronic synovitis with persistent effusion.
Bodies can usually be felt beneath the joint covering, more or less defi-
nitely fixed in position; but sometimes cannot be felt, or disappear from
touch for a time, or upon motion of the joint, and reappear either errati-
cally or upon certain motion or manipulation—as a rule, best understood
by the patient himself, as, indeed, is often the best method of unlocking
the joint.
Contrary to the case where dislocation of joint cartilages, such as the
semi-lunar, has taken place, loose bodies usually lock the articulation in
anomalous positions. The history, method of occurrence, and, perhaps,
palpable presence of the loose body, will furnish enough evidence for
differential diagnosis.
Such manipulation as each individual case, or the patient himself, may
suggest, will unlock most joints. If this fail, nothing short of exploring
the joint and removing the offending body will avail. Often wearing a
brace or pad will prevent frequent joint-locking by securing the body in
one position, or by restricting certain movements of the joint which invite
the body between articulating surfaces.
If the distress therefrom becomes great, the bodies should be removed
Y incision. To do this it should be firmly secured before anaesthesia by
Pressure of a finger or strap, or better, by transfixion with an aseptic pin
or needle. If this precaution is not taken, the body will often have dis-
*PPeared beyond reach into the joint when the incision is made over its
former site. If the bodies are numerous, or cannot be brought near the
Surface, nothing short of exploration of the joint and the removal of all
Present in or around it will avail.
INJURIES OF JOINTs.
92ntusions of joints call for no other treatment than rest and evaporat-
ing lotions. Succeeding complications, such as inflammation or abscess,
* to be treated as elsewhere described.
474 DISE A SES OF JOINTS, C A RTILA GES AND LIGA MENTs.
Sprains.—Contusing injuries usually accompany or complicate sprains,
which may be defined as a condition of more or less stretching, bruising,
or laceration of the contents or immediate surroundings of a joint, and are
always the result of forcible motion of an articulation beyond its range of
function, or in a direction contrary thereto; in fact, sprains are mild
varieties of dislocations. The causative force may act directly or indirectly.
The hinge-joints are those usually affected. In the milder forms the sur-
rounding ligaments or tendon insertions may be simply stretched, and a
few vessels of, or the synovial membrane itself, be lacerated. This is fol.
lowed by an intense hyperaemia of the entire joint and surroundings,
especially of the subserous vessels of the synovial membrane, which often
leads on to synovitis; rarely to the suppurative form and to arthritis,
unless the subject is tuberculous. Swelling and Oedema quickly set in
and effusion rapidly distends the joint cavity. This exudate may become
plastic and even involve surrounding ligaments and tendon sheaths.
Hemorrhage into the joint may take place.
SYMPTOMS.—The injury is accompanied with intense sickening pain,
perhaps vomiting and shock, and more or less disability, according to
the extent of injury. The joint almost immediately swells and becomes
hot, and soon begins to throb with dull pain. The limb will be found
in that position which permits least tension in the joint. Motion is
exceedingly painful, and if ligaments are extensively torn, is anomalous.
If diagnosis cannot be readily made without much manipulation, anges-
thesia should be induced. Differential diagnosis from fracture, even
under ether, is often difficult; sometimes, as at the wrist and ankle joints,
impossible. Wherever this doubt exists the case should be treated as for
fracture. Strict adhesion to this rule will save many an unfortunate
result. f
TREATMENT.—The case seen early—within an hour or two—and diag:
nosis established, a sprained joint should be plunged into either very cold
or very hot water, and there allowed to remain twenty or thirty minutes,
until the bloodvessels about it have thoroughly contracted. Swelling,
effusion, and inflammation are thus prevented. It is then elevated and
firmly bandaged from below upward. The extremity is to be kept thus
bandaged and elevated for twenty-four hours, when a plaster or other
snug-fitting dressing should be applied, and he may then be allowed to sit
up. The cast is to be renewed as swelling goes down, and left on from
one to three weeks, according to the extent of the injury. Passive motion
and counter-irritation by liniments, or otherwise, may then be necessary,
or a supporting brace may become advisable. ſº
If, however, the sprain does not come to hand until swelling, effusion,
or inflammation has set in, success with the bath will not be so marked,
and hot, cold, or evaporating lotions, the ice-bag, and perhaps poultices and
counter-irritation will take the place of tight bandaging until swelling
goes down sufficiently to justify the plaster dressing.
WOUNDS OF JOINTs.
Wounds of joints are of two classes; those opening the joint through
the integument, including such accidental wounds as lacerated, incised,
punctured or gunshot, and the premeditated ones of the surgeon; and
those attacking the articulation from beneath the integument, such as fº
W O U N DS OF JOIN T S . 475
tures and dislocations. The latter class may communicate with the air and
likewise become, as are all those from without, open (compound) wounds.
All open wounds of joints may be, or become, septic or poisoned from
outside influences; but closed joint wounds can only become infected or
septic from the blood, by sloughing of their coverings, lymphatic conduc-
tion, or from rupture of the deep glands of the skin.
DIAGNOSIS.–Closed wounds of joints have been discussed under other
headings, and need not further concern us here. Open wounds in the
neighborhood of joints now have comparatively few points of diagnosis or
differential diagnosis capable of puzzling the surgeon, because the very
mode of treatment establishes the exact nature of the wound. That is, all
wounds must be thoroughly cleansed. Hence wounds near joints are to
be opened up to their bottom, if at all deep, and incidentally their nature
is thus established. The danger of mistaking serious for trivial injuries
until sepsis sets in is thus avoided. Joint wounds may be palpable from
their extent, display of cartilage, flow of synovial fluid, or be made so by
exploration.
If the case is old, a wound which has entered a bursa and set up Sup-
puration must not be mistaken for articular involvement. To avoid such
mistakes, even in cases where there seems to exist no doubt that the joint
is involved, it should not be laid open before penetration of its cavity is
proved.
Early reached and properly treated, uncomplicated open joint wounds
should almost always progress favorably to perfect cure, with unimpaired
utility. But if infection has taken place and suppuration set in, the case
is one of utmost gravity. (See Acute Purulent Arthritis.)
TREATMENT.-Any wound or open fracture near a joint should be re-
garded with extreme care and suspicion. The surrounding parts should
be cleansed and the wound then investigated. If the wound stop before
entering the joint it should be cleansed, sutured, and the limb be put upon
a splint until fairly healed. But if a probe or the finger carried in enters
the joint, or, this failing, the wound has been laid open and proved to
penetrate, the opening into the synovial cavity should be made sufficiently
large to wash out the joint thoroughly with 1:1000 corrosive sublimate
solution.
. The articulation having been freed from foreign matter and the syno-
vial membrane and integument separately sutured with chromic catgut,
* dressing and splint are applied and left for three weeks, when
Passive movements are to be commenced. Subsequent local or constitu-
tional signs of inflammation in the joint will indicate immediate re-open-
*š, Irrigation, and possibly curetting of the cavity, and the introduction
of ºrubber drain-tube to the bottom of the joint.
. Violent septic arthritis must be met with free incisions, curetting, wash-
*g, and gauze packing of the entire joint. Or, if these measures fail, and
Without resorting to them in aged or broken-down individuals, excision
**mputation must immediately be performed.
: "Pº", or compound dislocations are to be cleansed, reduced, the joint
**ted, usually a drain-tube introduced, the synovial membrane, torn
*nts, etc., sutured as far as possible into normal position and the
Outer wound united.
mi reduction cannot. be effected, even after free incisions have been
aCie, the end of the dislocated bone must be excised.
o. a splinter of an open fracture will wound a joint situated a
8 *tance from the original injury. Especially is this apt to occur in
476 DISE A SES OF JOINTS, CARTIL AGES AND LIG AM ENTs.
longitudinal fractures of the upper tibia. Proper treatment of the open
fracture would, however, eliminate danger from the joint opening, but a
septic condition of the fracture will almost invariably be followed by dire
consequences to the knee, and perhaps kill the patient. Open and com-
municating fractures involving a joint demand prompt exploration of the
same, removal of fragments, blood, etc., or excision, or amputation, ac-
cording to circumstances. Precisely the same is to be said for gunshot
wounds involving joints; if the joint surfaces are only grooved or cracked,
however, washing out and drainage will alone be required.
In all cases of joint injury rest and immobilization for weeks must be
insisted upon.
If effusion, swelling, and disability persist after healing of a joint
wound, active counter-irritation, a rubber bandage, massage, or some form
of supporting apparatus must be employed.
(See Chronic Arthritis, Chronic Synovitis, Ankylosis.)
DISLOCATIONS.
DEFINITION.—A dislocation or luxation is a violent displacement of
a bone from its normal relation with another bone at the place of mutual
articulation. The term dislocation is similarly applied to an intra-articular
fibro-cartilage when it has been displaced from its normal position. It
will be seen that I limit the term to articular displacements due to trau-
matic or muscular violence, as I regard the so-called pathological or spon-
taneous dislocations as mere symptoms of other diseases, generally arthritis
or paralysis of muscles, and the congenital dislocations instances of malfor-
mation from arrest of development or foetal disease. I admit the possi:
bility of congenital dislocations being sometimes due to violence received
by the foetus in utero, but such a bare supposition does not warrant the
application of the term dislocation to conditions which resemble other con-
genital arrests of development. The term “old” is applied to dislocations
which have not been reduced for some time after their occurrence. The
definition, it will be observed, is quite arbitrary and ambiguous, and no
rules can be laid down to demark the exact time when an acute disloca-
tion becomes one of this class. Thus a dislocated elbow is commonly spoken
of as “old” when it has remained unreduced for three weeks, and a sim-
ilar persisting lesion at the shoulder joint assumes the term when it has
existed from four to seven months. e
That bone which is more remote from the trunk is the one which is said
to be dislocated. Thus dislocation at the hip is called a dislocation of the
femur, not of the innominate; dislocation at the knee is termed a disloga-
tion of the tibia, not of the femur; and dislocation of the ankle is de'
nominated a dislocation of the tarsus. The displacement of the bone
may be in various directions; thus, backward, forward, upward, down-
ward, or laterally. Each joint is liable to sustain dislocation in certal"
directions rather than in others, this tendency being due to the shape
of the articulating surfaces and the manner of muscular and ligamentoº
attachments about the joints.
Dislocations at amphi-arthrodial joints, such as are found between 09"
tiguous vertebral bodies, at the pubic symphysis, and between the $88.
ments of the sternum, are sometimes called diastases. I prefer to Tºri"
the term diastases to epiphyseal fractures, and to apply the words dislo"
tion and luxation to these as to other joints.
I) IS LO C A TI O N S. 477
A dislocation is complete when no portion of the articular surfaces
remain in contact. Complete dislocations are rare in hinge-joints, but
common in ball-and-socket articulations, Incomplete or partial disloca-
tions, often called subluxations, are luxations where the displacement is
not sufficiently great to cause loss of mutual contact between portions
of the articular surfaces. As in fractures so in dislocations, the lesion
may be complicated. Laceration of soft parts, rupture of large vessels
or of nerve-trunks, fractures involving or not involving the joint-cavity,
and similar accompaniments, constitute the complications that make the
term complicated dislocation applicable. When an external wound leads
to the seat of dislocation the injury is called an open dislocation, in con-
tradistinction to one not so exposed to the entrance of air, which is a
closed dislocation. The terms “compound ’’ and “simple * are as unde-
sirable here as in connection with fractures, and I have accordingly
employed the better terms, “open’ and “closed.”
When a dislocated bone has its primary position altered by efforts at
reduction, involuntary muscular action, or other cause, a consecutive or
secondary dislocation is said to exist. For example, an iliac dislocation
of the head of the femur may be converted into a sciatic dislocation; the
latter would then be called a consecutive or secondary dislocation, the
former a primitive or primary one. t -
CAUSEs.-The predisposing causes of dislocation are relaxed or stretched
ligaments, muscles weakened by paralysis or atrophy, old tears in the
ligamentous capsule, and imperfections in the socket from either accident
or disease, and such relation of the normal articular surfaces and liga-
ments as will readily permit displacement. The greater the normal
freedom of motion, and the more exposed the joint is to accidental blows,
the greater is the tendency to suffer dislocation. Hence the prečminent
frequency of luxations of the head of the humerus. Dislocations at the
elbow occupy in point of frequency the position next to dislocations at the
shoulder, which are the commonest of all luxations. Certain positions of
the bones at the moment of receipt of injury tend to allow the occurrence
of dislocation. Thus a blow on the chin is more apt to dislocate the jaw
if the mouth is open at the time; so axillary luxation of the head of the
humerus is more readily produced when the arm is abducted and elevated.
The exciting causes of dislocations are external violence and muscular
Contraction. The strength of the ligaments surrounding the joint and
their disposition in relation to the direction of the applied force will often
determine the direction of the dislocation and also the character of
the injury; that is, whether it shall be a fracture or a dislocation, or
both ; for violence will usually either break or luxate, according as the
force drives the bone toward the weak or strong portions of its liga-
mentous capsule. External violence may exert itself directly upon or
near to a bone or joint, or indirectly as when applied at a distant point or
extremity of a bone or limb, the intervening bone or bones and their
attachments acting upon the principle of one or other of the classes of
levers to produce the luxation. Thus a fall upon one foot whilst the body
ls in an erect posture may produce a dislocation of the knee or hip, and
* Case is recorded where a blow of the fist upon the upper portion of the
humerus produced a dislocation of the head of that bone from its articular
Savity. Likewise, twisting forces are common causes of certain disloca-
º, notably those of the ankle, hip, and elbow. They are apt to occur
in this manner when one portion of an extremity is held firmly whilst
the other is given a rotary, lever-like motion, as when the foot is suddenly
478 DISE ASEs of Joſ NTs, C A RTIL AGES AND LIG AMENTs.
caught and the whole weight of the body is thus brought to bear on the
ankle-joint, dislocation will be the almost inevitable result. It is most
probable that muscles frequently lend great assistance to external violence
in the production of dislocations, for it is a well-known fact that men
whilst intoxicated seldom sustain dislocations, and that much more force
is required to produce luxations in the cadaver than in the living body.
Muscular action may give rise to dislocations suddenly, as during voluntary
motions or convulsive seizures of any description, or in a more gradual
manner, as is witnessed in certain pathological changes in joints, or as a
result, perhaps, combined with the former, of chronic contractions or con-
tractures, producing the so-called “spontaneous” dislocations. These
Causative factors are all accidental or pathological, but there are certain
persons who, through possession of loose articulations or injury, have
developed habitual dislocations, and can at will produce and likewise
replace these deformities. Muscular contraction is a very important
element in the study of dislocations, for it may increase displacement,
render the course of the displaced bone to its present final position uncer-
tain, and in some cases greatly increase the difficulty of reduction. Dis-
tention of joints by fluid renders their bony elements peculiarly liable to
displacement by either muscular or traumatic action. Fracture or unequal
growth of one of two parallel bones renders joints situated at their ex-
tremities prone to luxation, or even may directly cause that accident.
PATHOLOGY..—The pathology of dislocations is of great interest. In
incomplete dislocations little change is to be noted; the ligaments are
stretched but not usually torn and ecchymoses may be present in and about
the joint, but seldom does any momentous damage or impairment of func-
tion result. Complete dislocations, on the other hand, nearly always pre-
sent tearing of ligaments, surrounding tendons, and muscular attachments,
particularly those having origin from or insertion into the capsule itself.
If the dislocation be typical there is apt to be quite limited tearing of liga-
ments, but where extensive laceration has taken place the resulting de-
formity will usually be irregular. The capsule of a dislocated joint need not
of necessity be ruptured, but may be entirely stripped from its bony attach-
ments. In complete luxations of hinge-joints the ligaments are frequently
merely stretched, but such displacements of ball-and-socket articulations
are always attended with laceration of the capsule. This rent most fre-
quently consists of a linear slit through which the head of the bone has
been shot. It is situated, as a rule, near the rim of the glenoid cavity in
the shoulder and in the hip at the acetabular edge. A knowledge of the
probable location of this rent is of utmost importance in reduction.
The luxated bones are apt to render more or less damage to sur-
rounding structures, and muscles, nerves, arteries, fascia and skin, either
or all, may sustain injury thereby. They may be stretched, bruised,
or torn, the latter, in cases of arteries such as the popliteal at the knee or
the axillary at the shoulder, being most formidable complications.
Modern surgery has rendered open dislocations, as those involving com-
municating lesion of the skin or mucous membrane, of practically the
same pathological significance as the closed variety. In voluntary
muscular, also in certain pathological dislocations, the ligaments are
simply stretched and surrounding structures are not of necessity injured:
If the joint is quickly restored to its normal relations by reduction and
maintained at rest for the requisite time, the injured ligaments and other
structures quickly regain their normal condition, although the joint may
always be weak and more liable to future displacement than before it
DISL O C A TI O N S. 479
received the primary injury. If, on the contrary, the dislocated bone
remains in its new and unnatural situation a remarkable series of phe-
nomena take place. The margins of the now unused socket atrophy and
FIG, 2.82.
* 3: sº º 2 - * w R
º Él ; º i º w
º | § |
º
ſh;
º
§
Old unreduced suprapubic dislocation of the hip. (Cooper.)
disappear, it becomes more shallow, and finally is obliterated by bone and
fibrous material. This process will occupy in different cases times varying
from a few months to many years, and cases are upon record where no
FIG. 283. FIG. 284.
w §§
ſº N §s §§
§ $$NSS,\\
S. sº N S
§ º
Y ºS Sº
§§§
* -. ***
§ "ſº ~$s
\\ \\,\ *\" N Mººse -
WA, \ N li -
tº ! \ N tººk
\º W § \ \\ § .
&\}}
False joint resulting from unreduced dislocation of femur. (Cooper.)
especial ºhanges had occurred after a lapse of ten years and it is to be
Wººl that in these cases no change would ever have taken place.
ere the socket thus remains the synovial membranes and cartilages












480 DISE ASES OF JOINTS, C A RTIL AGES AND LIG AMENTs.
have been preserved and have resisted atrophic influences. The dislodged
head of the bone meanwhile has created a new socket or cup-shaped
depression for itself by pressure, atrophy and condensation of the struc-
tures upon which it rests. The new socket will, in time, have raised
edges, be lined with eburnated bone-like or fibrous material, which some.
times becomes covered with a membrane resembling true joint or synovial
membrane, which secretes a lubricating fluid having many of the
physical attributes of true synovial secretion. A species of capsule may
even envelop the new joint in course of time. The head of the bone
usually undergoes some flattening and atrophy, but may remain un-
changed. The formation of a new joint is rapid in children but occupies
years for its completion in any save the most youthful adults. By these
natural resources very fair function of a limb may be regained, even if
the luxation continue unreduced and unsightly deformity remains. The
pathological significance of inflammation about dislocations is very great,
for by its means vessels and nerves are apt to form adhesions to the dis-
placed bone extremity, which may give rise to rupture of those structures
when attempts are made at reduction. Inflammation and its effects may
also permanently ankylose a joint which has been dislocated, or may even,
in predisposed individuals, give rise to purulent arthritis.
SYMPTOMS.—The principal symptoms of dislocation are:
1. Deformity.
(a) Absence of a known prominence.
(b) Unnatural presence or disappearance of a depression.
(c) Changes in length, axis, and general conformation.
(d) Swelling.
. Rigidity.
. Absence of crepitus.
. Pain.
5. Force not generally required to maintain in position after reduction.
The diagnosis and differential diagnosis of luxations cannot be made
out with a single sign; sometimes it is impossible, even to the most expe-
rienced, when all available diagnostic resources are brought into requisi-
tion. In this section it is proposed to describe principally typical disloca-
tions, and not to enter upon their differential diagnosis, as that has already
been elaborated under Fractures.
Deformity, more or less marked, is an inevitable accompaniment and
sign of dislocation. The bones entering the structure of a joint are dis.
placed, and hence it is impossible that its contour and appearances should
not be changed. The position of these separated joint elements is usually
the same and typical for the same dislocation. The absence of one ele-
ment of an articulation is noted, and an unnatural prominence has made
its appearance in the vicinity of the joint, the axes of the bones are
changed from that of their normal relation to each other, and there have
occurred various other changes, as in the length and circumference of the
limb. Certain attitudes, which will be described under Special Disloca-
tions, are significant of particular dislocations.
The swelling which is apt rapidly to supervene when displacement has
occurred is not usually so great as to prohibit diagnosis, although not in-
frequently this symptom may entirely mask the true mature of the injury.
Strong pressure with the fingers or hand, or an elastic bandage for a few
moments, may so dissipate infiltration that salient prominences and lººk
marks, or even all portions of the affected bones, may be made out. This
failing, the judicious use of a well-tempered exploring needle may determinº
:
DIS LO C A TI O N S . 481
relative positions. When swelling has come on with great rapidity, and
circulation has ceased in the distal distribution, rupture of the main artery
most probably has complicated the original injury. Preternatural rigidity
or loss of function also usually accompanies dislocation. Separated joint
surfaces, as a rule, have the same relation to each other in the same dis-
location, and are held firmly and rigidly in that position unless great
laceration of ligaments or profound shock also be present, when the con-
trary, or even extreme mobility, may substitute this symptom. Immo-
bility is rarely absolute, and some degree of motion can usually be elicited,
which is limited by a more or less elastic check imparted by the remaining
portions of ligaments and the resistance of soft parts surrounding the
dislocated bone. If the injury is also associated with fracture, rigidity
will not usually be present. Utmost caution must be used in diagnosing
dislocations, in patients whose age permits the possibility of epiphyseal
fractures, to distinguish the former from the latter, as both possess points
of great resemblance.
The corresponding bones, joints, and regions of both the injured and
sound side of the body should always be compared, and the two hands
made to examine synchronously and contrast the corresponding depres-
sions, prominences, and “landmarks” of the two sides. If this be made
a rule of practice and procedure, many an incorrect diagnosis arising from
inappreciation of the peculiar topography of the patient under considera-
tion will be avoided, and still other cases will thus be quickly robbed of
their diagnostic difficulties.
True crepitus cannot be developed in a case of dislocation unaccom-
panied by fracture, but it is likewise true that this sign cannot be devel-
oped in every case of fracture. Often a friction sound or sense can be
perceived in dislocations, which is developed when compressed fibrous or
muscular tissues and the displaced bone are moved upon each other, and
the simple movement of dry or otherwise altered synovial membranes is
quite sufficient to produce this “false crepitus.” This symptom is unusual
in Very recent luxations, and does not often make its appearance until
One or more days have elapsed since the occurrence of injury; but fric-
tion of a torn ligament may give rise to it at any period of the case.
Dislocation crepitus is much more obscure than is that of fracture, unless
the latter happen to be deeply situated or when inflammation has caused
softening of the disrupted surfaces. A dislocation complicated by a small
fracture, as of a chip from an acetabular rim or a torn-off tuberosity, may
Present, either or both forms of crepitus. Such injuries are often impos-
sible of more exact diagnosis than supposition.
Pain in dislocations is frequently more unbearable, and of a dull
throbbing or stretching and tearing variety than is the case with that of
factures. If nerves have been pressed upon or torn, tingling, numb-
*; or anaesthesia and paralysis of their distributions will be tempo-
*ily or permanently present, according to the degree of nerve injury
*stained., Muscles are placed upon the stretch, and the bone extremity
* Probably pressing powerfully upon surrounding structures—an aggré-
gº of causes quite sufficient to account for the very marked subjective
ºptoms of which cases of dislocation so often pathetically complain.
Unless taken in conjunction with all the other signs of dislocation
*d position after reduction is a symptom of no great moment. It
*...* act that dislocations when reduced customarily remain in position,
but the contrary is as often true if there has been great laceration of liga-
31
482 DISE A SES OF JOINTS, C A RTILA GES AND LIG AMENTs.
ments or soft parts, whilst many fractures, notably certain ones about the
wrist, will retain their position perfectly when set or reduced.
Open or compound dislocations present very little difficulty in diagnosis,
for their character is easily cleared up by the opportunity for direct ex.
amination which is afforded during the necessary process of treatment.
Luxations complicated by fracture have been discussed under the latter
heading. They are injuries of much gravity as regards diagnosis, treat-
ment, and prognosis.
PROGNOSIS.—The general prognosis of a given dislocation is favorable
or unfavorable in direct ratio to its complications. Simple luxations
promptly and completely reduced and kept at rest for the requisite length
of time practically never of themselves endanger life, limb, or function; the
slit in the capsule firmly heals, the displaced surrounding tissues quickly
return to their former condition, and little save some swelling and perhaps
Some pain and stiffness remains to remind the patient of his recent accident.
But this pain and stiffness—usually the result of the necessary immobiliza-
tion of the joint to insure healing of the torn structures—may continue for
a long time-or even in exceptional instances lead to permanent disability.
Some weakness or atrophy may also follow simple displacements; this prob-
ably being due not only to inaction of the muscles but also in part to stretch-
ing or bruising of the proximate nerves or muscles. Atmospheric changes
are apt to have a forecast in the painful stiffness which the injured parts
may assume before a change of weather, for perhaps even years after dis-
location. Much also, in all forms of dislocations, depends upon the par-
ticular joint involved, the degree of the displacement, the condition of
health and the reparative powers of the individual, the means employed
for reduction, and the time after accident when treatment was instituted,
Thorough reduction may be rendered impossible by a portion of liga.
ment or muscle occupying the joint cavity, and preventing the replace-
ment or retention of the dislocated bone.
Secondary or recurrent dislocations are rarely of special danger, but
the prospects of permanent cure are extremely slight. When luxations
are complicated by rupture of the main artery of an extremity the
prognosis becomes most grave, and loss of the limb or even of life is the
common result. Torn nerves, muscles, or tendons are not of such serious
import, as they can often be restored to functional activity by operation.
Open dislocations have been robbed of most of their former terrors and
dangers by modern wound treatment, but they will always be much more
serious injuries than simple luxations, from their liability to become in-
fected. If they can be guarded from this latter complication the chances
of saving the joint and ultimately restoring it to usefulness are very good.
Old dislocations or recent ones, which it is found impossible to reduce,
are not to be prognosticated so unfavorably as might at first sight seem
necessary, for often by the formation of false sockets and articulations
much of the functional activity of a limb may be restored, which use:
fulness is prone to increase, not to decrease as time goes on. But, un-
fortunately, pressure exerted by the bone in its new location may cause
much distress or danger. The degree of disability in these ancient dis’
locations will depend largely upon the nature of the joint involved. Thus
ball-and-socket joints when unreduced give rise to much less interference
with function than do similar conditions in hinge joints, and even one
variety of dislocation may give rise to less disability than another at the
same articulation. Thus, deformity is much less in a sciatic dislocation
at the hip or a subglenoid at the shoulder than is the deformity resulting
D ISL O C A TION S, 483
from other dislocations of the corresponding bones. Attempts to reduce
old dislocations are always serious undertakings, from the danger of rup-
turing arteries which may, through inflammatory action, have become
attached to the displaced bone or its fibrous surroundings. Especially is
this danger salient in old luxations of the humerus.
TREATMENT.-Spontaneous reduction occasionally takes place, more
especially in partial luxations and in those of the shoulder. This desid-
eratum may be brought about by movement during sleep, falls, or after
unsuccessful attempts at reduction have failed of their purpose, but have
so broken up adhesions that the force of muscular contraction or volun-
tary motion afterward draws the displaced bone into position.
Except in certain complicated cases, treatment of acute dislocations
should always be instituted at the earliest possible opportunity, and the
earlier reduction is attempted just so much more readily can it be attained.
There is often a period lasting a short time after the accident during
which the muscles have not begun to contract, and at this time some dis-
locations are most readily reduced. The writer once had opportunity to
prove this assertion in the case of a fellow swimmer who sustained a sub-
coracoid dislocation of the humerus by his arm being forced upward and
outward in striking the water whilst diving. It was reduced with utmost
ease by manipulation before more than one or at most two minutes had
elapsed. No especial care was taken of this member afterward, but dislo-
cation never recurred. The indications for treatment are: 1, to reduce
the dislocations; 2, to secure firm repair without inflammation, and 3, to
restore function.
Reduction is to be accomplished by constitutional relaxing measures,
and by manipulation. Mechanical force is never required or permissible
in recent luxations. Prolonged painful efforts to reduce a dislocation
should never be made, and relaxation by ether should be secured in all
rigid dislocations of the larger joints; also in case of any joint should it
resist our first few efforts or give rise to excessive pain upon motion.
The primary stage of ether, or some abrupt question or accusation put
to the patient, may occasionally direct attention from the injured parts
and permit the surrounding muscle to be surprised and the joint reduced
by a rapid manipulation, but, usually, an-
*sthesia to the stage of profound relaxation FIG. 285.
must be attained before manipulation can
properly be applied and reduction effected.
Reduction made without the addition of
mechanical force to the ordinary powers of
the surgeon constitutes replacement by ma-
nipulation, which method is always prefer-
able to any other. But in certain cases
the hands of an assistant may be addi.
tionally employed or a better hold upon
the part obtained by wrapping it in cloths,
ºr by throwing a “clove hitch” or noosé
knºt above some bony prominence, which
Will prevent slipping or damage by traction
upon Soft parts.
The object of manipulation is to secure through one or more consecutive
Pºsses of extension and counter-extension, rotation, pressure, adduction,
*duction, flexion or extension, the replacement of the dislocated bone.
Y these processes relaxation of some structures and tension of others is

484 DISE A SES OF JOINTS, CARTILA GES AND LIG AMENTs.
attained which either assist, permit others to assist, or are prevented from
hindering the return of the bone to its socket by the route of exit. From
this it will be seen that to reduce luxations by manipulation an accurate
comprehension of the mechanism of dislocations must be possessed by the
surgeon who may be called upon to replace them. Rude manipulation if
FIG, 286.
’ ‘’’A/, * r * * *
!, \
} w ||| |
f k ºil. "#|| | W
i.; |...}}| ” //t/ ºff//*' ||| ſ
(śī # ſ j Paſº | º ºS ſº fºr 2.
º |'' . jj t º .* º ºft }||
º: §§ ##### ź %:/º // %/6% !//),
3. *} - “. º º .. ºft - % --> ". . . & - j} % /,”, "/.
& &^T}\}}\ \*4%/.4% ......
Clove-hitch knot applied. (AGNEw.)
FIG. 287.
Noose knot.
persisted in may often accomplish reduction in the hands of ignorant per-
sons, but exact anatomical knowledge is vastly safer, more satisfactory,
and successful. The surgeon should be familiar with those motions best
calculated to relax the bone capsule, or to remove other obstructions, and
to bring into play such muscles or ligaments as will assist him in his en-
deavors to replace the bone. Sometimes a rocking motion combined with
manipulation will insinuate an obstinate bone into its proper position.
Manipulation to prove successful must be applied systematically, and the
sequence of its various objects must follow in regular order. Thus,
obstructive tension is first to be overcome. Then the bone is to be
dislodged and gotten opposite the capsule rent and finally forced into pºsiº
tion; which last two procedures are often accomplished through making
portions of ligaments, etc., act as pulleys or levers. As the capsule rent
is made by pressure of the head of a bone, hence the lesion is always in
the direction of dislocation, and the rule is always, if possible, to return
the bone in the exact direction of dislocation. If only a slit exists in the
capsule that ligament must be relaxed to permit reduction, but unless *
flap has been torn from one edge the capsule will never prevent reduction






D IS I, O C A TI O N S. 485
by occupying the normal position of the displaced bone. The existence
of an obstructive flap is an extremely unfortunate occurrence, and one
which nothing short of an operation will relieve in some cases. Reduc-
tion will sometimes be further obstructed by muscles or tendons slipping
over or under the dislocated head. For these complications, as when the
metacarpal bone of the thumb slips under a head of the flexor tendon,
nothing short of division of the restricting band will suffice, that the
reduction may be completed.
If swelling interferes with reduction we should be content to wait until
it in part or wholly subsides. This takes place with rapidity, and little
is lost by the pursuance of such a course.
But cases will occasionally be encountered in which manipulation will
fail, or where anaesthesia is refused or inadmissible, and to these we will
be driven to apply the application of force. This agent is brought into
action by means of extension and counter-extension, energetic rotation,
and by direct or indirect pressure, or one or all of these measures in con-
nection with manipulation. The required force must gain access to the
limb through certain mechanical attachments. If bandages or cloths are
used for this purpose they should previously be moistened, for in that con-
dition they are less liable to slip.
Clove hitches, noose knots, elastic bands, or the metal attachment plates
of Lewis, which are shown under Refracture of Deformed Union. After
Fracture, can be used for this purpose. Great caution must be observed
that pressure or traction be not made upon the skin or soft parts, but that
bone extremities are made the points of resistance. By these means in-
definite extension and power, limited only by the strength of the distal
bone, may be secured. Forcible reduction should be made to simulate
the motions of manipulation as nearly as possible; but if this cannot be
attained then the force should be applied in the direction which will bring
the head of the bone directly to the socket, or to such proximity to it
that lateral pressure or rotation will complete the reduction.
. The power must be applied gradually, steadily, and with the greatest
judgment; a rocking motion may be superadded at times with benefit to
force the dislocated bone from entanglements, or by chance to slip it into
the socket.
Gradual continuous extension by elastic bands or weights acting over
a pulley often proves of great utility. Up to fifty, or more, pounds of
Weight may thus be employed, but it will be found that lesser weights
ºcting for a long time will accomplish more than will greater amounts
for a shorter time. Compound and other pulleys, until recently so much
in Vogue, are to be unequivocally condemned for recent luxations, and
only most rarely can there ever arise necessity or indications for them in
ºny form of dislocation. Anaesthesia is as beneficial and requisite during
the Reduction of displacements by forcible means as in manipulation.
Force is to be applied as follows: 1. The power is to be exerted in a
Pºoper direction. 2. It must not be applied in a spasmodic or violent
manner, but continuously, and with a gradual increase of amount. 3. The
P* must be rotated and rocked in all directions to free the head of
i. ‘. º ºntanglement or adhesions. 4. When resistance of muscles
the l A sufficiently overcome to permit the head of the bone to reach
**Vºl ºf the cavity from which it has been replaced, an adroit move-
* of the part must be made by the hands of the surgeon toward that
cavity, whilst at the same instant the extending force should be relaxed
Y an aSSistant.
486 DISE A SES OF JOINTS, CARTIL AGES AND LIGA MENTs.
Should even these measures fail, then will arise the advisability of insti.
tuting such operative measures as subcutaneous or open division of the
restricting tissues, or even of the neck of the dislocated bone itself; the
excision of its head or of the whole joint, or, finally, of amputation.
A dislocation is known to have been reduced when the articulation
assumes its normal contour and functions, and by the direction of the
axis of the limb or the elements of the joint. The fact is frequently an-
nounced by the before-mentioned moist or muffled snap. The dangers
incident to the application of force are proportionate to the presence and
mature of adhesions, and to the amount applied.
After being reduced the joint must be kept at rest by means of splints,
bandages, or apparatus for a few days or weeks, according to the severity
of the dislocation, the joint involved and the nature of complications.
At the expiration of this time passive motion is begun, and shortly
afterward active movements, or customary occupations, may be resumed.
But movements in the direction of the former capsule tear should be
avoided for as long a time as possible. If these precautions are not con-
sidered the risk of recurrence or of establishing an “habitual dislocation”
becomes very great. Electricity, massage, hot and cold douches, and
injections of Strychnia will prove of benefit if muscles have lost their
power. Should inflammatory reaction occur its symptoms are to be met
with the usual means.
Treatment of Old Dislocations.
Much that has already been said applies equally to the treatment
of old dislocations. For reasons already stated it is justifiable to
make judicious attempt at reduction of any dislocation, no matter what
may be its age. In this variety of dislocation passive motion, poulticing,
massage and extension should be kept up for days or weeks before an
attempt at reduction should be undertaken. Any restricting tissues
should be divided some time previously. Manipulation, even if it does
not accomplish its ulterior object, frequently gives the patient a wider
range and ability of motion than he had before. Attempts to break up
or reduce old dislocations are always to be undertaken with the full
knowledge of both surgeon and patient of the great risks to be encoun-
tered in all such operations.
The most common accidents attending the modern reduction of old dis-
locations are rupture of vessels and nerves, fracture, and rendering the
injury open or compound by giving way of the skin. Rupture of vessels
is almost exclusively limited to arteries, and of the latter, principally to
the axillary, and are most fatal accidents under any form of treatment.
Their occurrence is recognized by the sudden formation of a pulsating
tumor in the neighborhood of the old injury. Exceptionally the artery
does not rupture until several days after the attempt at reduction, or ºn
aneurism may form either with rapidity or otherwise. Gangrene of the
limb may follow pressure upon or laceration of vessels.
Fracture, if it take place close to the dislocated head may prove of
more benefit than injury by forming an artificial joint and save subsequent
recourse to operation for the same purpose. Recoveries have taken place
in all varieties of these accidents. Torturing neuralgia, persistent odema,
aneurism, varix and gangrene are possible sequelae of unreduced luxations
or of efforts made for their relief. &
The treatment of open or compound dislocations has been discussed
under Wounds of Joints.
S PEC I A L ID IS LO C A TI O N S. 487
SPECIAL DISLOCATIONS.
Dislocations of the Vertebrae.
Dislocations of the vertebrae unaccompanied by fracture are injuries of
rarity. The ultimate effect of almost all casualties of this mature is
lethal; most commonly immediately, but exceptionally death is postponed
for months. Some cases recover. The seat of lesion is most commonly
in the cervical region, less frequently in the dorsal, and never, so far as
surgical history goes, in the lumbar region. The most common disloca-
tion is that of the axis. The cervical region is predisposed to these acci-
dents because of its range of motion and freeness of articulation.
Most dislocations of the cervical spine are simple or uncomplicated, but
may be complete or incomplete. The region bounded by the fourth and
sixth vertebrae is most vulnerable. Any variety of displacement may
injure the cord, rupture its vessels, or give rise to subsequent inflamma-
tion or effusion.
The treatment of spinal dislocations consists of reduction, if feasible,
and subsequent care of bladder, rectum, and surfaces exposed to pressure,
as in fracture complicated by cord injury. The water or air-bed and
extreme cleanliness will likewise be found of great utility to prevent
pressure necrosis.
Dislocations of the Cervical Vertebrae.
Dislocations below the axis are usually forward; that is, all the vertebrae
above the seat of displacement are thrown forward, but lateral or rotary
dislocations are not unknown in
FIG. 288. this region.
These luxations are caused by
indirect violence bending or twist-
ing theneck. If complete, the pos-
terior common vertebral, also the
lateral, ligaments are torn.
Save in certain well-marked
W
º
º
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i
2. /
, , ;
; : " . . . . . .
º . .” t
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. .
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Bilater - º * * * -
*al dislocation forward of fifth cervical Dislocation of cervical vertebrae by
Vertebra. (AYREs.) flexion; median section. (BRYANT.)

488 DISE A SES OF JOINTS, C A RTIL AGES AND LIG AMENTs,
cases exact diagnosis is very difficult in dislocations of the cervical spine,
The head is bent rigidly on the breast in forward, and in the opposite
direction in backward dislocations. A prominence or depression, accord.
ing to the direction of the dislocation, may sometimes be noted by a finger
carried into the pharynx. If the injury be above the origin of the phrenic
nerves, death is usually instantaneous.
Treatment consists of extension by hands placed upon the chin and
occiput and counter-extension by pulling upon the patient's feet; or by
means of a folded sheet drawn over the shoulders combined with manip.
ulations calculated to disengage the luxated vertebrae, and direct pressure
applied at the same time to the neck and, perhaps, through the pharynx.
Atlo-aavoid Dislocations.
Alto-axoid dislocations come next in order of frequency. Three varie-
ties exist: the odontoid process of the axis may be fractured and thus
permit dislocation of that vertebra backward and crushing of the
cord; the odontoid ligament or some fibres of its transverse portion
may be torm and permit the odontoid process of the axis to slip beneath
it; or the atlas may be rotated upon the axis until the articular ligaments
rupture and permit the former bone to rest obliquely upon the latter.
These lesions result from force applied to the head, from falls, blows, and
twists; whilst the presence of vertebral caries greatly predisposes to them.
The symptoms and consequently the exact diagnosis of these, as of other
cervical dislocations, are vague and unsatisfactory. They usually prove
rapidly fatal, and great precaution must be observed in the treatment, as
instant death is liable to follow even trivial attempts at reduction, from
injury to the cord by pressure from the odontoid process. Nevertheless,
it is our duty to attempt such reduction by traction (as above) in the
line of the spinal column, manipulation, and direct pressure. If success
attends the surgeon’s efforts care must be taken to retain the head in the
proper position by pillows or other means.
Occipito-atloid Dislocations.
Occipito-altoid dislocations are occurrences of great rarity and fatality,
being due to great violence tearing the condyles of the occipital bone
from the articulating cavities of the atlas. -
Dislocations of the Dorsal Vertebrae.
Dislocations of the dorsal vertebrae occur, but usually are accompanied
by fracture, because of the great force required to lacerate the powerful
ligaments and joints which are to be found in that region. They alº
caused by violent flexioms or rotations of the body. The diagnosis is self.
evident and precisely similar to that of fracture in the same region, and
treatment consists of application of the same measures as for other Yeº
tebral displacements, except that continuous extension and counter-exten-
sion should form a more prominent feature of after-treatment.
Dislocations of the lumbar region without fracture are unknown. They
require no separate consideration.
SPECIAL DIS LOC ATION S. 489
Dislocations of the Ribs from the Vertebral Column.
A few cases of this variety of injury appear in surgical history of times
now remote; none have been recorded during the past forty-four years.
They, as a rule, accompany terrific lethal traumata. Diagnosis is made by
the absence of the head of the rib from its vertebral socket, and treatment
is to be supplied by a broad band highly encircling the chest.
Dislocations of the Coccya.
These unusual injuries take place principally in women, resulting from
falls, kicks, or other direct violence, or during parturient efforts.
Three varieties have been observed : forward, which is most frequent,
backward, and lateral. The symptoms of the accident are great pain,
swelling over the region, and rectal examination discloses the displace-
ment and its variety.
The forward luxation is to be reduced by hooking the finger over it in
the rectum and drawing it downward into position. Beyond manipula-
tion and pressure, no definite rules can be given for treating this form of
luxation. Instant relief follows replacement, but recurrence is probable.
Old or inveterate dislocations may demand excision of the affected parts.
(See Excision of Joints.)
Dislocations of the Jaw.
This dislocation occurs in four per cent. of all luxations. It may be
partial, bilateral, or unilateral. A shallow gelnoid fossa and lax articular
ligaments predispose to the injury; whilst yawning, laughing, sneezing,
blows, and falls are exciting causes. Attempts to separate the jaws ex-
cessively, or blows upon the chin whilst the mouth is open, are prolific
causes of luxation.
The mechanism of this dislocation is brought about by the internal
pterygoid muscles becoming a fulcrum, and the muscles inserted into the
chin becoming, as it were, the long arm of a lever, which, with the assist-
ance of the external pterygoids, cause the condyles of the jaw to press
upon and rupture the capsular ligaments, and spring in front of the articu-
lar eminences, when contraction of the masseter and temporal muscles
draws them forcibly upward until they are arrested by the zygomatic
* and the typical deformity is produced. Rarely the capsule is not
Ol' D.
The symptoms are wide separation and firm fixation of the lower jaw;
* Vacuity is noticed in front of the ear, and the condyles may be felt
beneath the zygoma. *
. A backward dislocation has been described in which the condyles are
violently forced through the anterior wall of the auditory canal. Anaes-
thesia is not required in the treatment of this dislocation, which consists
* the surgeon carefully protecting his thumbs with strips of bandages,
and then with them pressing downward upon the last molar tooth upon
each side of the jaw, whilst, at the same time, the palms and fingers grasp
*ch side of the maxilla externally and press it backward. By these
*nºuyres the process of dislocation is exactly reversed; tension of the
* Pterygoid and masseters is overcome by the downward pressure;
the condyles are pressed backward into position, and, upon releasing the
490 DISE ASE'S OF JOINTs, CA RTIL AGES AND L I GAMENTs,
pressure, are drawn with great force into position by contraction of the
temporal and masseter muscles. If the surgeon's fingers are not pro-
tected or removed to the side of the teeth quickly, they are liable to be
injured from the force with which the molars are drawn together.
FIG. 290. FIG. 291.
/( &
{ \\
S. S
SS
- t
RNNºw? º
S$ § Š § º f W
Nº.
* ...? º
W
º
| NS §
s N
9//
§
Žº-SNilſº %
º Yº-w'.
* * : sº {}^*.
tº "..ºly
1
/*
Bilateral dislocation of lower jaw. Deformity resulting from bilateral dis-
location of lower jaw. (AsHHURST.)
Unilateral displacements are to be treated in a similar manner. If in
subluxations the teeth are firmly together, simple forcing of them apart
will suffice for reduction.
FIG. 292.
N
!///?" |
wº / % / % º
\
º \\
2’s
w N ſºlo &
Žx-ºff/º Azº/ ſº
d tº 2. ' | a
* ... ... --- 2", . §)
} 2.
%
|
f | ſº ~ w
ſ/ || t ...lº- * ,
..SSSS, | 'sº
| Mºssº | | ..);
\s wº Sº, | 7 NS$ Rºž
w
Reduction of dislocated jaw. (ERICHSEN.)
Old maxillary dislocations are to be treated as acute ones first, and, this
failing, the forcing apart of the posterior portions of the jaw by levers or
Stromeyer's forceps, or even the excision of the condyles, is permissible.
After reduction the jaw must be kept immobilized for at least &
week by means of a Barton or similar bandage, and the patient fed
principally upon liquids. If this rule is neglected there is great danger








S P E CIA. L DIS LO C A TI O N S. 491
of recurrence or of the establishment of habitual exarticulation, subluxa-
tion, or a snapping sound during eating.
FIG. 293.
Stromeyer's forceps.
Dislocations of the Sternum.
This dislocation is unusual and, from the violent nature of the force
required to produce it, has proved fatal in almost 50 per cent. of cases in
which it has occurred. Direct force is the usual cause. Reduction is
impossible in most cases, but, if the patient survive the complications he
is not, as a rule, incommoded by the resulting deformity. Extension of
the chest by bending the dorsal spine over a block of wood or round
pillow together with manipulation and moulding may be tried, and should
they prove successful a broad bandage must highly encircle the chest for
Some weeks subsequently. Anaesthesia will favor replacement.
Dislocations of the Clavicle.
I shall speak of luxations of the outer end of the clavicle as disloca-
tions of the scapula.
Dislocations of the clavicle occur at the sterno-clavicular articulation in
either a forward, backward, or upward direction. Dislocation at this joint
is favored by a shallow glenoid cavity and
by the great range of shoulder motions, FIG. 294.
which indirectly affect the clavicular ar- --
ticulation. The disarticulation may be
complete or incomplete.
Hypertrophied or violent movements of
the shoulder are the most universal Cause,
but slow dislocation may result from nature
of occupation stretching the retaining liga-
ments. All dislocations in this region are ; ſº s ºf
Very easy of reduction by proper manip- Yºº ...º.
ulation of the shoulder and direct pressure Dislocation of sternal end of
gombined, but are more than correspond. clavicle. (BRY ANT.)
ingly difficult to retain in place.
. The symptoms are sharp local pain and head of clavicle in new posi-
"on, before, above, or behind normal situation. In backward displace-
ments aphonia and dysphagia of varying degrees may be caused by
Pressure of the dislocated head upon the trachea and oesophagus. These
i. Symptoms rapidly disappear even if the luxation continues unre-
Treatment is usually successful so far as primary reduction is concerned,
**currence is almost inevitable, and sooner or later becomes habitual


492 DISE ASES OF JOINTS, C A RTII, AGES AND LIG AMENTS,
or permanent. . The head of the bone may be excised if it produces dan-
gerous or painful pressure symptoms. In reduction the shoulder must be
drawn outward and forward in forward dislocations; outward and back-
ward in backward, and upward, or upward and outward, in upward
dislocations. By these shoulder manipulations in all three varieties
the dislocated head is coaxed to the margin of its socket, when direct
FIG. 295.
Dislocation upward of the sternal end of the clavicle. (R. W. SMITH.)
pressure and moulding are applied, and the process is restored to its
normal position. When reduced it must if possible be supported for four
weeks by means of bandages (such as the Velpeau) and pads, or by a
spring truss or other form of mechanism. Pressure must be exerted in
the direction of the articulating cavity.
Fractured clavicle position in bed, in addition to the above means,
yields the best results. Backward displacements always prove the most
tractable.
Dislocations of the Scapula.
These displacements are usually called dislocations of the acromial end
of the clavicle, but in accordance with the rule that the distal bone is the
one dislocated, they are here termed dislocations of the scapula. As in the
case with most luxations they may be complete or incomplete. When com-
plete the dislocations of the scapula may be sub-, supra-, or post-clavicular.
Their general causes are direct violence to the shoulder or muscular effort.
When scapular dislocations are complete not only are the ligaments of the
scapulo-clavicular joint ruptured, but also often portions or the whole
extent of the conoid and trapezoid are torn.
Subclavicular dislocations are recognized by the elevated acromial end
of the clavicle and the partial rotation of the inferior angle of the scapula
toward the spine, which latter symptom is due to the dragging weight of
the arm. There is marked local pain, and the attitude attributed to frac:
ture of the outer end of the clavicle is, in these cases, likewise assumed.
Treatment consists of upward, or upward and outward, or backward

SPECIA L DISL O C A TI O N S. 493
movements of the shoulder, together with direct pressure and moulding.
In doing this the arm should be kept in contact with the patient's chest.
whilst upward pressure is made upon the
elbow. FIG. 296.
Retention of the injured parts is difficult.
A Velpeau or similar bandage or apparatus,
or a broad strip of adhesive plaster carried
beneath the elbow, up both sides of the arm,
made to cross over the acromial end of the
clavicle and secured upon the chest, back
and front, must be worn, preferably in con-
junction with the dorsal position in bed, for
a month.
Supraclavicular dislocations present the
acromion raised whilst the clavicle can be
traced to a certain point beneath, when it
disappears to palpation. Reduction of this
variety is to be accomplished by downward Subclavicular dislocation of
and backward traction upon the shoulder, scapula. (BRY ANT.)
whilst the arm is kept parallel to the trunk,
and counter-extension is exerted by traction upon a sheet wound around
the chest. º:
Post-clavicular dislocation has only twice been observed in surgical
history. It is to be recognized by the position of the clavicle directly in
front of the acromial process of the scapula. A mingling of various
shoulder motions and manipulation would probably reduce the displace-
ment. After-treatment would be the same as for the previous varieties.
Dislocations of the Humerus.
These are the most common of all the dislocations, a fact readily ex-
plained by the shallowness of the glenoid cavity, the lax capsular ligament,
and by the great range of motion and liability of the shoulder to direct
or transmitted traumata. Middle life is the most common time of occur-
rence, and the accident is rare at its extremes.
Dislocations of the humerus group themselves into three principal
Varieties, which, in order of frequency, are: 1. Downward and some-
What inward, or subglenoid, often termed axillary. 2. Forward, which
embraces two sub-varieties, the subcoracoid and subclavicular. 3. Back-
Ward or subspinous. Other technical or irregular dislocations also have
taken place, but possess no clinical importance.
Direct or, most commonly, indirect violence is the exciting cause of
dislocation at this joint. Thus, waggons passing over the shoulder and
fist blows upon the arm have produced it, but in vastly more instances
the head is exarticulated by force employing the arm as a lever.
Downward or Subglenoid Dislocations.
In downward dislocation of the humerus the capsular ligament is torn
*xtensively upon its lower surface, the head of the bone occupies a posi-
"on upon the anterior surface of the scapula immediately beneath or,
Perhaps, beneath and a little to the inner side of the glenoid cavity, where
* is held between the tendons of the triceps and subscapularis muscles.

494 DISE ASES OF JOINTS, C A RTILA GES AND LIGA MENTS
The axillary contents are compressed and the circumflex nerve may be
so stretched or torn as to result in permanent paralysis of the deltoid.
FIG. 297,
º º *** |ff \
|... º. 4 *s sºsº &
º ł & W. ë WN sº º |
# * º º |º ==
sººs. Tº
~~2. &; N º Ryº'
^{ {/,
Deformity of downward or subglenoid dislocation of the humerus. (STIMSoN.)
Whilst the bone is thus situated the deltoid and spinati muscles are made
exceedingly tense, or may even be partially ruptured; the subscapularis
FIG. 298.
Downward dislocation of humerus. (GRoss.)
and craco-brachialis muscles are likewise upon the stretch, but to, a
less marked degree, and the teres major and minor are relaxed. The









SPECIAL DIS LOCATION S. 495
long head of the biceps muscle may have been dragged out of its groove,
or the great tuberosity of the humerus torn off.
Subcoracoid Dislocations.
When this dislocation has been produced, the anterior portion of the
capsular liagament is lacerated. The humeral head slips through this
rent and is brought to a standstill
* - FIG. 299. upon the inner surface of the neck
of the scapula beneath the cora-
gº coid process, or exceptionally, as
º far back as the subscapular fossa.
Subcoracoid dislocations may be
º
º
~-
S.
s
N
sº
º
2.--
i
i
§i
&
ºi
§
º
N
#
£º
S
E"
š
FE::
S --
|
FIG. 300.
sº-
š#is ſº
>
# -->=
º).
º
{ %
iſºgº
ºft”
*Aºi º
YS --------- :----, - . .
\; ====ºãº
}.” Yº: 2-.
º º 2. ... " º: ºr º
º
... .sº
*
º
**::::::-
*
a s ==
º
Wº % § Wº
**º
- =º º
W 4%
& 24
==º
--- zºº
*Tº cº-º-º: -
Subcoracoid dislocation of left shoulder. Subclavicular dislocation of head of
(STIMson.) humerus. (GRoss.)
produced secondarily from the subglenoid variety by spasmodic contrac-
tion of the clavicular portion of the great pectoral and coraco-brachialis
muscles, or during attempts at reduction.
Subclavicular Dislocations.
In this form of luxation the dislocated bone extremity rests upon the
chest immediately below the clavicle, and is covered by the pectoralis
majºr and minor muscles. (Fig. 300.)
The acromial and spinous portions of the deltoid, the inner fibres of the
°ºraco-brachialis, and the short and long heads of the biceps muscles are
º *y tense, whilst the teres major and minor are correspondingly re-
3.xeOl.
Subspinous Dislocations.
This dislocation is one of rarity. The head of the displaced bone
to be found posterior to the glenoid cavity upon the dorsum of the
Scapula immediately Subjacent to its spine.
is







496 DISEASES OF JOINTS, GA RTIL AGES AND LIGA MENTs.
The supraspinous and subscapular muscles are either torn or ex-
tremely tense, as are also, but in less degree, the long head of the biceps
and the clavicular portion of the deltoid.
FIG. 301. FIG. 302.
§
t s
º
}
sº º r
# *, * ;
** %.
ź \
%
ãº
g Ž a &#: ^2,
§ { Ž * , º 2 \,
** J. : * %, “ , , º,
R.' §. Aº % " Itſ," ...,' ſº %
w s *… %.
%2% %.7. T-->
§ ğ. **: * * *
º Wºźlſ -
; : ſº ſ Şsº
Żºłł.
hº | ſº }
º f ſ º
§mplº-
§§9 *º-
º
Subspinous dislocation of head of hu- Subspinous dislocation of head of hu-
merus. Front view. (ERICHSEN.) merus. Back view. (ERICHSEN.)
FIG. 303.
Subspinous dislocation of head of humerus. (ERICHSEN.)
SYMPTOM'S AND DIAGNOSIS.—For purposes of diagnosis ether should
unhesitatingly be administered if any doubt persist. In the following
table, modified and adapted from Agnew, are given the symptomatology
and differential diagnosis of dislocations of the humerus.
Downward Dislocation. Forward Dislocation. Backward Dislocation.
(Subglenoid.) (a. Subcoracoid form.) (Subspinous.)
1. Shoulder ewtremely flat- 1. Shoulder flattened, but 1. Shoulder moderately flat-
tened. not eactremely so. tened.
2. Acromion very conspicu- 2. Acromion prominent. 2 Acromion moderately
OUIS. prominent.
3. Depression below entire 3. Depression greatest at pos- 3. Depression greatest aſ ".
arch of acromion. terior part of arch of térior part of arch 0
acromion. acromion.










S P E CIA. L DIS LO C A TI O N S.
497
4
Downward Dislocation.
(Subglenoid.)
, Elbow projecting from
side.
Axis of humerus directed
below glenoid cavity.
, Inability to place hand of
injured side upon sound
shoulder, or upon top of
head.
. Presence of hard, hemi-
spherical tumor in acilla.
. Pain and numbness in
arm and fingers.
Backward Dislocation.
(a. Subcoracoid form.)
4. Elbow projecting from
side.
5. Axis of humerus anterior
to and below glenoid ca-
vity.
6. Inability to place hand of
injured side upon sound
shoulder, or upon top of
head.
7. Presence of hard, hemi-
spherical tumor in acilla,
but higher than in sub-
glenoid.
8. Pain and numbness in
arm and fingers very
marked.
(b. Subclavicular form.)
Differs from subcoracoid as
follows:
Acromion erceedingly promi-
ment. The round, hard
tumor is immediately be-
low clavicle. Elbow di-
rected backward. Other-
wise identical.
Forward Dislocation.
(Subspinous.)
. Elbow at side of body, and
arm thrown forward.
. Axis of humerus directed
behind glenoid cavity.
. Ability to place hand of
injured side upon sound
shoulder and upon top
of head.
. No hard, round tumor in
aicilla, but one present
below spine of scapula.
. Great pain in shoulder;
little in arm; no pain or
numbness in fingers.
TREATMENT.—The anaesthetic state to the point of muscular relaxation
should, as a rule, be secured before attempts at replacement are undertaken.
Reduction is always to be accomplished by manipulation if possible, and
it will be found an exceedingly unusual dislocation of the humerus that
FIG. 304.
-- “\\\\\ > .
Šºš à iès āşş
* ...: §§ & ºft.
gºs Nº.
t ==Rºl
ti i. lºl ſ
Reduction by foot im axilla. (ERICHSEN.)
°ºnot thus be replaced. In using this method the governing principles
Which have been already set forth are to be employed for the various
humeral dislocations as follows: For the subglenoid variety the forearm
is flexed upon the arm to relax the long head of the biceps. The elbow













32
498 DISE ASES OF JOINTS, C A RTIL AGES AND LIG AMENTS,
is then grasped, and the arm raised by abduction to the side of the patient's
head to relax the deltoid and supraspinous muscles. Now the forearm is
supinated to relax further the long head of the biceps. Whilst the arm
is held in this position by one hand the surgeon places his other upon the
prominent humeral head in the axilla, and as the arm is drawn outward
to a right angle with the body, lifts the head into its socket.
Subcoracoid and subclavicular dislocations are reduced in a similar
manner, save that after elevation the arm is to be rotated outward before
being carried down, that the spinati and teres minor muscles may be still
further relaxed.
In dealing with the subspinous variety the arm after being carried by
extreme abduction to the side of the head is rotated inward to relax the
subscapularis, when the bone may easily be replaced by direct pressure
from the fingers during adduction. Manipulation failing, the elbow
should be grasped and drawn forcibly upward, while at the same time
downward pressure is made upon the shoulder by the other hand. Next
the surgeon may stand behind the patient's couch, place his foot upon the
shoulder, and make rocking to-and-fro traction and rotation.
If even after this manoeuvre the dislocation persist, the surgeon must
place his unbooted foot in the axilla for counter-extension and make
forcible traction upon the arm.
Other methods of reduction are: by right angle traction, using for
counter-extension either the bootless foot upon the chest-wall, or a sheet
wound around from the opposite side; by bending the arm down over the
knee acting as a fulcrum in the axilla;
FIG, 305. by placing an air-bag or other pad in
arºsa the axilla and bandaging the lower
#º arm as closely to the side as possible,
}\ which has proved successful, if kept up
for days, even in seemingly hopeless,
acute, or ancient cases; and lastly by
force in the direction opposite to that
of displacement. After replacement
the arm must be kept in a Velpeau
or other similar bandage for a week,
and great care must be exercised in its
use for a much longer period.
Treatment of old humeral disloca-
tions is always attended by great danger
of serious accident. Unless contra-indi,
cated by the history, a luxation of
the humerus is scarcely ever too old to
try reduction upon. But if the history
indicates great inflammation and the
likelihood of arterio-venous adhesions,
the deformity had best be let alone or
Reduction by knee in axilla. (Cooper.) treated by other means than reduction.
- If determined upon, reduction must be
attempted by separation of adhesions repeated a number of timº
before the final operation, when manipulation and force are employed.
This failing, if the deformity justitifies so severe a measure, the neck of
the bone may be sawn through, and a false joint established, or its head
exsected. Various accidents frequently occur during forcible treatment

S P E CIA. L DIS LOC ATION S. 499
of these dislocations, consisting of rupture of vessels, nerves, muscles, or
of the neck of the bone itself, and abscess. Wounds of the bloodvessels
may be apparent at once by the sudden formation of a fluid tumor in the
axilla, or may announce themselves later in the shape of formation of an
aneurism or varix. If the artery is torn the wrist pulse is absent, and
FIG. 306.
A $ Zºº
5 tº: 3
§ º
- º-
º £º Y.
& tº §ſº | * *- _-- T.
ğ Nº g Ç.rtººn º
ę- y R A NY. 2: …- - - ----- **------
~ Hºs *
- º { - , s * *-----"
& Žº ºf as * º º * 2-z * *-ºs-
| fººº..."
sº #. Üß 1, Aw, I',
wº *—ºº-º-º-º:
t W § r=
\{A
gº! Q
WYZºº º E-º *mºsºm-º.
Ç Sº -- º ——-T: -
Reduction by upward traction. (CoopFR.)
probably the rapidly formed tumor in the axilla will have pulsation and
bruit. Tumors appearing in the axilla at any time after a dislocation of
the humerus should excite suspicion and always be auscultated before
any operation upon them is undertaken. Only general principles can be
given for the treatment of these accidents. If the artery be torn, ligation
of the subclavian or pressure thereupon whilst the tumor is slit open and
the torn ends each secured, is recommended. Venous rupture can be
dealt with in the same manner, or, if possible, by simple pressure. Rup-
ture of nerves may be repaired by their secondary suture. Fractures and
ruptures of muscles often prove advantageous from the subsequent relaxa-
tion and formation of an artificial or false joint, but motion after fracture
must be very guarded lest the vessels be torn by sharp edges or spicules—
a far from imaginary danger. -
Conjoint Dislocations of Radius and Ulma.
Conjoint dislocations of the radius and ulna take place at the elbow,
and in either of four directions: backward, forward, inward, and outward
(or laterally). The backward dislocation is much the more common,
usually being produced by indirect violence acting through the forearm
When the elbow is extended. The bones are thrown in various positions
under and behind the condyles of the humerus, and further drawn up by
action of the triceps. The capsule is torn and the arm rigidly flexed at
about a right angle, although occasionally some flexion and extension, or
$Yen lateral motion, may be present. The forearm is shortened and the
biceps and brachialis anticus are very tense. Great pain is apt to follow
any motion.
Usually the diagnosis is palpably evident, but in case of doubt anaes-
thesia will quickly make it certain as well as allow thorough replacement.












500 DISE ASES OF JOINTs, CARTILA GES AND LIGA MENTs.
This is to be accomplished by making traction upon the forearm and
backward pressure upon the lower end of the humerus by a hand or by
FIG. 307.
//// A.
º > # ! ! r
Ç ſº ,, , , , , Zzz Sulu.… Sº
&\! %22. N.N.N.N. v. x , Z////// ./////ſ.Lºllittitut re u_%
- º %2 a " * “...au/.
- ***** --
~
- ? — `-
% |
~. --> *-
25.27 -->
* 't - I W
-2 * , *///zz, -*" 11
a * , -Nvv */zzzzz,, --
t
º " ſ ºlºr
غ ſº &A
&^%!º N
-N.
Backward dislocation of radius and ulma. (LISTON.)
the knee, or the latter may be employed as a fulcrum around which to
bend the forearm. When by one of these methods the bone is brought
into position the forearm is flexed and
thus retained for two or three weeks; FIG. 309.
then passive motion is instituted. Stiff.
ness need not be anticipated in disloca-
tions of the elbow.
FIG. 308.
Yºº º º
Sºº
§§2
º
º sº
*{A}<
* 2%
W.-: º
N º º | º
ſ
º
wº
r
º
:*:
º
/
ſ
i
f
-*
§āş
§
Sº
§
Backward dislocation of radius and ulma, Reduction of dislocation of radius *
(GRoss.) ulna backward. (HAMILTON.)


















S P E CIA 11 D IS LO C. A. TI O N S. 501
Dislocations of the Radius and Ulma Forward.
Dislocations of the radius and ulna forward are unusual without frac-
ture, being produced by direct violence. The forearm is supinated and
lengthened, and at a right angle with the arm.
Treatment consists of forced flexion and extension, and counter-exten-
sion, or flex and press down upon the forearm.
Lateral displacements of the radius and ulna are rarely complete.
They are unmistakable and treated by moderate extension and direct
pressure.
Divergent Dislocations of the Radius and Ulna.
Divergent dislocations of the radius and ulna occur, but are very rare.
The bones are both dislocated but do not accompany each other. There
are two varieties, the antero-posterior in which the ulna is thrown behind
the humerus and the radius in front, and the transverse where the ulna is
displaced to the inner side behind the epitrochlea and the radius to the
opposite side of the humeral condyles. They are to be diagnosed and
treated upon general principles.
Dislocations of the Radius.
In luxations of this character the head of the radius is thrown from its
annular ligament and socket, either forward, outward, or backward. The
former direction is taken most frequently. The head is absent from its
FIG. 310.
Backward dislocation of the head of the radius. (GRoss.)
FIG. 311.
Forward dislocation of the head of the radius. (GRoss.)
normal position and present in a new locality, but the other bones of the
elbow are in proper position.


502 DISE ASES OF JOINTS, CARTILA GES AND LIGA MENTs.
Reduction is often very difficult, but to be attained usually by extension
and counter-extension in the direction of dislocation plus direct moulding
pressure. Retention after reduction is frequently impossible, but fortu.
nately no great deformity or loss of function ever results if dislocation
persists. An anterior angular splint and direct compress must be kept
on for three weeks.
Dislocations of the Upper End of the Ulna.
Dislocations of the upper end of the ulna take place in a backward
direction as a result of indirect violence. The injury is a very common
complication of high radial fracture.
FIG. 312.
Dislocation of upper end of ulna. (CoopFR.)
The radial head remains in position, but the ulnar extremity is displaced
beneath the condyle of the humerus; the forearm is rigidly fixed at a
right angle and pronated. Reduction is accomplished by placing the knee
in front of the elbow and making right angle traction upon the forearm
and direct pressure upon the displaced end of the ulna. This failing the
forearm should be hyperextended and traction made upon it, thus con-
verting the ulna into a lever of the second class, which brings the coronoid
process over the condyles of the humerus.
Dislocations of the Lower End of the Ulna.
Dislocations of the lower end of the ulna, from its articulation with
the radius, take place in either forward, backward, or inward direction;
the forward variety being induced by violent supination of the forearm,
and the backward form by forcible pronation. Reduction is easily accom-
plished by fixing the radius and then restoring the ulna to proper position
by direct pressure. Antero-posterior splints should be kept on from three
to four weeks.
Dislocations of the Carpus.
This dislocation almost never exists without fracture. The direction of
displacement is either forward or backward, and is to be diagnosed by the
abrupt angle formed by the displaced carpus and the extremities of the

SPECIA. L DIS LOC ATION S. 503
radius and ulna, and by the relation of the former to the processes of the .
latter, more especially to the styloid process of the radius. . Restoration is
effected by extension and backward and forward motion of the hand.
FIG. 313.
Backward dislocation of carpus. (FERGUSSON.)
Dislocations of individual bones of the carpus occur in an upward
direction and have been twisted out of place. Manipulation and direct
FIG. 314.
Forward dislocation of carpus. (FERGUsson.)
Pressure will usually reduce them, but failing in this they should be ex-
°ised through a sufficient incision. A pad, palmar splint, and bandage
must be applied and worn for about a week.
Dislocations of the Metacarpal Bones.
Dislocations of the metacarpal bones are not uncommon, in direction
º either an upward or backward direction, and are easily reducible
y the usual method of extension and pressure.
Dislocations of the Phalanges of the Hand.
Dislocations of the phalanges of the hand are of common occurrence,
usually taking place at the metacarpo-phalangeal junction. They are, as


504 DISE ASES OF JOINTS, C A RTILA GES AND LIGAMENT's,
a rule, difficult neither of recognition nor treatment; simple traction by
the hand of the surgeon, perhaps assisted by a clove hitch about the in-
FIG, 3.15.
Extension by Indian puzzle. (BRYANT.)
jured finger, or by the Levis or “Indian puzzle” apparatus, usually suf.
ficing for restoration.
FIG. 316.
—%. I f gº U-
•- ~2. s.-- Sºl Nº. yºs
3 ** * tº-º º xt D | Šs
*N (@, a “NX. mTL-III, ſº ſåſſº §
~sse-SS s== arr-2 *J -
[& * is-º
Levis’s extension apparatus.
But at times one of the displaced bones becomes entangled, and then
skilful manipulation, or even division of the constricting band, will be-
come necessary. Especially is this
FIG. 317. true of backward dislocations of the
&#s proximal phalanx of the thumb. In
this luxation the head of the meta-
carpal bone may slip through the in-
FIG. 318.
*
E.ºr-sº§=<šs§:s§
-
i
i
d-
:
:
s:#ff
Nº Sº-º:
*
*
.*
liff. % *
d |
º
N
2.
2.
% º 5
º 2^
- Backward dislocation of proximal phala”
\ . ^ of thumb, showing metacarpal head thrust
Dislocation of proximal phalanx of through and held by heads of short flexor
thumb backward. (AsHHURST.) muscle. (AGNEw.)
















S P E CIA. L. D IS LO C A TI O N S. 505
terval between the two heads of the short flexor muscle, when forcible
reduction becomes impossible.
Reduction must then be accomplished by manipulation as follows:
extend the thumb upon the wrist until its tip points to the elbow, when
the end of the phalanx will press upon and separate the then relaxed
heads of the short flexors; then place a finger behind the phalanx to pre-
vent its head slipping upward, and bring the thumb down to its proper
position. This manoeuvre failing, the restricting tendon must be divided by
subcutaneous or open incision. The parts, in any case, must be kept at
rest by a spica of the thumb or splint for three weeks. Old dislocations
of this joint may demand, should all of the above measures fail and dis-
ability justify, the excision of the metacarpal head, or even amputation
of the member through the metacarpo-phalangeal joint.
Dislocations of the Femur.
Luxations of the femur take place at the hip-joint, and comprise about
nine per cent. of all dislocations. The head of the femur, after leaving
the acetabulum, may occupy any position about the joint, depending upon
the direction of the applied force, the position of the limb at time of
accident, and the extent of liga-
mentous and muscular lacera- FIG. 319.
tion. As a rule, regular dislo-
cations may be said to occur
when one or both branches of
the ileo-femoral ligament remain
intact, and the irregular or
anomalous when that ligament
is extensively or completely
lacerated. The rôle of this liga-
ment in the production and
treatment of hip dislocations is
of extreme importance. It origi-
nates upon the front and outside
of the anterior inferior spinous
process of the ilium, crosses
downward, spreading over the
anterior surface of the hip-
joint, and divides into two por-
tions; the outer to be inserted
into the trochanter major, and
the inner into the trochanter
millor. This ligament being ex-
tremely, powerful, usually pre-
vents the head of the femur
quitting the acetabulum save in
a posterior or lateral direction.
Femoral dislocations are al-
Ways caused by indirect violence,
and may be classed in two great
divisions: those where the head Ileo-femoral ligament. (BIGELow.)
is thrown anteriorly to the gle-
noid Cavity, or forward dislocations, and those where it is displaced pos-
teriorly, or backward dislocations. Of each of these classes there are

506 DISE A SES OF JOINTS, C A RTILA GES AND LIGA MENTs.
two principal varieties, which will be described, also a great number of
unpractical subdivisions which will not be separately considered. Back-
ward dislocations comprise more than three-fourths of hip displacements.
They are divided into those directly backward into the sciatic foramen
(ischiatic), and those backward and upward upon the dorsum of the ilium
(iliac). The upward variety is most common of all hip dislocations,
whilst the directly backward dislocation ranks second.
Of forward dislocations we have the forward and downward into the
thyroid foramen, and the forward and upward upon the pubis, or pubic
dislocation; the latter being rare, but the former ranking third of all hip
displacements. The capsular and round ligaments are invariably torn,
and the femoral vessels may be injured in forward, and the sciatic nerve
in backward dislocations.
Femoral dislocations are invariably to be first treated by manipulation
under profound anaesthesia, but should this method fail, then extension
and counter-extension in the line of dislocation may be judiciously em-
ployed; but should both measures prove inefficient after several trials, at
intervals, incision and division of the restricting tissues, section of the
neck, or even excision of the head, should receive consideration.
Posterior or Backward Dislocations.
When these dislocations occur the capsule is ruptured posteriorly upon
its outer aspect, and the head of the bone is shot in a backward or upward
and backward direction.
Backward and Upward (Iliac or Dorsal) dis-
JFIG. 320. placements take place when the limb is abducted
and forcibly rotated inward, or by a force applied
from below when the legs are crossed. Simple
inward rotation, however, may prove sufficient for
its production.
SYMPTOMs.-The thigh is somewhat flexed and
adducted, the knee of the injured thigh is slightly
above and in front of its fellow, and is in contact
with the lower and inner portion of the oppo-
site thigh. The foot is forcibly inverted and the
ball of the great toe touches the inner portion of
the opposite instep. The injured hip is exceed-
ingly prominent, whilst the head of the femur can
usually be felt upon the dorsum of the ilium.
There is shortening of the injured limb to the ex-
tent of from one to two and a half or three inches,
according to the height of the head upon the ilium ;
flexion and extension are moderately interfered
with, but the motions of adduction and abduction
are almost impossible. Numbness or tingling of the
sciatic distribution may or may not be present, but
in any case always is moderate.
Backward and upward Backward (Ischiatic) dislocations occur whilst
(or iliae) dislocation of the thigh is at right angles with the pelvis and is
the femur. (CoopFR.) abducted and rotated inward; the head of the femur
is displaced directly backward and comes to a stand-
still in the sciatic foramen. Portions of the glutei, gemelli, and obturator
externus muscles are usually lacerated by the head in transit.

SPECIAL DIS LOCATION S. 507
SyMPTOMs.-The thigh is slightly flexed, inverted, and adducted; the
knee touches the opposite limb at the inner and upper margin of the
atella.
p The extremity of the great toe of the injured side just touches the
metatarso-phalangeal articulation of its fellow. Shortening never exceeds
half an inch, and may even be lacking,
Its presence is best demonstrated, as FIG. 322.
suggested by O. H. Allis, if the thighs
be flexed to a right angle with the
pelvis and the condyles of the femurs
compared.
The hip is somewhat prominent.
Numbness, tingling, or palsy of the sci-
atic distribution may be very marked.
The head of the femur is lower and
less prominent than in the upward
FIG. 321.
**-- - -
Allis's test for shortening in backward Backward (ischiatic) dislocation of
dislocation of femur. the femur. (CoopFR.)
and backward displacement, and the psoas and iliac muscles being tense
the trunk is thrown slightly forward. Rectal or vaginal examination
may clear up a doubtful diagnosis by demonstrating the head in the
Sciatic foramen.
Treatment of Posterior Dislocations (Iliac and Ischiatic).
Reduction can almost always be accomplished by manipulation. The
Patient should be etherized to relaxation and placed flat upon his back.
The surgeon then grasps the leg at the foot and knee, flexes the leg upon
the thigh and the thigh upon the abdomen; then adducts the limb and
*9tates it outward, carries it to the sound side, sweeps it outward across
the abdomen, and brings it out straight, when the head will return to the
socket, perhaps with a very audible snap.
. It will be observed that during these manipulations the ileo-femoral
ligament is relaxed by flexing the thighs, which also in the simple back-
Ward dislocation frees the head from possible entanglement with the
*ndon of the obturator internus; that external rotation and circum-

508 DISE A SES OF JOINTS, CARTILA GES AND LIGA MENTs.
duction winds the outer branch of the ileo-femoral ligament around the
neck of the fermur and thus carries the head over the acetabular rim and
into normal position. Extension and counter-extension in the line of dis.
FIG. 323. FIG. 324.
Reduction of backward (iliac Mechanism of reduction of backward disloca-
and sciatic) dislocation of the tions of the femur. (AGNEW.)
femur. (BIGELow.)
location may be judiciously employed should manipulation fail, but if
both prove inefficient after several trials at intervals, open arthrotomy, or
section of the neck or even excision of the head should receive con-
sideration.
Anterior or Forward Dislocations.
Forward and downward (thyroid or obturator) dislocations result from
the application of force when the limb is abducted; the inner and posterior
portions of the capsular ligament are torn and the head of the femur is .
thrust into the thyroid foramen and rests upon the obturator externus
muscle.
SYMPTOMS.–The limb is lengthened from one to one and a half
inches, abducted, and the heel is somewhat raised when the patient stands,
The toes point forward and may be everted; the hip is flattened and
the trunk is inclined forward and to the injured side. The femoral head
can be distinctly felt below the horizontal ramus of the pubis. These
symptoms are to be interpreted as follows: abduction is due to tension of
the glutei muscles and to the tenseness of the inner branch of the ileo-
femoral ligament; the body is inclined to relax the stretched psoas
magnus and iliacus muscles.
TREATMENT must be conducted whilst the patient is fully relaxed by
anaesthesia. Reduction is accomplished by manipulation, exactly as for
backward dislocations, save that inward rotation and circumduction are
here employed. e
Thus the psoas muscle and ileo-femoral ligament are relaxed by flexion,
and the internal branch of that ligament is wound about the neck of the
femur in inward rotation and circumduction, and draws the bone over
the acetabular rim into position. e
Anterior luxations may be converted into posterior varieties during
manipulation, when obviously rotation and circumduction must be made
as for reduction of the latter class.

SPEC I A L DISL O C A TI O N S. 509
Forward and upward dislocations (pubic) are quite rare and most in-
frequent of all femoral displacements. Hyper-extension of the thigh,
FIG. 325.
FIG. 326.
Forward and downward dislo-
cation (thyroid or obturator) of
Forward and downward dislocation of the femur.
the femur. (Cooper.)
(BIGELow.)
FIG. 327.
\
2 < .. & º e
Reduction of forward dislocations
* * * Mechanism of reduction o
(iliac, thyroid and pubic) of the locations of the femur. (BIGELow.)
femur, (BIGELow.)
plus an inward rotary motion or a blow upon the foot are the most usual
*ans of production of these unusual injuries. The anterior inner por-




510 DISE A SES OF JOINTS, CA RTIL AGES AND LIG AM ENTs.
tion of the capsular ligament is lacerated and the head of the femur
rests usually upon the pubis in front of the horizontal ramus, although
exceptionally it may not be arrested before
FIG 329. it has even passed above the pubis.
Fº SYMPTOMS.–The linb is shortened and aly.
ducted, the foot much everted, the thigh some.
what flexed, the heel is raised a little from the
IFIG. 330.
* f : %:==S$
s ſ/ º %: *:::=ES
º %%: 2
W. % %
2% - \\
\
ºft/ 2^ /* §
W. ź% / al
غš
ſ Ø ... lºcºş
Aſ' .. §s
g *
º
# {
:
** {
º
. # * iſ: º º
ºjº.
... • *-ºs \\ *Nº. Nº ºn
º
&m.
ºft
º
*
t
%2%
S
Šis
SJ-s
GS
=jº
:=lsº
: #=
Forward and upward (pubic) dis- Forward and upward (pubic) dislocation
location of the femur. (CoopFR.) • of the femur. (AGNEw.)
ground, and the bony head can be felt in front of, or above the pubis.
Abduction and eversion are due to tension of the anterior branch of the
ileo-femoral ligament and external rotators of the hip. Reduction is
attained by the same manipulation as for forward and downward displace-
ment, but flexion and abduction, previous to internal rotation, should be
more decided.
Old Dislocations of the Femur.
Femoral luxations are termed old when they have remained unreduced
upward of six or eight weeks; reduction has been accomplished many
times when the injury had persisted to periods as long as five years.
Prudent attempts should be made in any case, regardless of duration, by
appropriate manipulation and extension and counter-extension; never,
however, employing great force or persistence. If there is a history of
inflammation, or if great changes have occurred in the acetabulum or
femoral head, manipulative efforts should not be attempted. In any case
if deformity and disability are great section of the femoral neck or excision
of the head may become permissible. Subtrochanteric section of the femur
may, in other cases, be employed with good results, and should fracture
occur at or near this point during reduction endeavors it will be fortunate
as then passive motion can be kept up and a useful false joint thereby






















S P E CIA. L I) IS LO C A TI O N S.
511
secured. Paralysis of the nerves, or pressure upon blood vessels may
demand operation.
abscesses may follow any interference.
The Sciatic nerves may be torn during reduction ;
Dislocations of the Tibia.
Dislocations of the tibia occur at the knee-joint and include 1 per cent.
of all dislocations.
backward, outward, and inward. Rotary
dislocation also, but rarely, is produced
by twisting force. Any of the prin-
cipal varieties may be complete or par-
tial. These injuries, especially if com-
plete, are always serious, and are.
accompanied by such extensive lacera-
tion of ligaments and surrounding tis-
sues and vessels as to demand excision
or amputation. The popliteal vessels
and nerves are especially liable to
stretching or rupture; a clot may sub-
sequently be formed in the artery. The
direction of displacement can be recog-
nized with facility by the bony land-
marks of the joint, but occasionally,
when complications or great swelling
have occurred, anaesthesia may be neces-
sary to confirm or make the diagnosis.
Shortening will be present if there is
overlapping; the part may be either
rigid or flaccid. The direction of the
foot will indicate rotary dislocation
and its direction, should the displace-
ment have assumed that type; the
crucial ligaments are almost invariably
torn.
Reduction of tibial dislocations is
made by traction, extension; and oppo-
site rotation for the rotary variety.
Subsequent rest upon a posterior splint
for several weeks is essential. Then
massage and passive motion. Anky-
losis of varying degree is apt to suc-
ceed.
According to frequency, dislocations occur forward,
FIG. 331.
;|
%
º2
r--
s
2
º
º
-º
º
º
OF FENTUR
%,...au.º-HEAD OF TIBA
PAT eux-Kº ſº.";
, 2.3 e .*
Zºº &. - £---
º 3.3%.3
*** firiº
:
S$
§§§§
§
w
Roberts's case of unreduced dislocation
of patella.
Dislocations of the Patella.
Dislocations of the patella occur with outward or inward displacement
of that bone or it may be partially or completely rotated upon its axis,
9r the latter may occur
location,
in conjunction with the former.
because of the axes of insertion of the patellar ligaments, is
Outward dis-
3. $9mmon; all are caused by muscular contraction or direct violence.
*plete rotation has twice been reported, and cases of habitual luxation
are upon record.
* *
& 8 tº *
te *
i.
:
:
.
º:
:
:
:


512 DISE A SES OF JOINTS, CARTIL AGES AND LIGA MENTS,
Reduction is effected by rapidly succeeding partial flexions and com-
plete extensions of the leg, plus manipulation of the bone itself and
pressure in the direction opposite to that of dislocation. This failing,
especially in complete rotations, incision and forcible replacement be.
come necessary.
Dislocations of the Fibula.
Dislocations of the fibula take place at either of its extremities. The
bone is forced from its tibial articulations, and forward, upward, or back-
ward displacements are possible. To reduce them the knee is partially
flexed and direct pressure is applied, and succeeded by splint or bandage.
Dislocations at the Ankle-joint.
. Under this head are included only dislocations of the foot as a whole
from the tibia and fibula. These occur backward, forward, and laterally,
are most frequently associated with fracture, and as often difficult to dif-
ferentiate therefrom. Lateral dislocation is almost always associated with
fracture of a malleolus. They are to be reduced by flexion of the leg,
direct pressure, and manipulation of the foot. Should contraction of the
calf muscles constantly reproduce the dislocation and not be controllable
by a temporary tight bandage, the tendo-Achillis must be divided.
Dislocations of the Various Bones of the Tarsus.
Dislocations of the various bones of the tarsus are not infrequent inju-
ries, easily diagnosed, and are treated by direct pressure, manipulation,
or should these methods fail, by excision of the displaced bone.
The astragalus may be dislocated backward, forward, and outward, or
forward and inward, In the former variety the extremity is shortened,
the astragulus may be felt in front of one of the malleoli, whilst the foot
is extended and twisted to the opposite side. When displacement is back-
ward the foot is extremely flexed, the instep is short, and the heel elon-
gated. The astragalus is to be felt beneath the distorted and tense
tendo-Achillis.
Reduction of the forward and lateral varieties can usually be performed
by flexion of the leg, traction upon the foot, and direct pressure upon the
astragalus. Division of the tendo-Achillis may assist in replacement.
Backward dislocations usually prove irreducible, and the bone should be
excised at once or at a later time.
Metatarsal dislocations and those of the phalanges of the toes are rare
injuries, usually due to crushing force necessitating amputation; other-
wise they are to be treated upon general principles of reduction.
DISLOCATION OF CARTILAGES.
Dislocation of the Costal Cartilages.
Dislocations of the costal cartilages from their various junctions with
the sternum, the ribs, and from their points of mutual contact, are poss!"
ble, but of very infrequent occurrence. Direct or indirect force is always
the causative factor.
*
• * * • , o, . * *
s' **
* *
A * *
' (y,
SPECIA. L ID ISL O C A TI O N S. 513
Symptoms are undue prominence or depression at the seat of articula-
tion, undue mobility, perhaps modified crepitus, pain, or disturbed respi-
ration. These displacements are to be treated by moulding, manipulation
of shoulders, forced expiration or inspiration, and after reduction are to
be kept in place by means of suitable pads or bandages.
Dislocation of the Ensiform Cartilage.
Dislocation of the ensiform cartilage has only twice been reported ; in
both instances backward and by direct force. Symptoms were intense
gastric pain, and vomiting, embarrassed respiration, absence of ensiform
upon palpation. Reduce by same methods as for dislocated costal carti;
lages. If distress is great, and these methods fail, a hook may be inserted
through the integument and beneath the tip of the ensiform, when it may
be drawn back into position. Or a finger may, through an incision, be
likewise hooked under the cartilage. If it cannot be so reduced, or if dis-
location is constantly repeated, then nothing will remain but to excise the
offending cartilage through a vertical incision of its own length directly
over it. The cartilage is then seized with lion forceps, its surrounding
attachments carefully divided, it is withdrawn, and the wound sutured
with or without a small drain.
As life advances dislocations of chest cartilages give place to fractures,
because of the ossific deposits in these cartilages in the aged. Treatment
would be the same as that for fracture of the respective proximal bones.
Dislocation of the Semi-lunar Cartilages.
Dislocation of the semi-lunar cartilages is not an uncommon injury;
is directly produced by excessive flexion or a sudden wrench, and is
almost limited to persons of middle age, especially those who have lax
or previously diseased joints. The displacement is generally backward,
but may be in the opposite direction. Both cartilages may participate in
the dislocation, but more usually the inner one alone is affected. Both
knees may be attacked at the same or different times. The etiological
factors are a relaxed or previously lacerated knee-joint or crucial liga-
ments, and excessive flexion; by which the cartilages are forced out of
place, perhaps crumpled upon themselves, and become wedged at some
point between the femoral condyles and the tibia, stretching or tearing
the crucial ligament, if they have not previously been the seat of rupture,
and appreciably separating the articular surfaces of the bones entering
the joint.
SYMPTOMs. During stooping, squatting, kneeling, or other excessive
flexion of the knee a sudden, intense, sickening pain is experienced in
one or both knee-joints. The joint has become locked in a position of
extreme flexion and cannot be extended by the patient or by application
of force. If predisposition exists the accident may happen to a joint
When it is but partly flexed, and when dislocation occurs perhaps throw
the person violently down. Compared with the corresponding joint the
ones entering it are notably separated, and perhaps the displaced carti-
lage can be felt in the interval. If the luxation is not soon reduced
effusion will take place, inflammation arise, and, possibly, abscess later
. Even when early replaced, effusion and a sharp synovitis may
OW.
33
514 DIS E A SES OF JOINTS, C A RTILA GES A N D LIG AM E N T S.
TREATMENT.—The displacement can almost always be reduced instantly
by hyperflexion of the knee over the edge of a table or around a bed.
post, followed, while extension is made by a hand behind the calf, by sud.
den full extension. For this anaesthesia is advisable, as the accompanying
pain is great. Following reduction of such
FIG. 332. cases the joint should be immobilized for
three weeks by a plaster dressing or splint
that inflammation may be averted and the
ruptured ligaments be given a chance to
unite. If reduction cannot be thus accom-
plished after a number of efforts, and in
cases where constant recurrence (which
cannot be prevented by wearing a tense
rubber knee-cap or apparatus which will
prevent more than a slight degree of flex-
ion) renders a patient unfit for occupa-
tion or enjoyment of life, the following
operation, devised by Annandale, should
be forthwith performed. Starting, ac-
cording to whether the internal or ex-
Clamp to prevent dislocations of the ternal cartilage is affected, upon the
semi-lunar cartilage. (MARSH.) inner 9. Outer border of the insertion
of the ligamentum patella, an incision is
carried upward and inward to an extent of three inches, and downward
until synovial membrane is reached.
FIG. 333.
** * *
--E::=:::::::#E::===
====E=#EEE #Nº.3
-- --~~~ ==E=E=-
s===##
E. *3
º::::::: * * º
---> r:--> --> T.:*: ;
:------> - - - - - F- ------- *-
-Etitºr ***=-, -, *.***
Apparatus for cases subject to dislocation of semi-lunar cartilage. (MARSH.)
All bleeding being arrested, the membrane is opened as freely as P08
sible in the line of incision, the offending cartilage caught and pulled to
the surface with a blunt hook or forceps, and there sutured by at least
three sutures of strong catgut to the fasciae and periosteum covering the
tibial head. The synovial and superficial wounds are then separately
sutured and, the limb being extended, a plaster dressing or suitable splin'
is applied and not removed for several weeks, when gentle passive mo"?
ments may be made, and at the end of two months the patient may be




E X CIS I O N OF J O IN T S. 515
allowed to walk. This operation failing to give relief, the affected
cartilage may, through a similar incision, be bodily excised.
OPERATIONS UPON JOINTs.
Aspiration of joints is performed by introducing an aspirator needle
through the perfectly cleansed integuments, usually at the most promi-
nently distended point, into the joint cavity, and thereby withdrawing the
fluid contents.
Washing out or irrigation of joints may be performed either by pump-
ing the irrigating solution through the aspirator needle, and then sucking
it out again, by introducing two canulae upon the same or opposite sides
of the articulation and pumping in through one and out through the
other, or by making a short incision in the axis of the joint and through
it pumping the fluid.
FIG. 334.
Nº º } \\ #| º
W//º \\ & % i *
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Aspiration apparatus.
Exploration of joints is accomplished through incisions exactly similar
to those for excision of the corresponding joint, whereby the articulation
is laid open to touch and sight. -
, Erasion of a joint indicates laying it open as for excision, and, if the
disease is found to involve simply synovial membrane, ligaments, or Super-
ficial cartilages, removal of the affected parts by knife, scissors, or curette
Without interference with bone, afterward washing the cavity out and
treating, it as if excised. If thoroughly performed and early enough
undertaken this operation yields excellent results. *
ExCISION OF JOINTs.
By excision of a joint is meant the total or partial removal of the
*ticular surfaces and other structures comprising the articulation, or the
*Y*l of a portion of bone where ankylosis has taken place. Its
object is to secure total eradication of the disease with, in some instances,
Subsequent bony ankylosis, in others pseudo-arthrosis, or fibrous union.
ontra-indications are: very extensive bone or surrounding tissue in-










516 DISE A SES OF JOINTS, C A RTILA GES AND LIGA MENTs.
wolvement, Osteomyelitis, advanced age, organic complications such as
phthisis, amyloid disease, diabetes or nephritis, great exhaustion. Ex-
cision should never be performed for malignant disease of joints or
neighboring bones.
Excision may be indicated for:
(a) disease,
(b) ankylosis,
(c) injury.
(a) Disease most often demands excision. Chronic synovitis and the
varied forms of arthritis furnish a large majority of operations. Bone
abscess opening into a joint, and chronic gonorrhoeal or rheumatic
arthritis occasionally demand it.
(b) Ankylosis of certain joints, such as the elbow, knee, or jaw in
awkward positions, may justify excision.
Bad positions of the hip and shoulder always, and those of the knee
and jaw sometimes, can be better corrected by Osteotomy of proximal
bones than by excision. When the elbow, shoulder, or maxillary articu-
lations are excised, fibrous union and false joint should be striven for.
(c) Excision is unsuited for violent crushing, or very extensive gunshot
wounds of joints, or in those where the popliteal vessels are involved.
But in certain common shot wounds, fractures into joints, and disloca-
tions, it is eminently appropriate. In these, if bony ankylosis is not de-
sired, often a partial excision, as of one articulating surface, will suffice.
Excision may also be indicated for old unreduced or constantly recurring
dislocations, as well as for acute joint disease following injury or opera-
tion.
FIG. 335. FIG. 336. FIG. 337. FIG. 338.
Aº
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Bome-cutting pliers. Bome forceps.
OPERATIVE METHOD.—The instruments required for excisions .
ordinary dissecting instruments, retractors, a large-bellied stout scalp"

EXCISION OF JOINT S. 517
cartilage knife, bone raspatory, a strong hernia bistoury to divide liga-
ments, blunt bistoury, various bone forceps and cutting pliers, a Butcher,
motacarpal, Adams, and chain saw, stout bone gouges, a periostal elevator,
FIG. 339.
Chain saw.
curettes, chisels and mallet, drill, and bone or steel nails. Extra large
catgut may also be required for suturing bones together. Avascularity
should be secured by Esmarch's rubber band if the joint has not sup-
purated; otherwise simple elevation of the extremity followed by the
FIG. 340.
º
:----> º 77,7272^ & @º ‘º:
ass & PT .......----,
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- º NSSSSSSSSSSSSº...------------" -----eº
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* * * * * * * * * * * * = ** ****
Forceps for grasping large bones.
application of a tourniquet must suffice, for the danger of forcing pus,
etc., into the blood-current is considerable. -
, Incisions should be single, as straight and direct as possible, avoid
Sinuses, and be kept away from important bloodvessels and nerves. Mus-
FIG. 341.
Adams's osteotomy saw.
cles should not be cut if the incision can be carried through inter-
muscular septae. The joint having been laid freely open, all diseased
*ues are eradicated. "So far as the bones are affected they should be
*moved, but never more, especially in cases of epiphyses, than is abso-






518 DISE ASEs of Joi NTs, CARTIL AGES AND LIG AMENTs.
lutely necessary. Experience alone can teach the difference between
simple congested or inflamed cancellous tissue and that which harbors
infectious disease. Often diseased foci can be gouged or chiselled out of
|Fig. 342.
*śīllūţº
Butcher’s excision saw.
the medulla without further sacrifice of the shaft. In children a stout
knife will often do the work of a saw. The value of epiphyses should
ever be kept in mind. If subsequent bony ankylosis be desired, cancel.
Butcher’s excision pliers.
lated tissue must be exposed upon both surfaces of the joint. All por-
tions of the synovial membrane, other affected tissues, and sinuses, must
then be totally eradicated by scissors, curette, knife, or cautery. Sinuses
should be bodily excised, when possible. If deep and inaccessible, a
curette should be carried into them as far as possible.
FIG. 344.
Barker-Willard irrigation curette.
The tourniquet is now removed, and all hemorrhage stopped. Bleed-
ing from bone medulla can be controlled by a few moments' pressure
with a finger or pad, or by packing in a small wad of fine catgut and
leaving it. Carefully wash out the cavity, insert a good-sized rubber
drain in large joints or a hank of catgut into small ones, restore all parts
to as near normal position as possible, suture, dress copiously, place the
limb upon a proper splint, and always keep it elevated for the first half
day or so. - g
Most joints can be so excised and dressed that but a single dressing
completes the cure. The dressing in no case should be changed under
three or four weeks or more, unless there are distinct indications therefor:



E X C ISION OF J O IN T S. 519
Where fibrous union or false joint is required, dressings may be changed
and motion be commenced in four weeks. When unabsorbable drains
are left in, the wounds should always be dressed and the tubes removed
not later than the first week.
Some form of mechanical support will be required for a long time after
many excisions. y
PROGNOSIS.—With modern methods excisions, when early undertaken,
have come to be quite Safe and successful, and the scope of the operation
has become correspondingly extended. Risk of operation increases as
the trunk is approached.
Evcision of Temporo-maxillary Joint.
Excision of the temporo-maxillary joint is performed by making a one
and a half inch vertical incision downward from a point just behind the
middle of the zygoma, but in front of the temporal artery, carrying it
down through the masseter muscle, exposing the neck of the jaw, dividing
it with Adams's saw or cutting pliers, and then freeing the separated
condyle from ligamentous attachments. Simple Osteotomy of the neck
of the bone is preferable for ankylosis at this joint. Temporary palsy
of some of the facial muscles may follow division of the seventh merve
fibres.
Evcision of Shoulder-joint.
Make a four-inch vertical incision, beginning at the anterior tip of the
acromion process, and carry it downward through an inter-fascicular
partition of the deltoid until the capsule is opened
and the humeral shaft exposed. Free the deltoid FIG. 345.
from its capsular attachments. Divide the capsular
attachments of the head, and also the tendons in-
Serted into the tuberosities, rotating the arm inward
to divide the then tense spinati and teres minor
attachments, and outward for the subscapularis.
Dissect the long head of the biceps from its groove,
and hold it aside. Throw the humeral head outside
of the wound by carrying the elbow across the
chest toward the opposite side and then pressing it
upward and outward. Saw off the head with a
Butcher's or other saw, and trim any sharp edges or
spiculae left. If a common amputating saw is used,
the soft parts must be protected by a disinfected
Strip of wood or hard rubber. Remove all diseased
tissues, gouge out the glenoid cavity, or, if it is ex-
tensively involved, cut it away with pliers. Wash
Out the cavity, control bleeding, drain, suture, and
dress in such position that the cut extremity of
the humerus is in the glenoid cavity. That is, get Excision of shoulder-
he bone into position, dress and bandage as for joint Lineofincision.
facture or dislocation in the same locality. Re-
dress in about three or four weeks, and then, if the wound is suffi-
°iently healed, commence passive motion, massage, and electricity. A
th

520 DISE A SES OF JOINTS, C A RTIL AGES AND LIG AMENTS,
very useful arm may be looked for ; the muscles shorten, and a false
joint forms. Abduction will be much impaired, but the forearm will be
as good as ever.
Evcision of Elbow-joint.
The arm is avascularized by the rubber band or elevation and tourniquet,
slightly flexed and brought over a pillow or block with the olecranon look-
ing upward. Incision is begun two inches above the centre of the olecranon
and carried vertically downward four inches, bareing the humerus above,
the ulna below, and opening the joint in the
FIG. 346. centre. The articular extremities are then separ-
ated from their muscular and ligamentous attach-
ments, great care being observed to dissect the
ulnar nerve from its groove on the inner side of
the joint and to keep it held out of harm's way
during the subsequent manipulations. The nerve
is gotten out by slipping a director into the canal
from above and dividing the outer wall upon it.
Now the olecranon process is cut from the ulna
with pliers, the lateral ligaments, if still present,
are divided with a strong hermia knife, and by
flexing the joint the remaining bones are thrown
outside the wound and sawn off. If permissible,
not more than the articular surface of the humerus,
the olecranon above the coracoid process and the
radius above its tubercle should be taken away.
| The soft parts must be protected whilst the saw-
. . . . * tº ing is done. Eradicate all diseased surroundings,
*ision of *-joint, stop hemorrhage, irrigate, suture, drain, dress and
Line of incision. place the arm upon an obtuse angle splint be-
tween promation and supination to secure greatest
relaxation. Catgut drains will often answer here. Re-dress in three or
four weeks and commence motion. At the elbow false or movable joint
is always desired. A mechanical appliance must usually be worn.
If no more bone than has been indicated is removed the result will be
good and the forearm preserve excellent functions. But if more, espe-
cially of the radius and ulna is taken away, power of flexion is obliter-
ated by removal of the insertions of the biceps and brachialis anticus,
and rotation much interfered with ; in fact, above the forearm the member
will be useless, although below that point all will continue as before.
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Evcision of Wrist-joint.
By excision of the wrist-joint is meant removal of the ends of the
radius and ulna and of the first row of the carpal bones; and, perhaps
also of one or more of the second row, or even of the metacarpal
extremities. Great patience, caution, and anatomical knowledge are here
requisite. The parts are rendered avascular and an incision is made
beginning at or upon the outer surface of the forearm two inches above
the styloid process of the radius at a point just inside the inner margº
of the extensor communis digitorum and carried in a downward and inward
direction along the margin of that muscle and the tendon of the extenso"

E XC ISION OF J O IN T S. 521
indicis, until about the centre of the metacarpal bone of the index finger
is reached. The flaps are now well dissected back, and all underlying
tendons running over the joint freed from their sheaths and held aside by
retractors. If the pisiform bone is to be removed the attachment of the
flexor carpi ulnaris to it must be divided. Occasionally, the extensor
carpi radialis longior, or brevior cannot be gotten out of the way; so
must be divided and the ends marked by threads or otherwise for subse-
quent recognition and suture.
FIG. 347.
º
Excision of wrist-joint. Line of incision.
No tendons should be cut unless positively necessary, but when so, any
number may be freely divided, marked, and after removal of the bones
sutured. All tendons being out of the road, the radio-carpal ligaments
are divided, and, by strongly flexing the hand, the radius and ulna are
thrown out of the wound. Their under surface is then freed carefully
from tendons and nerves and the necessary amount sawn off. The hand
is then brought back, the inter-carpal joint opened and the first row
of bones excised, either individually or en masse, great caution being
observed when working near the radial artery.
The second row should likewise be removed if diseased. If required,
the metacarpal ends can be cut off best with pliers. The synovial mem-
brane and other diseased structures are then carefully removed, the cavity
Washed out, hemorrhage controlled, any divided tendons sutured, and a
drain, dressing and palmar splint applied. Passive motion of the fingers
should be commenced early.
Excision of the wrist is not a favorable operation, and the results are
often Wretched. Still, if even slight use of the fingers is retained, the
Patient will value the member much more than an artificial limb. Ex-
CŞion may be performed in apparently hopeless cases, and, should it com-
Bletely fail, amputation can be done after the member has been given a
final chance. *
Excision of any particular bone or bones of the carpus may be made
by the above (but more curtailed) incision, or by one directly over the
affected area.


522 DISE A SES OF JOINTS, CARTILA GES AND LIG AMENTs.
Eveision of metacarpal provimal evtremities can be made by a one and a
half inch vertical, incision directly over the joint, through which pliers
cut off the extremity.
Evcision of Metacarpo-phalangeal, and Inter-phalangeal Joints.
Excision of metacarpo-phalangeal and inter-phalangeal joints can be
performed through a vertical one to two-inch incision upon the upper
aspect of articulation. Articulating extremities are separated from their
bone shafts by cutting pliers and removed. No drain is required as a
rule.
Evcision of Hip-joint.
Usual Method.—The patient is turned upon his sound hip, and the oper-
ator stands facing the patient's back. Incision is begun one and a half
inches above and a little posterior to the great trochanter, and carried
down vertically in the femoral axis for a distance of five or six inches.
The bone is then exposed for the entire distance. Now the capsule is
FIG. 348.
s = ****
_- ºr * * x
*** **,
* * *s
2 * *
s
A
*
*
t
t
t
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ſ
Excision of hip-joint. Line of incision.
freely opened, and the neck of the femur divided transversely by an
osteotomy or metacarpal saw, or, if in a young child, by cutting pliers.
The head of the bone is then seized by lion-jaw forceps, the round ligament
divided if it still remains, and the separated bone removed. All possible
diseased structures are then eradicated, the cotyloid cavity well gouged out
and irrigated, all bleeding stopped, a large drain carried to the bottom of
the wound, and a copious dressing applied. Outside this, some steadying
apparatus, such as a plaster dressing to the whole limb and chest, exten-
sion and sand-bags of a side splint must be applied to secure perfect sub-
sequent rest of the involved parts. Lateral pressure upon the wound by







E XC ISI O N OF JOIN T S. 523
a hip-band or sand-bag is advantageous for a few days after the operation,
as also is moderate elevation of the limb to promote muscular relaxation
and drainage.
As much more of the femur as may be diseased must always be cut off,
after separating the muscular attachments of the trochanters and inter-
trochanteric line. By sparing the trochanter minor the psoas and iliacus
attachments will be saved. The acetabulum, if diseased, may be cautiously
clipped away. A high-heel shoe will be required upon the affected foot,
and usually some sort of a leg-brace, having attachment to a body corset;
if much of the femur has been taken
FIG. 349. away, crutches, in addition, will be
required.
Second Method.—This is applica-
ble to cases requiring excision in the
earlier stages before great bone de-
struction has taken place or abscesses
FIG. 350.
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Excision of hip-joint by anterior method. Excision of knee. Lime of incision.
Line of incision. (MACCoRMAC.)
have burst through the capsule. Incision begins upon the front of the
thigh half an inch below the anterior superior iliac spine and continues
downward and a little inward for a distance of three inches. In following
his line, the knife gains free access to the capsule and joint by sinking
between the tensor vaginae femoris and glutei muscles on the outside, and
* rectus and sartorius on the inner side. The joint is them opened and


524 DISE AS ES OF JOINTS, C A RTIL AGES AND LIGA MENTS.
irrigated, the saw introduced, and the femoral neck divided in the direc-
tion of incision, and removed after division of the round ligament.
The other steps of operation are identical with the method already
described.
Evcision of Knee-joint.
This joint should always be brought into as extended position as possible
by gradual pulley extension before excision is undertaken ; otherwise
much bone must be needlessly sacrificed, or too much tension excited in
bringing it straight at the time of the operation.
FIG, 35l. The extremity having been made as straight
as possible and avascular, an incision is made from
a point in the centre of the thigh three inches
above the centre of the patella directly downward
to the tubercle of the tibia. (Fig. 350.) The
flaps are then held back and the patella is sawn
through vertically. Next the quadriceps and
patellar tendons are slit to their full extent, the
knee still further bent, and one-half of the
patella and its attachments pulled to each side
as the other bones of the joint are shot out,
and the crucial ligaments divided. The neces.
sary amount of the femoral condyles and tibial
head (usually about half an inch of each) are
then sawn off by either a Butcher saw from
s without inward, or by an amputating saw in
W the opposite direction. In the latter case the
contents of the popliteal space must be pro-
tected by a strip of hard rubber slipped beneath
the bones. Then the synovial membrane or
diseased cancellous structures are eradicated as
usual, all the remaining cartilage cut away, the
tourniquet removed, hemorrhage controlled, the
bones returned, and the cavity well irrigated.
After reduction of the bones, the patella should
be dissected out if found diseased. Care must
be exercised not to wound the popliteal vessels
whilst sawing or cutting away affected soft parts.
The bones may be nailed together by steel nails
through the skin after the parts are sutured, but
it is preferable to drill holes through them and
into these insert powerful sutures of chromi-
cized catgut, or through them drive ivory or
- bone nails, so as to fasten the bones rigidly
Bone drill together. The patella likewise, if not diseased,
is sutured, or drilled and nailed, and the split
quadriceps and patellar ligaments are united by catgut stitches. Drain-
age is to be assured by passing tubes through openings made through the
skin on either side of the bottom of the wound, and one from above,
around the patella into the subpatellar region. Copious dressings and a
long posterior splint are then applied, and the limb kept elevated, for
several days. If the case is successful—that is, bony union and ankylosis
are secured—the patient may be allowed to walk in from eight to tell
weeks. Shortening is obviated by raising the appropriate heel. No brace
will be required unless bony ankylosis does not occur.
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E X CISION OF JOIN T S. 525
Modifications.—If conditions will permit, incision may be made along the
inside of the tendons and patella and that bone and its attachments slipped
entire to the outer side of the joint when the
bones are shot out. Or, if disease is very exten- FIG. 352.
sive, incision can be made transverse and the Ø |
patella sawn through in the same direction. In ſ %
excision for deformity incision may be in either
direction, the flaps separated, and a sufficient
wedge to correct deformity taken from the anky: |
losed bones as a whole. If the case is complicated
by contraction of the hamstring tendons, or if
there is any tension upon these after operation, they
should be divided subcutaneously with a tenotome.
Excision of the knee is almost absolutely safe in
properly selected cases and is in them quite certain
to yield a good result and a perfectly serviceable
limb.
;
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Evcision of Ankle-joint.
After avascularization an incision is begun three
inches above the external malleolus and carried
downward along the posterior margin of the fibula,
around the malleolus and forward to within half §.5
an inch of the base of the fifth metatarsal bone. Bone drill.
The flap is dissected up and the peronei tendons
divided. The lower end of the fibula is now cut with saw or pliers
and the external malleolus removed, when the astragalus comes into
view. The foot is then inverted and the upper surface of the astragalus
sawn off, or the whole excised if extensively diseased. Next the end
of the tibia is cleared of all attachments and the necessary amount
sawn off and removed. If this cannot be readily accomplished through
the primary incision upon the inner surface of the foot, another incision
running around the internal malleolus and terminating at the cuneiform
bone should be made. This flap is dissected back, the tendons, nerves,
and vessels are carefully displaced from their grooves and either the tibia
shot out or a narrow-bladed saw inserted behind the bone and made to
cut from behind forward, the soft parts being meanwhile held aside and
protected. The divided portion of tibia is then freed from attachments
and extracted through either wound. The leg and foot must afterward
be kept upon a right angle splint or in a fracture-box. If it has been
necessary to divide any tendons they must subsequently be sutured.
The results of ankle excision are not gratifying so far as subsequent
usefulness is concerned, although the wounds heal well and the parts
Present a good appearance. Amputation is usually the preferable measure
at this joint.
Pºcision of Metatarso-tarsal, Metatarso-phalangeal, and Inter-phalangeal
Joints.
Excision of metatarso-tarsal, metatarso-phalangeal, and inter-phalangeal
Jºnts is performed in the same manner as are corresponding excisions
of the carpal articulations. But as the digits are comparatively useless,
*d as deformity following the operation may impede locomotion or pro-
duce discomfort, amputation is usually to be preferred to excision.

C H A P T E R X. I X.
RESPIRATORY ORGANS.
SURGICAL DISEASES AND INJURIES OF THE NOSE.
Foreign Bodies in the Nose.
SMALL stones, beads, and peas are occasionally pushed into the anterior
nostrils by children and become fastened in the nasal chambers. Very
rarely small seeds or fruit stones may get into the posterior nostrils during
vomiting. Such foreign bodies, if allowed to remain, set up inflamma-
tion of the mucous membrane of the nose and give rise to an offensive
discharge which sometimes is mistaken for grave disease of the nasal
structures. Foreign bodies should be removed from the nasal cavities by
a small hook, such as comes in pocket cases, or a strabismus hook or some
similar instrument. It is usually necessary for the surgeon to illuminate
the nasal cavities by means of a forehead mirror. When foreign bodies
cannot be removed in this manner they may be washed out of the nostrils
by means of a douche. The tube of the douche is placed in the nostril
opposite to the one which is occluded, while the patient's head is bent
forward with the mouth open. The stream of water then passes around
the posterior border of the septum and into the closed nostril behind
the foreign substance. This latter is then washed out by the current
coming from behind. The foreign body might be pushed back into the
pharynx and thus removed, but there is danger of it falling into the glottis
and of producing asphyxia. It is better, therefore, to extract such sub-
stances from the anterior nares.
Rhinoliths, or nose stones, are concretions of phosphate of lime and
mucus which sometimes form in the nose, having for their nuclei small
crusts of secretion or foreign bodies. These rhinoliths should be removed
in the same manner as foreign bodies. If they are large they can be
crushed previously with a pair of forceps.
Epistaais.
Bleeding from the nose may be the result of injury, or it may occur as
a symptom of fibroid or malignant tumors in the nose or pharynx. . It
occasionally occurs spontaneously, and is due in such cases to congestion,
of the mucous membrane; often associated at the time with congestion of
the brain, cirrhosis of the liver, granular kidneys, heart disease, ScurVY:
or some of the essential fevers. It is due occasionally to impoverished
condition of the blood, and is, as is well known, an early symptom of
typhoid fever. Bleeding is said to occur at times from small ulcers upon
the mucous membrane. tº
Epistaxis is usually exhibited by an escape of blood from the anterlºº
nostrils, but it may run backward into the pharynx and, getting into the
E PISTA X J S. 527
stomach, be subsequently vomited, giving the appearance of haematemesis.
It may get into the larynx and be coughed up in a red, frothy state re-
sembling haemoptysis. Such errors are avoided by examination of the
pharynx and fauces in a good light. When the blood comes from the
nose it will be seen trickling down the posterior wall of the pharynx.
The treatment of epistaxis involves the consideration of the causes
which lead to its occurrence and repetition. The visceral factor in such
bleeding should be treated by appropriate medical means.
Traumatic epistaxis, as a rule, ceases spontaneously and needs no treat-
ment. It should be remembered also that in cases of plethora, in which
there is congestive headache or other symptoms of cerebral engorgement,
bleeding from the nose may be a salutary symptom. Internal remedies,
such as gallic acid, preparations of lead, opium and ergot, are given to
diminish the tendency to nose-bleeding, but are of little value at the time
of its occurrence. In cases of moderate severity the patient should be
made to lie down with his head considerably elevated, and with iced
#,
FIG. 353.
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Method of plugging the nares from in front.
cloths applied constantly on the nose. He should then grasp the carti-
laginous portion of the nose with his thumb and forefinger in such a way
* to keep the nostrils tightly closed. This will prevent respiration
through the nose and thereby permit clots to form, thus arresting the
flow of blood. The firm pressure by the fingers prevents the access of air
*nd gives an opportunity for the clots to close the bleeding orifice. It has
been Suggested that pressure with the finger upon the facial arteries will
limit the amount of blood flowing through the nose and aid in arresting
hemorrhage.
When these simple measures are not sufficient to arrest the bleeding,
and the patient shows signs of great exhaustion from the loss of blood,
** Proper to plug the nose upon the side which is bleeding. This may

















528 R E SPIR A TO R Y O R G A N S.
by done by passing a long and narrow rubber bag, from which the
air has been expelled, along the floor of the nares so that it will extend
from the anterior nostril to the posterior nostril, and inflating it with
air. Pressure is thus made upon the walls
FIG. 354. of the nasal cavities.
The most effectual means of plugging the
nostrils is by means of small pieces of
Sponge threaded upon a strong cord. The
proper method of doing this is to tie a piece
ºº:: of antiseptic sponge, about as large as a
India-rubber inflating tampon for good-sized marble, to the end of a piece of silk
plugging the mares. ligature. The sponge is then pushed along
& the floor of the naris until it reaches the
posterior opening of the nasal cavity. That it has been pushed all the
way back can be determined by the length of the string, or by the surgeon
putting his finger into the pharynx. When this first piece of sponge has
been properly placed, a single string will hang out of the anterior nostril.
A similar piece of sponge with a hole in the middle should now be
threaded upon this string and crowded back by means of the forceps into
the nasal chamber. By thus packing with successive pieces of sponge the
whole nasal chamber from the anterior to the posterior opening, bleeding
is absolutely prevented by pressure of the sponge completely filling the
masal cavity. The sponge may be allowed to remain in place for from
twenty-four to forty-eight hours. If the nose has been thoroughly washed
out previously with an antiseptic solution, which of course must be of the
non-poisonous kind, and if the sponges and silk are thoroughly antiseptic,
there is little danger of putrefaction even when the packing is allowed to
remain for a longer time. Usually, however, from thirty-six to forty-eight
hours is sufficient to preclude the possibility of recurrence of the hemor-
rhage. This method is far superior to the use of Bellocq's canula, or any
modification of the principle by which a string is brought out of the
mouth after being attached to a plug thrust up behind the soft palate.
Nasal Catarrh,
The term masal catarrh is used to indicate inflammation of the mucous
membrane of the nasal cavities. It usually shows little or no ulceration.
There are three forms.
1. Simple nasal catarrh, in which there is a thin mucous or muc0:
purulent discharge without thickening of the mucous membrane and
without incrustation of secretion or fetid odor. *
2. The hypertrophic form, in which the mucous membrane, especially
that over the turbinated bones, is swollen and infiltrated with inflamma;
tory deposits, and in which there is a change of voice and formation of
crusts within the nose. tº
3. The atrophic form, often called dry catarrh, in which there is
atrophy of the glands of the mucous membrane, so that the nasal cavities
are enlarged beyond the normal condition, and are, of course, larger than
is the case during the existence of hypertrophic catarrh, in which, the
mucous membrane is swollen. The atrophic form is accompanied by
great fetor, and seems to be a stage following the hypertrophic conditiºn:
Offensive odor does not seem to be a characteristic of hypertrophiº

3 U R GICAL DIS E A SES AND IN J U R IES OF T H E N O SE. 529
catarrh, unless atrophy has begun in some portion of the diseased mucous
membrane.
The term ozaena is often indefinitely used by surgeons to indicate the
existence of a fetid nasal discharge. The term should be discarded, how-
ever, because such fetid discharge may occur in atrophic catarrh and in
tubercular or syphilitic disease of the nose, as well as from foreign bodies
impacted in the nostrils, and from other causes. Since the term ozºena
conveys no idea of the pathological condition, it should not be employed.
A head mirror and speculum, or rhinoscope, are necessary for the correct
determination of these various conditions.
TREATMENT.-The treatment of nasal inflammations, except when
due to syphilis or gonorrhoea, is not very satisfactory, except in the hands
of a specialist. Various forms of sprays thrown into the nose by means
of an atomizer are valuable; and local treatment of various kinds applied
directly to the diseased area are the most efficient means. Constitutional
treatment is required to aid these local measures, since nasal disease may
depend upon syphilis, tuberculosis, and other conditions leading to bad
health ; but too much stress cannot be laid upon the necessity for efficient
local treatment. Hypertrophied tissue may be removed by the snare, or
by the application of the galvano-cautery, or the curette.
Nasal Polyps.
Tumors occurring within the nasal cavities, as sessile or pedunculated
masses, are called polypi or polyps. The most common form of polypus
is the myxoma, although fibroma, sarcoma, and carcinoma are not very
infrequent.
The myxoma is the one meant when the term polypus is ordinarily
used. These polypi are soft, gelatinous, semi-translucent, pinkish or
yellowish-white masses, which have their attachment to the mucous mem-
brane in the neighborhood of the upper or middle turbinated bones;
although they may arise in the antrum and other cavities connected with
the nose. They seldom grow from the roof or septum of the nasal
chambers, are generally covered with ciliated epithelium, and are mul-
tiple, although one or two of the group generally exceed the others in
size. In shape, they may vary from the globular to the pyriform or
ovoid form.
SYMPTOMS.-The respiratory obstruction due to the condition causes a
Shange in the tone of the voice, giving it the so-called nasal sound. The
interference with respiration is increased in damp weather, because the
tumor swells from absorption of moisture. An increased feeling of stuffi-
ness in the nose therefore occurs under such circumstances. There is
$onsiderable nasal discharge, which is usually not offensive; some frontal
headache at times, and, possibly, impairment of the sense of smell. The
Patient is apt to be continually snuffling, because of the interference with
*Spiration and the flow of mucus. , Obstruction of the tear-duct may
999 ºr secondarily, and the bones of the nose may be pushed out of place,
* that the bridge of the nose is widened by the pressure of the internal
*ors. Reflex cough and asthma have been attributed to nasal polypi.
DIAGNOSIS.–Inspection of the interior of the nose will usually make
the diagnosis clear, since hypertrophy of the mucous membrane and the
* forms of nasal polypi show redness of the surface, very different
from the yellowish pearly color of a mucous polypus.
34
530 R. E SPI R A TO R Y O R G. A. N. S.
If the tumors occupy a high situation, or if they are not very largely
distended by the absorption of moisture, it may be difficult to see them
unless a speculum is used in the anterior nares, or a rhinoscope employed
for the examination of the posterior nares. . The surgeon, by introducing
his finger into the mouth and carrying its tip behind the soft palate, may
sometimes be able to feel a mass protruding from the posterior mares into
the pharynx.
TREATMENT.-Extirpation of the tumors is the proper treatment, and
may be done by the galvano-écraseur, or by avulsion with forceps. The
cautery gives less pain and loss of blood, but, in any event, bleeding is
not important and the pain need not be severe; the latter can be
obviated by painting or spraying the interior of the nose with a solution
of cocaine. When the surgeon desires to pull out a myxomatous polypus
with the polypus forceps, this instrument should be introduced into the
nose in such a manner that the blades open vertically; they should then
be pushed up until the gelatinous masses can be seized near their pedicles
and pulled from their attachments by twisting. The base may be cauter-
ized with the galvano-cautery or some chemical agent. If the polypus
protrudes from the posterior nares, a forceps introduced by the mouth
may sometimes be effective.
Intra-nasal fibroid polyps usually arise from the posterior part of the
septum or from the superior turbinated bone, and may project into the
pharynx, antrum, or pterygo-maxillary fissure. It may occur that the
growth will force its way into the orbit, into the cranium, or out upon
the cheek, having previously caused absorption of the bony walls of the
nasal cavity. Such fibroid tumors may develop in the pharynx and grow
into the nasal cavity, or they may extend from the nose into the pharynx,
thus obtaining in both cases the name of naso-pharyngeal polypi. When
such a growth has obtained considerable bulk it is impossible to determine
whether it has had its origin within the nose or in some of the adjacent
cavities.
Obstruction due to fibroid polypus is more marked than that due to
the myxomatous variety; and the tumor is distinguished by its hardness,
redness, and tendency to bleed, and by the fact that its bulk is not
changed by damp weather. This form of polypus occurs most commonly
in young adults. It is treated by avulsion, ligation, or excision. The
galvano-ecraseur may be found very useful in removing moderate sized
fibroid polyps.
When these growths have obtained considerable size it becomes neces:
sary, if removal is desirable, to separate the nose from the face and turn
down the organ, or to gain access to the tumor by splitting the upper lip
and turning the ala out of the way. The upper jaw may in other instances
be cut loose and turned outward so as to give access to the naso-pharyn-
geal cavity, or the soft and hard palate may be split with the aid of a saw
or chisel. These operations may be undertaken because of the obstrug-
tion which the growth causes, or because of bleeding from it which
threatens the patient's life. It is justifiable to adopt such radical meas:
ures because of the non-malignant character of the tumor; whereas if it
was known to be a malignant tumor such operations would perhaps be
improper since complete removal would be scarcely possible. i-
it is stated that such growths sometimes atrophy in patients reaching
middle life, and that an operation which simply cuts away a portion of
the tumor is preferable to the major operations. Ligation of the twº
SU RG ICAL DIS E A SES AND IN J U R IES OF THE N O SE. 531
external carotid arteries has been practised in order to cut off the blood
supply to the fibroma within the nose and thus assist in its shrinkage.
Malignant polypi, which are sarcomatous or carcinomatous, increase
rapidly, soon infiltrate the surrounding tissue, which undergoes ulceration,
and produce involvement of the lymphatic glands. If operation is not
undertaken very early it is usually futile. Recurrence is frequent, even
after prompt interference.
Adenoid Vegetations in the Pharyna.
In the vault of the pharynx there occur during childhood growths of
adenoid tissue somewhat similar to the hypertrophy of the tonsils, which
is not uncommon at a similar age. This pedunculated, sessile, or fringe-
like growth obstructs the breathing, impairs the quality of the voice, and
interferes with the hearing. It is also apt to be associated with nasal and
pharyngeal catarrh, or enlargement of the tonsils. The hypertrophic
masses may be felt with the finger passed into the pharynx and are apt to
bleed when manipulated. The obstruction to respiration causes the child
to breathe through the mouth, and leads to symptoms pertaining to mouth
respiration. These adenoid vegetations may atrophy as the child increases
in age, but it is often necessary to remove them with forceps or curette
because they induce deafness. The rhinoscope or head mirror is necessary
in these operations. Astringent applications may be of some service in
mild cases.
Deformities of the Nose.
Deformity of the nose may be congenital or the result of injury. Oc-
casionally, as a result of injury, a blood tumor forms between the mucous
membrane of the septum and the cartilage or bone forming that partition.
These submucous collections of fluid resemble abscess of the septum and
appear as soft swellings of the mucous membrane. Abscess is similar in
appearance, but, as a rule, it follows signs of inflammation. Abscess of
the septum should be treated by incision. These bloody extravasations,
however, are usually slowly absorbed.
Occasionally bony or cartilaginous tumors grow upon the septum ;
they are usually near the floor of the nostrils. Such growths may even
extend across the nasal chamber and come in contact with the lower tur-
binated bone, forming a sort of bridge within the nose. It is not unusual
for the septal cartilage to be more or less deformed, either congenitally or
as a result of traumatism. Such deviation of the septum as well as
the cartilage and bone tumors above spoken of, may lead to injurious
FIG. 355.
obstruction which will require operation.
Piagram of deformities of nasal septum from author's “Cure of Crooked Noses.”
Deformity due to syphilitic necrosis of the intra-nasal structures is
*Pt to show itself in depression of the bridge of the nose which causes
the tip of the nose to appear as a small elevation or knob upon the ante-

532 R E SPI R A TO R Y O R. G. A. N. S.
rior portion of the face. The entire nose, or a very large portion of it,
may similarly be lost from syphilitic ulceration. Portions of the nose
may be also removed by wounds, and, therefore, require reconstruction.
Improperly or carelessly treated fractures of the nasal bones and carti-
lage often give rise to very unsightly deformities of the nose, causing it
to have a bent or twisted appearance or to be the site of Some unbecom-
ing projection. The surgeon is often required to treat such mal-forma-
tions, and may, by judicious measures, restore the deformed outline. It
is very difficult, however, to improve the appearance of a nose in which
the bridge is sunken as a result of bone disease, or of congenital defi-
ciency in development. A number of more or less complicated opera-
tions have been devised for this purpose and are to a certain degree
successful.
A cartilaginous or bony tumor growing from the septum should be
chiselled or sawed away, as the obstruction leads to breathing through
the mouth, a disagreeable tone of voice, and often to nasal catarrh. If
the septum is deviated to any marked extent it should be put into place
by fracturing it with a strong forceps, or by incisions made into it with a
small knife, and subsequently be retained there by pins. If the devia-
tion involves a large portion of the septal cartilage, the cartilage should
be made flaccid by a number of incisions cut in it with a stellate nose-
punch before it is pinned into its new position. The point of a pin,
which should be from one and a quarter to one and a half inches long, is
then introduced into the more open nostril, after the septum has been
broken or cut and made flaccid, and its point thrust through the anterior
part of that portion of the septal cartilage which the surgeon wishes to
control and keep in its new relation to the other portions. This part is
pressed into the desired position and the point of the pin is then thrust
forward through the other chamber of the nose and its point firmly
buried in the tissues at the back part of this second nostril. By this
device the divided septum is firmly held in its new position as shown by
the diagram. The head of this pin will be just
FIG. 356. inside of the anterior maris and must be allowed
to remain for a week or ten days before it is
withdrawn. It is often well to introduce a
second pin from the external surface of the
front of the nose just below the nasal bone.
This aids in keeping the septal cartilage and
bone in proper place. The second pin should
have a flat head so that it may lie close to the
surface of the nose and be covered with a small
square of court plaster.
Author's method of pinning Submucous resection of the septal cartilage
nasal septum. and bony septum is the best method of curing
nasal obstruction when due to a limited deflec-
tion of the partition between the nares. The mucous membrane is incised
and lifted up from the septum, so that a tenotome or small saw can be
used to cut out the deflected cartilage and bone. The flap or curtain of
mucous membrane is then allowed to drop over the opening in the
Septum. -
If the organ is greatly distorted by reason of old fracture, the soft
tissues may, with a tenotome, be pared loose from the bones and the ex-
ternal nasal structures be twisted into place after the septum has been
divided and before the pin has been introduced. By proper pinning, the

A BSC E SS OF T H E A N T R U M . 533
nose can often be kept in the median line and a fairly normal contour
re-established.
This operation is always very bloody and requires etherization. The
pinning method is much better than the use of plugs to retain the parts
in position, since they do the work more effectually and leave the nostrils
free so that an antiseptic Solution can be used for washing out the nose
during the period of inflammation after operation.
The reconstruction of portions of the nose which have been lost is
called rhinoplasty. The most common cause of this condition demand-
ing such operative procedures is loss of the nasal structures from syphilis.
A columella may be made by cutting a piece from the centre of the
upper lip and turning it up, so that it may be sutured to the septal car-
tilage and the tip of the nose between the two nares. An ala may be
made by turning into the gap a flap dissected up from the cheek or upper
lip. A tip of the nose, or even a new bridge may be constructed from
the point of a finger which has previously been freshened, sutured to the
nose, and kept in that position by gypsum bandages around the arm and
head for several weeks.
Total rhinoplasty may be effected by turning down a large flap from
the forehead. This is called the Indian method of rhinoplasty in con-
trast to the Italian method, in which a large flap is taken from the upper
8,I’DOl.
ABSCESS OF THE ANTRUM.
Suppuration within the antrum may be incidental to dental irritation,
to tumor, to syphilitic necrosis, etc. One or more of the upper teeth may
have their roots penetrating the antral cavity; hence caries, or other
disease of such teeth, may lead to inflammation and suppuration of the
mucous membrane lining the antrum. Suppuration occurring here, as it
does, within a normal cavity, is properly called a purulent effusion. The
pus, as a rule, escapes through the nose or through the diseased tooth-
socket; hence, symptoms due to retention of pus in the quasi-abscess
cavity are not very common. When the pus cannot escape, however,
swelling of the cheek, protrusion of the eyeball, occlusion of the tear-
duct, stoppage of the nostril, and bulging downward of the hard palate
arise from this condition of the antrum, as in tumors occupying it.
Sometimes the walls of the antrum are so thinned by the inflammatory
process that pressure upon the cheek may develop crackling similar to
that which occurs in cystic tumors of the lower jaw as well as in tumors
of the upper jaw. Fluid within the antral cavity may sometimes be
diagnosed by percussion on the cheek over the diseased bone, which will
develop a percussion note different from that found over the bone on the
Opposite side. When antral pus does not find vent through a tooth-socket
or through the opening into the middle meatus of the nose, pointing may
OCCur upon the cheek or in the roof of the mouth.
The treatment of pus in the antrum consists in puncturing the bone
below the upper lip above the canine tooth, or by extracting the tooth, if
it is badly diseased, which seems to have its fang extending upward into
the cavity of the jaw. The antral wall of the upper jaw is so thin that
* can be perforated with a strong knife and treated. The cavity should
then be washed out with carbolic or beta-naphthol solution. The opening
in the bone should be kept patent by frequent washing by means of a
*W*inge, and, possibly, by the continuous wearing of a metal stile or plug
534 RES PIR ATO R Y O R. G. A. N. S.
so as to prevent, occlusion of the orifice made for drainage. During
eating, a little piece of cotton may be put into the opening in order to
prevent the entrance of food, if the retention of a stile or plug is not
enforced.
Suppuration, similar to that which occurs in the antrum, may at times
occur in the mucous sinus of the frontal bone and require evacuation by
trephining the bone at the root of the nose.
DISEASES OF THE AIR-PASSAGES.
CEdema of the Glottis.
Swelling of the mucous membrane of the larynx or of the folds between
the epiglottis and the arytenoid cartilages, due to inflammation or to
dropsy, resulting from Bright's disease of the kidneys, may give rise to
serious obstruction. This oedema of the glottis, when of an inflammatory
kind, may arise from the inhalation of hot steam, the swallowing of acids
and other irritating substances, insect stings, or to idiopathic laryngitis.
The treatment of this condition, when asphyxia is too immediate to
allow delay for medical remedies, is scarification of the swollen mucous
membrane by means of a curved knife introduced through the mouth.
The tongue, during the operation, can be held down by means of a tongue
depressor, or by the finger of the Surgeon. Opening the larynx in the
crico-thyroid space may be required to prevent suffocation in severe cases,
which the surgeon fears to leave unattended between his visits.
Fracture of the Laryna and Trachea.
The laryngeal cartilages and rings of the trachea may be broken by
blows upon the throat, as from a base-ball or in attempts at homicidal
throttling. It is usually the thyroid cartilage which is severely fractured.
In such injuries the vocal cords may be dislocated and death ensue, at
once from asphyxia, due to spasm of the glottis. Suffocation may like-
wise occur from hemorrhage, as a result of laceration of the mucous
membrane lining the larynx. Such laceration will probably be indicated
by the coughing up of bloody mucus. It is wise to perform tracheotomy
in all cases of bad fracture of the larynx and trachea, because of the
great danger of sudden death being caused by rapid inflammatory swell-
ing of the intra-laryngeal structures, or to emphysema under the mucous
membrane and in the tissues of the throat. The broken cartilage can at
times be held in place by the application of adhesive plaster on the out-
side of the throat. Better apposition, however, can be obtained by cutting
down upon the injured cartilages and uniting them properly by means of
catgut or silk sutures.
Foreign Bodies in the Air-passages.
Foreign bodies can gain entrance to the larynx and trachea only when
the glottis is opened. Contact with the margin of the glottis induces
instant spasm, which closes the chink and prevents admission of any
intruding substance; hence, foreign bodies can only pass into the air-
passages when the glottis is, as it were, surprised. Accordingly, foreign
substances usually get into the air-passages when there is sudden, violent
D IS E A SES OF T H E A I R - P A S S A. G. E. S. 535
inspiration made at a time when the patient is holding a pebble, a bean,
or some such substance in the mouth. Coins thrown up in the air to be
caught in the mouth sometimes slip through the chink of the glottis,
Food and intestinal worms, which have been regurgitated or vomited into
the upper part of the pharynx, may occasionally find their way into the
larynx and trachea. Bodies so admitted into the air-tract may be caught
between the vocal cords and detained in the larynx, or after passing be-
yond this point may lie loose in the trachea or even get down into the
bronchus. The right bronchus, being in a more direct line with the wind-
pipe than the left, is the tube in which foreign bodies, going lower than
the trachea, usually become lodged.
Foreign substances impacted in the larynx at once give rise to violent
spasm of the glottis, by which the patient may be immediately suffocated.
The lividity of countenance, the gasping for breath, and the shrieks of
the patient are followed by foaming at the mouth, insensibility, and Sud-
den apnoea. If the foreign body is small enough to permit the passage
of air alongside of it, death may not occur even if it is impacted in the
larynx; and the first spasm of respiration, which has just been described,
may subside and the patient regain consciousness. A phonia is character-
istic of the impaction of such small foreign bodies in the laryngeal cavity.
Spasm of the glottis in such cases occurs at irregular times, in any one of
which death may take place. A period of irritation succeeds the obstruc-
tive period, and is characterized by pain, coughing, and expectoration of
blood-stained mucus. These irritating symptoms are especially prominent
if the body has sharp edges, and occur when the foreign body is in the
trachea and bronchus, as well as when it is impacted in the larynx.
Bodies loose in the trachea may produce violent symptoms. They are
liable to be coughed up against the lower surface of the vocal cords and
cause spasmodic asphyxia, in which the fatal end may occur, or they may
at such times become impacted in the larynx. The symptoms are similar
to those already described. The patient is cyanosed, and often is more
comfortable in the sitting posture than in the recumbent one. There is,
perhaps, feebleness in respiratory sounds on auscultation, which is espe-
cially marked on one side of the chest when the corresponding bronchus
contains the foreign body. From the occurrence of secondary bronchitis
Various ralés may be heard in the lungs. In some instances a peculiar
Whistling or flapping sound may be perceived when the stethoscope is
placed over the larynx or trachea, due to vibrations in the current of air
produced by the foreign body.
. The diagnosis in cases of obscure history may be made by auscultatory
Signs, and by the fact that foreign bodies are liable to show difficulty in
expiration, while croup and other obstructive diseases of the larynx show
more difficulty in the performance of inspiration. Laryngoscopic exami-
*tion will often reveal the presence of a foreign body entangled in the
folds of the mucous membrane lining the interior of the larynx.
TREATMENT—It is not usual for foreign substances within the respi-
*atory tract to be spontaneously expelled. They may remain for many
*onths, and cause, as a secondary result, hemorrhage, ulceration, abscess,
chronic disease of the lungs, and fatal exhaustion. The danger of fatal
*P*m of the glottis occurring suddenly renders it important that the
*hea should be opened, as a precautionary measure, as soon as it is
determined that a foreign body is lodged therein. The habit indulged in
Y Some of inverting the patient and slapping him upon the back in order
that the offending substance may be expelled is dangerous, and should
536 R E SPIR A TO R Y O R. G. A. N. S.
never be attempted until after the trachea has been opened, since impac.
tion of the body upon the lower surface of the glottis may cause imme.
diate asphyxia. . Anything impacted in the larynx may possibly be
removed by the laryngeal forceps with the aid of a laryngoscope. In
such instances, of course, tracheotomy is not required, although the sur-
9eon should be prepared to plunge his knife into the crico-thyroid space,
and admit air to the Suffocating patient, in case his manipulations cause
spasm of the glottis. - º
Where extraction through the larynx and mouth is impossible, the
thyroid cartilage should be laid open by a median incision, and carried
upward after a puncture has been made in the crico-thyroid membrane.
The offending body should then be removed with the least possible lacer.
ation of the mucous membrane. A tube should be left in the wound for
a day or two until all danger of inflammatory swelling within the larynx
has passed. When the body lies in the trachea or bronchus, tracheotomy
should be performed instead of laryngotomy, subsequent to which the
mucus in the tube should be coughed up by the patient, or sucked out by
a syringe or aspirator in the hands of a surgeon. The patient should then
be inverted and permitted to cough in the hope that the foreign body may
be expelled. -
Search for the latter may be undertaken by means of the forceps intro-
duced carefully through the wound. If it is not found the sides of the
wound should be stitched to the skin, in order that extrusion may be per-
mitted by subsequent effort at coughing. The patient should be kept in
a room whose temperature is not less than 80° F., and the air of which is
kept moist by a steam atomizer or similar device. The foreign substance
may be so fastened in the trachea or bronchus that its expulsion may not
take place until several days have elapsed; at which time it is not impos-
sible that masses of exudate, similar to that found in croup and diphtheria,
may also be expelled. When the foreign body has made its exit, it is
wise to leave the wound open for a few days lest inflammatory swelling
should impede respiration. This is scarcely necessary, however, except in
those cases in which the foreign body has become impacted in the larynx,
because a considerable amount of swelling may take place in the trachea
without obstructing respiration. In rare cases a body lodged in the larynx
may be removed better by opening the pharynx between the hyoid bone
and the top of the larynx.
TUMoRS OF THE LARYNx AND TRACHEA.
Tumors of the trachea, as primary growths, are exceedingly rare; but
in the larynx various primary tumors occur, and are sometimes called
laryngeal polypi. Laryngeal tumors cause symptoms similar to those
induced by the presence of foreign bodies in the larynx. The forms
most commonly found are papilloma, epithelioma, fibroma, adenoma, and
myxoma. These may be pedunculated or sessile, and, if malignant, ulti-
mately involve the lymphatic glands and other structures of the neck.
Tuberculosis of the larynx occurs, and at times resembles epitheliom:
atous disease. Laryngeal tumors grow slowly and attain considerable
bulk, for the location, before marked symptoms occur. Their presence is
to be detected by the laryngoscope; and, if small, they may be removed by
the forceps, snare, cautery, or laryngeal guillotine. In cases where there
is great tendency to spasmodic dyspnoea, due to irritation from the intrº
T U M O R S OF T H E L A R Y N X. A N ID T R A C H E A . 537
laryngeal condition, precautionary tracheotomy may be required, as when
foreign bodies are impacted in the glottis.
When a tumor located within the larynx cannot be removed through
the mouth, in the manner described, it becomes necessary to do the opera-
tion called thyrotomy.
Thyrotomy, or splitting the thyroid cartilage, in the middle line, is
accomplished by incision of the skin over the larynx, by which the thy-
roid cartilage and crico-thyroid membrane
are exposed. The crico-thyroid space is then FI (; . .357.
opened with a knife, and the incision carried gº
upward through the thyroid cartilage almost §º
to its upper margin. It is important not to
split the entire cartilage into its two halves,
but to leave a portion of it at its upper border
intact, in order that the lateral halves may
retain their relative position after the tumor
has been removed and the sutures applied. §§ §§§
During this operation the head of the patient ºft
should be thrown well back, in order to make §§§
the laryngeal region prominent. When the Zºº Yº
larynx has thus been opened by external ś
incision, its interior may be examined, and . ;
any growth removed by means of forceps §§
and scissors. The cartilaginous tissues are º
then sewed together with fine catgut, and the
external parts sutured and dressed in the
ordinary manner. A solution of cocaine
should be used to prevent pain during the
removal of such growths through the mouth ;
and it may even give sufficient anaesthesia
for the operation of thyrotomy, if it is in-
jected under the skin about the line of the
proposed incision.
Papilloma of larynx.
(TREVEs.)
A pharyngotomy between the hyoid bone
and the larynx may, at times, afford a good route for the extirpation of
laryngeal tumors.
Epithelioma of the larynx requires removal of the larynx, called
laryngectomy, which should be done in all cases, where the diagnosis is
clear, at an early stage of the disease. The larynx is removed by means
of an incision in the middle line of the neck from the hyoid bone to the
third ring of the trachea. The thyroid body should be drawn downward
*Way from the field of operation. The trachea is then separated from the
Surrounding structures, and divided transversely at the level of the second
*g. The lower portion of the windpipe is next plugged with a tampon
of gauze or sponge, through the middle of which passes a large tube by
Which the air and ether vapor are admitted to the lungs. This plugging
prevents the blood flowing from the seat of operation into the air-passages.
!he larynx must now be freed from the tissues on either side, separated
from the hyoid bone above and the pharynx behind, and thus totally
*moved. The enucleation being thus completed, the radical extirpa-
tion of the epitheliomatous tissue is accomplished.
After the Superior laryngeal arteries and other vessels have been tied,
the dressing, consisting of antiseptic gauze, is packed into the cavity left
by the removal of the larynx. Subsequent to the operation the patient




538 R E SPI R A TO R Y O R. G. A. N. S.
is nourished by enemata or through an oesophageal tube until the wound
has cicatrized, while respiration is carried on through the lower portion
of the trachea. After cicatrization has been accomplished, an artificial
larynx can be adopted and the patient given a certain amount of speech.
TRACHEOTOMY.
Tracheotomy, or opening of the windpipe, may be required to prevent
Suffocation in cases of obstruction in the larynx. Such obstruction occurs
in the membranous inflammation which takes place in croup or diph-
theria, in the occluding swelling of tubercular and syphilitic laryngitis,
and in the spasm of the glottis which arises from foreign bodies or tumors
in the air-passages. Cicatricial narrowing of the larynx may remain after
the cure of syphilitic ulcers, and may cause obstruction demanding trache-
otomy. When there is danger of asphyxia, it is wisdom on the part of
the surgeon to open the windpipe before the patient's strength has been
exhausted by dyspnoea. The operation, if properly done, is not at all
a serious one, provided it is performed at a time when the symptoms
do not require haste. Many of the accidents which accompany the
performance of tracheotomy are due to its postponement until the patient
is moribund; hence arise many of the complications to what is other-
wise a comparatively simple operation.
When the surgeon divides two or three rings of the trachea, the opera-
tion is called tracheotomy; when he divides the crico-thyroid cartilage
and the crico-thyroid membrane, or only one of these structures, the
operation is termed laryngotomy. If the lower portion of the larynx
and the upper part of the trachea are opened, the operation is called
laryngo-tracheotomy. $
Etherization may be dispensed with in many cases, since the painful
part of the operation is in the cutaneous incision, which may be ren-
dered painless by hypodermic injections of cocaine. The sense of pain
is practically absent, moreover, in conditions of imminent suffocation
from prolonged laryngeal obstruction. I myself, however, nearly always
prefer general anaesthesia, especially in infancy, since movement of the
child, even if it suffers but little pain, interferes with the operation.
When the trachea is to be opened, the patient's shoulders should be
raised by thrusting a pillow under them, and the head thrown back sº
as to put the neck on the stretch. A median incision is then carried
from the crico-thyroid space almost to the sternum. Its length depends
upon the thickness of the neck and the consequent depth at which the
trachea is situated. The veins, swollen because of interference with
respiration on account of the patient being in a state of asphyxia *
the time of operation, should be avoided if it is practical. Their
division, however, is not a matter of serious moment, since, they stoP
bleeding as soon as respiration is reëstablished. The dissection is Con-
tinued in the middle line, through the deep fascia and between the
sterno-hyoid muscles, until the thyroid gland is exposed. The isthmus
of this body should be pushed downward, or drawn upward, according
as the surgeon intends to open the trachea at the lowest accessible
point or in a higher position. When the isthmus, on account of iº
size, cannot be displaced, a ligature should be tied around it on each
side in order to prevent hemorrhage, and midway between these liga-
tures it should be divided. The windpipe can be recognized by its
T R A C H E O TO M. Y. 539
white color. A tenaculum is hooked into the tracheal wall to steady
it, a sharp-pointed knife then thrust into the windpipe, and two or
three rings divided in an upward direction. The incision must, of course,
correspond with the median cutaneous incision, in order that the open-
ing in the windpipe may not be closed by the overlying tissue covering
it after the surgeon has permitted the trachea to slip from the tenacu-
lum. It is very important that no blood should get into the trachea by
the first inspiratory effort after the opening is made, and from thence be
carried into the bronchi. Such inhalation of blood may suffocate the
patient. . In some cases, it may be impossible to stop all bleeding before
the tracheal cut is made; therefore, the patient should be turned upon
his face with his head over the edge of the table, and retained in this
position while the opening is made. . The blood will then flow out of,
instead of settling in the bottom of, the wound. The danger of its
being sucked into the air-passages will thus be averted. As soon as
the rings have been divided, it is well to thrust a pair of forceps into
the trachea in order to hold the lips
of the wound apart. In this manner FIG 35S.
a supply of air is at once given to
the patient, and the false membrane
or mucus which has obstructed the
respiratory passage, can be removed.
It may be necessary to wipe out such
obstructing material with a feather
or camel's-hair pencil passed into
the windpipe, or to suck it out by
lmeans of a catheter to which an
aspirator or a syringe has been at-
tached. In diphtheritic cases it is
dangerous and foolish for the surgeon to suck out such membrane with
his mouth, since fatal consequences to the operator have often followed
this practice. After the trachea has been cleared, a tracheal tube may
be inserted in order that the respiration may go on without obstruction
from falling together of the lips of the wound. A tracheal tube consists
of a double canula, the inner one of which projects at the internal end a
little beyond the outer one. The object in having two tubes is to enable
the attendant to remove and clean the inner tube, as it becomes plugged
With mucus or dried secretions, while he leaves the outer one in the wound
in ºrder to make replacement of the inner tube easy.
The outer tube has flanges upon each side, by which it is held in place
by means of tapes and tied around the neck. I prefer, however, to fix
these Wings or flanges by means of sutures carried through the neighboring
skin with a needle. The upper and lower angles of
the Qutaneous wound may be sutured after the tube FIG. 359.
has been inserted. There are several forms of tracheal -
dilators made which are preferred by some operators
to the canula.
ºn diphtheritic patients less skilled nursing is re-
ſºired if, instead of introducing the canula, the sur-
$99, Cuts out a small rectangular portion of the
trachea and Stitches the edges of the tracheal opening Tracheal dilator.
* º skin. The tube requires constant watching,
l º be kept free from obstruction by dried membrane, secretion, or
990, by the frequent passing of a feather through it. In diphtheritic
Trachea tube, with valve.


540 R E S P J R A TO R Y O R G A N S ,
cases the inner tube should be removed and cleaned about every two
hours, and both tubes should be removed if there are any evidences of
serious obstruction.
The patient, whose windpipe has thus been opened, cannot talk unless
the orifice in the throat is closed by placing a finger over the tube, or in
some way preventing respiration through the anterior orifice. In four or
five days after the operation for diphtheria it is proper to make an attempt
to dispense with the tube; but if symptoms of laryngeal obstruction still
remain, the tube must be reinserted for a few days longer. It is essential
that the patient upon whom tracheotomy has been done should be kept
in a hot room with a moist atmosphere until the symptoms for which the
operation was done have subsided, since bronchitis or pneumonia are very
liable to occur from inspiration of cold, dry air. Inhalation of dust should
be prevented, if possible, by keeping a piece of mosquito-netting in front
of the opening in the throat. This, however, is often impossible in opera-
tions for diphtheria where there is frequent necessity for cleansing the
tube. The temperature of the room should be kept at 75° or 80° F., and
the air should be kept moist by means of an atomizer, or by a wet blanket
suspended in the room before a fire. The interior of the trachea and the
wound may be mopped with a solution of sodium carbonate in glycerin,
or with a solution of pepsin or of trypsin, in order to facilitate detach-
ment of the false diphtheritic membrane. It has been suggested that,
after tracheotomy for diphtheria, the windpipe above the seat of operation
may with benefit be plugged with sublimate gauze (1:2000).
A quick tracheotomy may be done in emergency cases by grasping the
larynx between the thumb and forefinger of the left hand and steadying
it in this manner, while a rapid incision is made with the right hand in
the middle line. In still greater emergency air may be admitted to the
lungs by plunging a knife through the crico-thyroid space, which is easily
felt as a depression about three-quarters of an inch below the most
prominent point of the Adam's apple. An opening thus made will
permit air to enter in sufficient quantity until a more systematic operation
can be done. I have operated in this manner by means of an ordinary
pocket-knife, which is usually always obtainable. Where it is impossible
to obtain a proper tracheal tube, a piece of a drainage-tube will tem-
porarily answer the purpose. If the patient has stopped breathing by the
time the surgeon has gained an entrance to the windpipe, artificial respira:
tion can possibly be started by blowing into the tube with an ordinary
syringe or a pair of bellows. It is wise always to introduce the largest
size canula that the trachea will hold. It must not be so large, however,
as to strip up the mucous membrane as it is pushed down into the wind,
pipe. A slight alteration as to its length or shape, and also its removal
from time to time, are desirable, because the pressure exerted by its internal
end may induce ulceration of the lining membrane of the windpipe. The
lobster-tail canula, with a blunt pilot for its introduction, is a favorite one
with me.
In cases of stenosis of the larynx in which the tracheal tube must be
constantly worn, a tube with an opening in the intratracheal portion will
enable the patient to expire through the larynx and to talk with Cº.
parative ease. If the tube has not this opening, and it fits tightly so that
no air passes above the opening, speech is impossible.
The point at which an opening in the air-passages should be made
depends upon the condition for which the operation is done. In diphtheº"
it is best to go as low down as possible; hence, a point below the isthm."
T R A C H E O TO M Y. 541
of the thyroid gland is probably the best place under such circumstances.
In tracheotomy for chronic disease of the larynx, a high tracheotomy
above the thyroid body is efficacious and makes a less difficult operation.
FIG. 360.
Double tracheal tube (lobster tail).
Intubation of the Laryma.
The introduction of a metal tube into the chink of the glottis and its
retention there for a period varying from several hours to several days, is
called intubation, and is in certain cases a good substitute for the more
serious operation of tracheotomy. Though especially employed in cases
of diphtheria and oedema of the glottis, it is possible that it may be of
advantage in cases of foreign bodies in the trachea, because it will prob-
ably prevent fatal asphyxia from spasm of the glottis, due to such foreign
body being coughed up against the lower surface of the vocal chords. In
such a condition intubation would seem to be of service as a temporary
measure until arrangements can be made to open the trachea for extraction
of the foreign substance.
Intubation, which is seldom required in adults, is performed with the
Child held in the nurse's arms without being etherized. A gag is placed
between the teeth on the left side of the mouth in order to hold the jaws
*part, and an assistant holds the patient's head well back. The surgeon
introduces his left forefinger into the mouth and by pressing down the
tongue he is enabled to guide the tube with his right hand into the glottis.
After it has been so introduced the detachable handle or obturator is re-
moved. The patient then breathes through the tube, which is kept in
place by reason of its shape. At the top of the tube is a flange to pre-
Nºt the instrument slipping into the trachea, and in this flange is a small
hole through which a long thread is passed before any attempt at intro-

542 R E SPI R A TO R Y O R. G. A. N. S.
duction is made. The ends of this thread hang from the mouth and are
used to remove the instrument from the pharynx if it is found not to be
properly placed when the detachable handle is withdrawn. If, however,
the surgeon finds the patient breathing well and the tube properly placed
the string is withdrawn and the instrument left in position. If all goes
well the tube may be left in position for several days. When its extrac.
tion is desired an instrument called by Dr. O'Dwyer the extractor is
introduced. This instrument is operated by expanding two blades or jaws
after its point is introduced into the calibre of the tube, thereby giving
the surgeon control of the latter and enabling him to withdraw it quickly.
During the introduction and withdrawal of the laryngeal tube respiration
is entirely arrested for a moment.
An advantage of intubation is that the consent of the patient's family
can be more readily obtained for the performance of the operation than
is the case in tracheotomy, which causes bleeding, and therefore seems to
them more undesirable and dangerous.
The objections to intubation are that the tube may slip into the trachea,
that it may be swallowed, and that food gets into the air-passages, thus
causing at times secondary pneumonia. It has been supposed by some
that there is danger that the false membrane of diphtheria may be pushed
down into the trachea by means of the tube, thereby increasing the res-
piratory obstruction. This objection, however, applies equally to the
insertion of a tube after tracheotomy. Intubation, moreover, does not
prevent tracheotomy being performed later, if the necessity for it arises.
Attempts have been made to correct the difficulty of feeding after intu-
bation, by attaching a sort of artificial epiglottis to the upper end of the
tube.
Intubation is a valuable addition to the surgeon's resources, for which
the profession owes much to Dr. O'Dwyer; but is often inferior to the
more radical operation, tracheotomy.
DISEASES OF THE CHEST.
Contusions and Abscesses.
PATHOLOGY AND SYMPTOMS.–Contusions and abscesses of the chest
wall require no special description other than to say that abscess of the
chest wall is occasionally secondary to purulent effusion in the pleural
cavity or to abscess of the lung.
Contusion or rupture of the lung tissue may occur without laceration
of the pleura. These lesions probably take place because the lung is sub-
jected to blows or concussions when the vesicles are filled with air and
the glottis closed, so that the air within the lung tissue cannot be forced
out at the time the force is applied. The symptoms of this condition are
spitting of blood, diaphragmatic breathing, dyspnoea, cough, bronchial
råles, and signs of localized pneumonia, or pleurisy. These symptoms
vary with the extent and location of the injury. Emphysema may occur
between the lung and the pulmonary pleura, and the air so extravasated
may find its way into the mediastinum and upward into the cellular
tissue of the neck and back. If the pluera is torn by the injury, blood
and air may escape into the pleural cavity and produce haemo-thorax or
pneumo-thorax with their characteristic physical signs.
Pulmonary abscess, or gangrene, and mediastinal abscess are occasional
I) IS E A SES OF T H E C H E S T . 543
sequences of lung injuries. Gunshot and stab wounds of the lung are
not infrequent ; and laceration of the periphery of the lung may happen
as a complication of fracture of the ribs. Laceration may occur from
puncture of the lung by one of the fragments at the time the fracture of
the rib is received, though subsequently no displacement of bone may be
discoverable, because the resiliency of the chest wall has brought the
fragments of bone into apposition.
The symptoms of such wounds of the pulmonary tissue are similar to
those described above as occurring from contusion and rupture of the
lung. Subcutaneous emplºysema is a very common concomitant of frac-
ture of the ribs when one of the fragments has injured the lung. In
such instances the air in the vesicles escapes into the pleural cavity, and
then during expiration is pumped through the opening in the costal
pleura into the subcutaneous cellular tissue.
It must be remembered that the lung extends downward at the lateral
and posterior aspects of the chest to about the level of the tenth rib,
while the pleural cavity extends as far downward as the twelfth rib. In
a wound of the chest below the tenth rib, therefore, the pleura alone will
probably be wounded, and not the lung. If a penetrating wound extends
sufficiently deep to traverse the pleural sac, puncture the diaphragm,
and enter the abdominal cavity, the organs contained in the abdomen
may suffer injury from the bullet or knife in addition to the damage sus-
tained by the pleura. The arching upward of the diaphragm renders it
possible for a penetrating injury, even higher than the tenth rib, to pro-
duce lesions of both the thoracic and abdominal viscera. When the
wound of the chest wall is a comparatively large one, its communication
with the pleural sac is often to be recognized by the sucking and hissing
sound produced by the air entering the chest during respiration. If a
large vessel in the lung is wounded, the bronchial tubes may be so filled
with blood as actually to drown the patient.
Pulmonary wounds heal like other wounds if protected from suppura-
tion and putrefaction. The air entering the pulmonary tissue through
the trachea is freed from pathogenic germs to a great extent by the filter-
ing process which it undergoes before it reaches the seat of the wound;
hence, if the chest wound be kept aseptic, there is little danger of suppu-
ration or septic pneumonia or pleurisy. Protrusion of a lung may occur
at the cicatrix of a large wound in the chest wall.
TREATMENT.-The external bleeding in chest wounds is usually not
Very severe, and needs no special treatment. If the blood comes from
the lungs it will probably be frothy and in greater quantity during expi-
ration than in inspiration. The flow of blood into the pleural sac, which
occurs at the same time or before escaping from the chest through the
external opening, will probably soon make sufficient pressure upon the
lung to stop the bleeding from the pulmonary tissue. The blood so enter-
ing the pleural cavity will, if kept aseptic, subsequently be absorbed; if
not kept antiseptic, it will break down into pus and cause traumatic
empyema.
Severe hemorrhage may supervene from wounds of the intercostal and
nanºmary arteries. The intercostal arteries lie in grooves at the inner
and lower margins of the ribs. Hemorrhage from one of these vessels
*y be stopped by seizing the bleeding point with a hemostatic forceps,
Which may be left in position for several hours. If arrest of hemorrhage
...this, means be impossible, the surgeon may perhaps be able to scrape
off, with a blunt instrument, the periosteum from the bottom of the inter-
544 R. E SPIR. A. T O R Y O R. G. A. N. S.
costal groove. This procedure separates the vessel from the bone, and
makes its ligation practicable. Another method is to push into the wound
the centre of a square piece of antiseptic gauze, and, after distending it
like a small bag within the chest, to stuff the pouch so made with small
pieces of antiseptic sponge or gauze. By seizing the projecting corners
of the square of gauze and drawing the intrathoracic mass firmly against
the internal surface of the ribs, pressure is made upon the intercostal
vessel and bleeding prevented. Resection of a portion of the rib is
seldom necessary to gain control of the vessel from which hemorrhage
OCCUl I’S. Ç
The internal mammary artery runs parallel to the border of the
sternum, and from a quarter to half an inch external to this margin.
Bleeding from a wound in the internal mammary artery should be treated
by ligation or by seizing the bleeding point with a hemostatic forceps,
which should then be left in position with antiseptic dressing packed
around it.
As a rule, little information is obtainable by the introduction of probes
into a chest wound. There is no objection to their use, if they are em-
ployed with caution and antiseptically. When the wound is large enough
to admit the surgeon's finger, which, of course, must be aseptic, a clear
understanding of the nature of the injury is often obtained.
The subcutaneous emphysema which is sometimes present in lung
injuries, is recognized by the elastic swelling of the skin, which crackles
when pressed upon by the fingers. This tumefaction, which is free from
any discoloration such as occurs in cutaneous inflammations, occurs
during the first few hours after injury, and afterward subsides gradually
without treatment.
Antiseptic cleansing of the wound, the introduction of sutures, and the
application of dressings, fulfil the local requirements of the thoracic
wounds. In order to keep the chest at rest as much as possible, a firm
bandage should then be applied. If suppuration occurs in the pleural
cavity, the wound must be thoroughly opened, a drainage-tube inserted,
and antiseptic irrigation carried on in the manner discussed under
Pleural Effusion. If the traumatic pneumonia is very acute and exten-
sive, venesection may be the only means to preserve life. In other cases
secondary pneumonia and pleurisy should be treated by ordinary medical
means. The fact that persons subjected to accidental wounds of the chest
are usually in a good state of health, and that, therefore, the intrathoracic
inflammation is of a sthenic type, indicates that active depressants and
purgatives are more often ncessary than in cases of idiopathic pneumonia
and pleurisy. The diagnosis of the inflammatory conditions within the
chest is made, of course, by the ordinary rules of auscultation and per-
cussion.
Bullets and other foreign bodies, unless their location is definitely de-
termined, and found to be accessible to the knife without adding much to
the original injury, should be allowed to remain imbedded in the tissues.
They often become encysted, and do no harm. If subcutaneous abscess or
a sinus indicates their position, the surgeon is justified in undertaking
operative search. Under such circumstances I have recently successfully
removed, after resection of the ribs, a piece of silver drainage-tube from
a young child's chest, where it had been for many months, after having
become lost during treatment for idiopathic empyema.
su RC, ICAL TREATMENT OF P L E U R AL EFF USIONS. 545
SURGICAL TREATMENT OF PLEURAL EFFUSIONS.
Aspiration of the pleural cavity or thoracentesis is performed in serous
effusion into the pleural cavity (hydrothorax). Incision of the chest wall
with the introduction and retention of a drainage-tube into the pleural
sac is the proper surgical treatment in cases of purulent effusion into the
pleural sac (empyema). In hydrothorax aspiration should be done com-
paratively early, or as soon, at least, as medicinal remedies do not produce
any marked diminution of the quantity of fluid in the cavity. Incision
and drainage should be performed as soon as the existence of pus is deter-
mined. Aspiration should be done with a hollow needle, and one of the
forms of aspirating pumps. Care should be taken that no air enters the
chest, and that the lungs and other structures of importance are not
injured by the point of the needle. If an aspirator is not obtainable an
ordinary trocar and canula is used. A long, rubber tube, however,
should be attached during the first flow of serum, immediately after the
trocar has been withdrawn, and the end of this tube placed below the
surface of a solution of carbolic acid (1:20). This precaution is taken
to prevent the sucking up of air into the chest when the flow of serum
becomes intermittent as the cavity is nearly evacuated.
Thoracentesis does not require general anaesthesia. If the patient is
very sensitive to pain the skin at the point of the proposed puncture may
be benumbed by a spray of ether or rhigolene, by a hypodermic injection
of cocaine, or by the application of ice and salt. The best position for
the patient is a semi-recumbent one, which can be changed during the
operation to a recumbent one, as he becomes weak. The place to insert
a puncturing instrument is in the sixth interspace close above the upper
border of the seventh rib and in a line with the middle of the axilla. If
careful auscultation and percussion indicate the presence of a localized
pleural effusion it may be necessary to select another spot; since it is evident
that a cavity containing fluid should be tapped near its lower wall, as this
gives the best opportunity for entire evacuation of its contents. As soon
as the aspirating needle enters the pleural sac the flow of serum is evident
in the glass tube near the needle, or in the bottom of the aspirator. The
escape of fluid should be at first somewhat controlled, in order that sud-
den evacuation of the contents of the pleural cavity may not lead to
Syncope. It is also wise occasionally to stop the flow for a moment. The
occurrence of cough is an indication to desist temporarily; while a dis-
Charge of blood through the needle means that the lung, or some vessel,
has been injured, and suggests the partial withdrawal of the instrument.
When the fluid ceases to escape the operation is concluded by drawing
out the needle, unless it is believed from the physical signs that the calibre
of the aspirator has been plugged by a mass of lymph sucked into the
tube. This complication is, as a rule, indicated by a sudden, rather than
a gradual, cessation of the flow. It may be possible, by changing the cur-
*ent in the aspirator, if the instrument permits such a procedure, to force
the lymph back into the chest. If this is impossible it may be necessary
. Withdraw the needle, remove the obstruction, and puncture in a new
place.
An antiseptic pad should be placed over the opening after the operation
* performed, and the patient treated by medical means as previ-
ously.
Drainage of purulent effusions in the pleural cavity is accomplished by
35
546 R. ES PIR. A. T ORY O R. G. A. N. S.
making a two-inch incision in one of the intercostal spaces just above the
upper border of one of the ribs and parallel to the rib. This site is
chosen for aspiration and incision, because the intercostal artery runs
along the lower edge of each rib. If there is any doubt about the possi-
bility of the space between the ribs being sufficiently large for the sur.
geon's purpose, the initial incision had, perhaps, better be made in the
middle of the intercostal space, rather than close to the upper border of
the lower rib. The sixth interspace is, as a rule, a good place for incising
the pleura. If there is any evidence of the pus collection being localized
the surgeon would naturally make his incision a little below the centre of
the area of dulness. As the patient after such an operation lies upon his
back, the incision should be made about an inch behind a line downward
from the middle of the axilla. The cutaneous incision should be suffi-
ciently large to permit a good size tube to be introduced. If the space
between the ribs is not sufficient a portion of the lower rib should be
excised. It is not often necessary to remove a section of the entire width
of the rib, as a semicircle cut out of the bone with bone forceps or saw
will usually give sufficient space for the tube. My own experience has
shown that excision of the rib for this purpose is seldom required. If,
however, it seems necessary to remove a section of the entire width of the
rib the operation should begin by an incision over the middle of the rib;
after which the periosteum should be detached and about an inch of the
rib sawed out. The intercostal artery in such an operation should be
secured before the pleura is opened.
After the dissection has been carried down to the pleura and hemor-
rhage stopped, if there be any, the pleura should be laid open to the full
extent of the external wound. The surgeon's finger can then be inserted,
the interior of the chest explored, and any bands of lymph that divide
the pleura into separate cavities broken up. Etherization is not essential
in this procedure, as the pain is not very much greater than that of aspi-
ration. Local anaesthesia is sufficient. A rubber drainage-tube without
side holes and with a calibre of about one-quarter of an inch should be
introduced about an inch into the pleural cavity and stitched to the skin
by wire or silk sutures. After the extremities of the wound have been
drawn together with sutures, a voluminous antiseptic dressing should then
be applied. The pleural cavity should be washed out with a solution of
carbolic acid (1:40), betanaphthol (1:4000), salicylic acid or boric acid
once in twenty-four hours. These disinfectant solutions are introduced
by hydrostatic pressure, obtained by attaching to the drainage-tube an-
other tube or pipe coming from a reservoir held about two feet above the
patient. As soon as distention of the cavity by the fluid produces pain
the supply-tube should be detached, or the reservoir lowered so that the
mingled pus and antiseptic solution may escape. One or two pints of
fluid may be introduced into the chest at one injection, and it may be
repeated until the outflow is very little stained with pus. Irrigation and
drainage in this manner should be continued for several weeks, and
should not be discontinued until it is evident that the cavity within the
chest has greatly contracted, and there is very little purulent collection;
When this occurs the drainage-tube may be withdrawn and the wound
allowed to heal by granulation. Too early withdrawal of the tube mºſ
permit re-accumulation of the pus, and necessitate a second operatiºn, ſº
order to relieve the septic symptoms which are liable to occur. If the
fistulous opening, left after the drainage-tube is withdrawn, remains for
many months, further treatment will be required. The condition is, *
I) ISE A S E S OF T H E N E C K . 547
rare instances, due to a broken portion of the tube having been left
within the chest ; but is more apt to happen because the drainage has not
been complete, or because the tube has been withdrawn too early. Dila-
tation of the fistulous track by the introduction of a sponge tent, or a
piece of compressed sponge, will often permit reëstablishment of irrigation
and thereby induce cure. In other cases it may be necessary to lay open
the sinus and resect a portion of a rib in order to obtain free drainage.
In some cases healing of the pleural cavity is prevented by the fact that
the pus sac will not collapse because of inflammatory thickening and
adhesions. Under such circumstances it has been advocated that two or
three inches of several contiguous ribs be excised in order that the
chest wall becoming flaccid may fall inward, and by coming in contact
with the pulmonary wall of the pus sac cause the cavity to become oblit-
erated. In performing this operation it is well to dissect away the thick-
ened costal pleura.
PULMONARY ABSCESS AND GANGRENE.
The operative treatment of pulmonary abscess consists in cutting into
the lung, after having incised the chest wall and pleura, in order to evac-
uate the pus confined in the lung tissue. Before such an operation is
attempted the most careful physical diagnosis must locate the abscess, and
even then it is wise to confirm the physical signs by introducing an aspi-
rating needle or trocar into the lung. When such abscess has been dis-
covered incision of the external tissues and lung is proper, and should be
followed by the insertion of a large drainage-tube so that irrigation may
be carried on. Excision of a gangrenous portion of the lung has been
attempted after opening the chest. The difficulties in diagnosing the po-
sition of the gangrenous area are similar to those met in diagnosing the
position of an abscess.
MEDIASTINAL TUMoRS AND ABSCESSEs.
Pus in the anterior mediastinum may be evacuated by an incision
between the costal cartilages, or by trephining the sternum. Such a pos-
sible condition should be given consideration when the surgeon is investi-
gating any obscure case of thoracic disease. Tumors of the mediastinum
should also be remembered in this connection.
DISEASES OF THE NECK.
Wounds of the neck should be treated as other wounds. If the trachea
or glottis is opened the parts should be brought together and sutured and
POVision made for drainage. Severe wounds of these structures are
ºften made in suicidal attempts. After the parts have been sutured an
*ophageal tube may be required for feeding the patient. If the tongue
º “piglottis has been cut loose from its attachments it may cause asphyxia
by falling upon the opening of the glottis. Sudden oedema of the glottis
*Y arise as a complication of wounds of the larynx. These complica-
{ions may render it necessary for tracheotomy to be performed, lest
*Ween the visits of the surgeon death may occur from sudden swelling
548 R E SPI R A TO R Y O R G A N S.
or rather obstruction of the chink of the glottis. Emphysema of the
neck may supervene after such wounds by reason of air escaping from
the respiratory tract into the subcutaneous tissue. Diffuse cellulitis of
the neck may follow wounds; and septic poisoning, secondary to ulcera-
tions in the mouth or pharynx, to Scarlet fever, and to diphtheria, is not
uncommon. If the cellulitis assumes a suppurative character free inci-
sion to prevent burrowing of pus, and antiseptic irrigation of the cavities
in which this is located, are urgently demanded.
Congenital cysts, called hydroceles of the neck, are due to the embry-
onic clefts not becoming entirely closed. A cavity is consequently left
which is filled with fluid. A most common surgical condition, however,
in this situation is glandular enlargement due to chronic lymphademitis.
These chronic lymphatic conditions are often the result of tubercular in-
fection and are very liable to become caseous and to break down into
puriform fluid. Acute lymphadenitis often arises as a complication
from diseased teeth. A lymphatic glandular enlargement situated over the
submaxillary or parotid salivary gland sometimes acquires considerable
bulk, and is liable to be mistaken for tumor or malignant disease of the
salivary gland. Chronic enlargement of the lymphatic glands of the
neck should be treated by constitutional remedies, such as tonics, cod-
liver oil, potassium iodide, a residence at the seashore, and attention to
hygienic surroundings. Locally the treatment should consist of counter-
irritation by means of iodine tincture or the ointment of the red iodide
of mercury. If after such measures they continue to enlarge it may be
proper to excise the glands before they have undergone puriform change.
This is desirable because they may become the primary focus from which
general tubercular infection may arise. If cheesy or puriform degenera-
tion has taken place it is proper to incise the skin over the softened mass,
to scrape away with a curette all the glandular tissue and diseased struc-
ture around it, and to dress the wound with iodoform. The depressed
scar left by such early incision is less deforming than the irregular and
puckered superficial cicatrix which usually remains after spontaneous
evacuation of the puriform collection.
The unsightly scars left by the occurrence in youth of such cervical
tubercular lesions may be made almost imperceptible by a small plastic
operation. An elliptical incision is made around the depressed cicatrix,
the skin is dissected loose for some distance on each side, and the edges
are then drawn together by sutures over the intervening depressed pol-
tion of skin, which has previously been made raw by scraping with
a knife edge. Thus the cutaneous structures are elevated to a level with
the surrounding skin, and the irregular scar converted into a straight,
white line.
DISEASES OF THE THY ROID BODY.
The function of the thyroid gland is probably control of the mucinoid
substances in the tissues, the regulation of albuminoid metabolism, and
the manufacture of blood corpuscles. Its atrophy or entire removal is
followed by the condition called myxoedema. (Fig. 362.) In myxoedema
the subcutaneous tissue of the patient becomes swollen with mucus. This
causes a condition resembling serous oedema, except that the tumefac.
tion is harder. The patient's lips and eyelids become puffy, his mind
heavy, his speech thick, the temperature usually subnormal and his intel-
ligence deficient almost to a condition of imbecility. There is loss of the
B R O N C H O C E L E O R. G. O IT R. E. 549
red and increase of the white corpuscles of the blood. The condition, as
far as known, is unamenable to treatment, and is finally fatal. It has been
attributed also to changes in the sympa-
thetic nervous system. The defective FIG. 361.
mental state, called cretinism, found at
times with goitre, is probably due to the
goitrous affection causing atrophic inter-
ference with the function of the thyroid
body.
BRONCHOCELE OR GOITRE.
* * * * ~
Tumors of the thyroid body are usu- º
ally included under the head of bron- %. “ º
o e º §§§ºğ
chocele or goitre, although in a strict || º º *N
sense the term should probably be em- ſº \{{=º
jloyed for enlargements of the gland and tº / Sº | º
ploy * *-rºsſ tº tº
not to its infiltration or substitution by
morbid growths. The thyroid gland in Myxoedema. (TREVES.)
women not infrequently becomes enlarged
from congestive swelling during sexual excitement, pregnancy, and at
menstruation. The congestive enlargement so occurring may remain
after the causative factors have passed away. The enlargement may
include both lobes of the gland as well as the isthmus, or it may
involve either lobe or the isthmus alone. At times pulsation occurs
in the enlarged gland and is so evident as to simulate aneurism. In
one variety of congestive goitre there is protrusion of the eyeballs and
irritability of the heart associated with the enlargement of the thyroid
body. This condition is a distinct general disease called exophthalmic
goitre. In this affection the thyroid gland is swollen, perhaps tender on
pressure, and may pulsate. The eyeballs protrude from between the eye-
lids, as a result, probably, of vascular congestion in the post-ocular tissue,
and the heart's action is irregular and feeble. Often there is a murmur
heard at the cardiac base. The patient is weak, anaemic, and often sub-
ject to anorexia and amenorrhoea. Gradual improvement usually takes
place under effective treatment lasting through many months. Cases,
however, do at times end fatally.
In addition to the congestive enlargement of the thyroid body, which has
been described, simple hypertrophy of the stroma and glandular elements
of the organ may occur. Fibrous and cystic changes also take place in
this organ, giving a form of goitre corresponding to these alterations.
Simple hypertrophic goitre, which is really a fibro-adenomatous change,
may follow the congestive form. The patient presents symptoms not
unlike those of exophthalmic goitre, except that the ocular and cardiac
Symptoms are absent. Interference with swallowing and respiration may
0CCur, as the position of the growth may produce pressure upon the
trachea and oesophagus. Giddiness may be induced by similar interfer-
ence with circulation, through the large vessels of the neck going to and
Coming from the brain. In fibrous goitre the stroma of the organ in-
creases more markedly than does glandular tissue, though the pathological
alteration is similar in other respects to the simple hypertrophy just
described. The thyroid enlargement may be soft and vascular if the
growth is rapid, or hard and dense if the change is more chronic in its
°ourse. The fibrous form very often affects but one lobe. Its displacing










550 R E SPI R A TO R Y O R. G. A. N. S.
pressure is very likely, therefore, to cause lateral deflection of the trachea
and oesophagus. As the thyroid gland lies below the deep fascia, any
enlargement gives rise to injurious pressure upon the other organs of the
neck, as has been indicated above. Such pressure is more apparent when
caused by a hard, rapidly growing fibrous goitre than when the change
is one of the other varieties of bronchocele. Flattening the calibre of
the trachea or interference with the normal movements of the tracheal
rings during respiration may cause a tendency to dyspnoea. The ana-
tomical attachment of the isthmus of the thyroid body to the trachea
causes the gland to rise and fall during swallowing. This furnishes a test
in the diagnosis between thyroid enlargement and other cervical tumors.
The rise and fall of the mass during deglutition of a little water or food
indicate at once the thyroid nature of the growth, since enlargement of
the lymphatic glands in the cervical region or other tumors of the neck
would in most cases not be affected by tracheal movements. One or
more of the acini of the gland may be converted into a cyst or cysts,
filled with colloid, serous, or bloody fluid, and constitute the cystic variety
of goitre. While the wall of such cysts may be very vascular it may also at
times become calcified. In extreme cases the whole thyroid body may be
converted into a series of cysts. Goitre is endemic in certain regions of the
world, especially in some parts of England and in the Tyrol, and is there
often associated with a peculiar deterioration of the brain called cre-
tinism. This has been attributed to the atrophy of the gland which
accompanies such thyroid tumors. The different varieties of goitre found
in these persons attain at times enormous bulk.
TREATMENT.—The treatment of goitre differs with the variety of the
growth.
The treatment of exophthalmic goitre belongs to the domain of medi-
cine, and consists in the administration of iron, digitalis, and similar
remedies.
The treatment of congestive growth is not unlike that of exophthalmic
goitre, and consists in the use of digitalis and tonics internally, and
counter-irritation by means of tincture of iodine, red iodide of mercury
ointment, and similar preparations externally. Ergot, ammonium chlo-
ride, and potassium iodide have been advocated in this form of goitre,
and are probably of value if given in large doses.
In fibrous goitre the remedies recommended for congestive and exoph-
thalmic goitre may be applied. The benefit obtained, however, is not so
evident in this form of bronchocele. When the growth is large and
causes pain and other symptoms of pressure, the surgeon should make a
cut through the deep cervical fascia, which will permit the tumor to bulge
forward, thereby relieving pressure on the important structures beneath
it. The incision may be open or subcutaneous, according to circum;
stances. When this procedure is not effectual, the isthmus of the thyroid
gland may be divided in the middle line after two strong ligatures have
been applied at each side of the proposed incision to prevent hemorrhage.
The repeated injection of alcohol or tincture of iodine, in ten minim doses
directly into the fibrous tumor by means of a hypodermic syringe, may
diminish the bulk by causing interstitial absorption. Cystic goitre.
should be subjected to evacuation by puncturing with a trocar an
canula, and subsequently to injections of tincture of iodine, tincture of
the chloride of iron, or a solution of carbolic acid, if the simple evacuating
puncture is followed by reaccumulation of fluid. Care must be taken
before injecting these irritants to see whether blood escapes from the
B. R O N C H O C E L E O R G O IT R. E. 551
canula after the fluid in the cyst has been allowed to flow out. If blood
flows, it is an indication of the possibility of a vein having been punc-
tured, and the point of the canula should therefore be withdrawn a
little before the injection is made. It is not safe, however, to inject such
irritating fluids into rapidly growing tumors, since they are apt to become
violently inflamed. Suppuration is sometimes induced by this method of
treatment, due to the invasion of pyogenic germs. Spontaneous abscess
of the thyroid gland I have found on one occasion. It should be treated
by free incision, in order that the pus and the suppurating tissue may be
evacuated and removed. Excision of the thyroid gland has been done in
cases where the size of the growth and its pressure symptoms have ren-
dered the operative risk of such an operation justifiable. According to
Horsley, excision of more than one lobe must not be performed, since re-
moval of the whole body will lead to myxoedema, and because excision of
the isthmus or of one lobe will usually remove the urgent symptoms.
C H A P T E R X. X.
DISEASES OF THE MOUTH,
HARELIP is a term applied to congenital fissure in the upper lip, and
may be single or double. The fissure, however, is always a little to one
side of the middle line, in a position corresponding with the suture be-
tween the inter-maxillary bone and the upper jaw of the corresponding
side. When harelip is double, a small portion of the lip lies between the
fissures. This central lobule may be very poorly developed; in fact, it
may be scarcely more than indicated, thus giving a double harelip the
appearance of a single cleft in the median line. The inter-maxillary bone,
which carries the incisor teeth, may be separated from the upper maxil-
lary bone of the same side by a cleft which corresponds with the cleft in
the lip. This is one of the forms of cleft palate.
Cleft of the palate is a congenital defect, corresponding in character
with harelip, occupying the hard or soft parts of the palate, or both. All
of these conditions are due to
FIG. 362. defect in coalescence some time
# - about the ninth week of foetal
life. When the alveolus is cleft
and the intermaxillary bone is
separated from the other portions
of the jaw by such congenital de-
fect, the harelip is often compli-
cated by protrusion forward of the
y
FIG. 363.
~ .. '', *
lauri º 2-—“S Ž.
Single and double harelip. Diagram of incision in operation for
(TREves) harelip.
incisor and inter-maxillary structures, which thus extend forward below
and in front of the nose as a sort of snout. The nostril on the side cor-
responding with the harelip is usually broadened and flattened, by reason
of the ala being carried outward.
Harelip, if at all extensive, prevents the infant from sucking well.
This circumstance, as well as because it is difficult for the child's lips to
be kept at rest after it has learned to speak, renders it proper to operate
when the child is between six weeks and three months of age, provided,
of course, that the general health is good. º
The plastic operation for harelip consists in separating the upper lip



H A R E I, I P. 553
from the gum ; in paring the edges of the fissure, and in bringing
them together with pin sutures in such a way as to leave no defect in the
vermilion border of the lip. Union by first intention is usually obtained,
if the operation is well done and the parts so arranged that there is no
tension upon the sutures. The child may be held in the nurse's lap with
his head placed between the two knees of the sitting surgeon, or it may
be placed upon an operating table. Ether is usually given. Compres-
sion forceps may be used upon the upper lip near the corners of the
mouth to prevent bleeding from the coronary arteries. A straight, nar-
row knife is then used to transfix the tissues on each side of the cleft and
to pare away the borders beginning high up in the nostrils at the angle
of the fissure. Sufficient tissue must be removed to make a wide raw
surface on both edges of the cleft, so that when the lip is brought together
there will be a wide surface of contact to cause union. The strip cut off
may be entirely removed or a portion may be retained at the lower part
in order to make the free margin of the lip bulge a little when the sutures
are placed. It is often well to carry the lower end of the incision a little
away from the cleft and then turn the knife toward the middle line so as
to leave a tag of tissue covered with mucous membrane.
The accompanying diagram (Fig. 363) shows this incision, which is
made in order that the parts which are brought together may pout a
little, and prevent the occurrence of a slight notch in the edge of the
reconstructed lip.
If this incision is not adopted an incision concave toward the cleft is a
good One, because when the concave edges are brought together in a
straight line a similar pouting on the margin of the lips is accomplished.
A steel pin is then carried through the two portions of the lip and across
the gap just beneath the wing of the nose. The flattened condition of
the nostril is thus corrected by the same pin which brings the upper part
of the gap in the lip together. A second pin is introduced about the
middle cleft, care being taken to pass it between the mucous membrane
and the coronary artery, in order that the pressure made shall arrest
bleeding. The forceps previously applied to prevent bleeding are now
removed. Catgut or silk sutures are then carried around the ends of
each one of these pins to bring the parts in apposition. A few fine catgut
or silk sutures are used along the margin of the lip and upon the internal
surface, in order to bring the mucous membrane into accurate apposition.
It is very important that the mucous membrane and the skin should be
accurately matched at the muco-cutaneous border as deformity is some-
times produced by having the mucous membrane run up higher on one
side of the repaired cleft than upon the other. This is a very unsightly
deformity after union has taken place.
... The wound is dressed with iodoform and collodion, and the child is
#d either at the breast or with a spoon. The pins are taken out upon the
third day, although the ligatures are allowed to adhere to the incision, in
order to assist in supporting it for a few days longer. The sutures in the
lºucous membrane may be allowed to remain until the fourth or fifth day.
The operation for double harelip is the same. Both clefts are pared and
99"rected at once, pins being passed through the flattened edges of the
lip and through the central lobule if it be large enough to be of any ser-
X* in filling the gap. The edges of this central lobule are, of course,
freshened; but if it is very short it may be necessary to preserve the
Pºngs from the lateral margins of the cleft and to use them in filling up
º j below the central portion of the lip when the final sutures are
pplied. -
554 D IS E A S E S O H' T H E M O U T H .
In case of absence of the nasal columella as a complication it may be
wise to turm up the central process of the lip to reconstruct the deficiency
in the nose. If the inter-maxillary bone or its alveolar portion protrudes
it may be cut away with bone forceps or bent up into place after fractur.
ing its attachments. The vomer, which is sometimes hypertrophied when
this protrusion is present, may be retrenched by excision of a V-shaped por.
tion behind the inter-maxillary bone. No attempt is made to correct the
cleft in the alveolar process, since the defect is covered by the lip and can
be remedied, when the child has reached adult life, by artificial dentures.
If union by first intention fails in attempts at curing harelip, it may be
necessary to do a secondary operation, in order to get a perfect result.
CLEFT PALATE.
Cleft palate, which is similar in its origin to harelip, is much more diffi-
cult to repair by plastic procedures. The cleft is in the middle line except
when it is in the anterior portion of the hard palate, when it may be a
little to one side of the middle line. The fissure may sometimes be double
in front with the incisive bone lying between the
two clefts. It is more common, however, to have
only the soft parts of the palate fissured. The
operation for the repair of the soft palate is called
staphylorrhaphy, while a similar operation on the
hard palate is called uranoplasty. Cleft palate
interferes with deglutition and speech, because it is
usually impossible for the patient to close the pos-
terior nares, which is essential in proper deglutition
and speaking. In infants deglutition is often very
difficult and the milk is regurgitated into the nasal
*- cavities. These conditions are, of course, greater
Fissure of soft, and hard when the cleft is a large one or involves both the
palate. (SMITH.) hard and soft palates. In the milder form the
child, when beginning to talk, should be especially
trained in articulation; as by special development of the muscles he
may be able to overcome this defect in speech to a great extent. In more
severe cases benefit may be derived by applying to an oral surgeon for
the adaptation of an artificial palate. Artificial palates, however, are
not sufficiently satisfactory to prevent the adoption by many of operative
proceedings in great palatal defects. r
The operation for cleft palate to be most successful should be done
before the child has fully acquired the art of speech. About the third
year is the proper time. If the patient is young he should be etherized,
but in adults the use of cocaine will render general anaesthesia unneces.
sary. The mouth must be held open by means of a gag. The edges ºf
the cleft, when the fissure involves only the soft palate, should be carefully
pared, from the angle of the fissure backward to the free margin of the
velum, after which the two sides of the velum must be brought together
by silk or wire sutures passed by means of a curved needle. º
Before passing the sutures in the operation of staphylorrhaphy it is well,
in cases where the cleft is large, to cut the two elevator and tensor muş
cles of the palate, in order to diminish tension on the soft palate, which
is about to be drawn together. This is done by passing a tenotome through
the soft palate on the inner side of the hamular process, which can be felt
FIG. 364.

E PIT H E L I O M A OF T H E LI P. 555
at the outer side of the roof of the mouth, and carrying the edge of the
tenotome upward and then downward, thus dividing the muscles. The
flaccid and immobile condition produced by the division of these muscles
will prove that the division has been successful. The sutures are then
passed and tied. . During the after-treatment the patient should be pre-
vented from coughing or talking, and fed on liquid food.
In the operation of uranoplasty, or closure of cleft in the bony palate,
two strips of mucous membrane with the underlying periosteum are sepa-
rated from the hard palate on each side of the fissure and drawn toward
the middle line, where they are held together by sutures. The incisions
for raising the muco-periosteal flaps are made antero-posteriorly near the
alveolar process, and along the edge of the cleft. The flaps are then dis-
sected up, but are left attached at both ends. The middle portions of the
strips are then pushed laterally toward the middle line and sutured,
while the raw surfaces left by their removal heal by granulation. The
soft palate is repaired as described above, Some surgeons prefer to cut
entirely through the hard palate with a chisel and displace the detached
portions of bone toward the median line. If preferred by the operator,
the patient's head may be allowed, in operations on the palate, to hang
over the end of the table, so that the roof of the mouth is below the
operator. The blood then runs into the nose and does not obscure the
field of work.
Operations for the relief of cleft palate, even when extensive, are often
quite successful, but at best they make a rather poor substitute for the
normal roof of a mouth. Subsequent to their use, careful training of the
child in articulation is very important.
EPITHELIOMA OF THE LIP.
Herpes, ulcerations of the non-malignant kind, and inflammatory fis-
sures or cracks in the lip belong to medicine. Epithelioma, however, is
$0 common an affection, especially among men, and in the lower lip, that
it deserves special attention at this point. It is possible that smoking a
clay pipe, and similar long-continued irritations, may be factors in the
Causation of this malignant disease. The upper lip is occasionally the
seat of epithelioma. At first the variation from health in the tissues is
$0 slight that it is overlooked; but after a time the patient notices a small
hard module, which subsequently ulcerates, or an intractable ulcer or fis-
Sure appears upon the lip and refuses to heal. Induration about the base
of the lesion steadily and gradually increases in size, and a little later
involvement of the submaxillary and cervical glands gives evidence that
the disease is a malignant one. Epithelioma of the lip does not cause
much pain; when ulcerated a thin discharge is secreted. Death may
take place from exhaustion or hemorrhage, or from secondary involve-
ment of the internal organs.
Ppithelioma and lupus of the lip are sometimes similar in appearance,
but the latter does not involve the cervical and submaxillary glands.
The diagnosis between epithelioma and chancre of the lip is exceedingly
*Portant. Chancre occurs at any age, while epithelioma is more common
after the age of forty years. Chancré begins as an ulcer, as a rule, whereas
*Pithelioma ordinarily begins as a nodule. In the syphilitic affection the
ymphatic glands are involved earlier; and the sore, even when it attains
* maximum, is not so extensive in its progress as the cancerous affection;
556 D IS E A SES OF T H E M O U T EI.
and in addition there may be some syphilitic fever. Secondary eruptions
may also appear, to assist in the diagnosis; and most important of all, the
syphilitic sore promptly yields to mercurial treatment. Epithelioma of
the lip, before secondary involvement of the internal organs has occurred,
is usually exhibited in the lymphatic glands under and behind the lower
jaw. The original site of disease and the involved glands slowly ulcerate,
and destruction of the tissues about the mouth and throat is finally very
extensive. Labial epithelioma should be treated by prompt and radical
operation, except when the disease has extended as indicated; then pro-
longation of the patient's life by anodynes and supporting measures is all
that can be done. Excision of epithelioma of the lip is accomplished by
the removal of a V-shaped portion of tissue with the base of the wedge at .
the margin of the lip. During the operation the lip is held everted by
an assistant's fingers, which also press upon the coronary arteries at each
side of the proposed incision. The excision should be done soon enough
to insure entire removal of the malignant mass. The divided lip must
then be brought together by one or two pin sutures, so passed as to make
pressure upon the coronary arteries and prevent bleeding. Along the
edge and inner surface of the lip the mucous membrane should be united
by fine catgut sutures. The wound should then be dressed with a little
antiseptic absorbent cotton, held in place by iodoform and collodion
painted upon it. It may be necessary in more extensive infiltration to
cut a larger portion of the lip away and to construct a new lip from the
tissues covering the chin by slipping up one or too large cutaneous flaps.
Excision of a portion of the jaw is required if the disease has in-
volved the bone tissue. Enlarged glands under the jaw and in the
neck should be removed at the same operation. The prognosis after
excision of epithelioma of the lip is usually quite good, if the portion
attacked permits of free removal. If the growth returns, it should be
removed a second time.
TUMORS OF THE MOUTH.
Tumors of various kinds may be found upon the buccal surface of
the cheeks and in the floor of the mouth. The most common form,
perhaps, is the cystic tumor, occurring beneath the tongue and usually
upon one side of the fraenum, to which the term ranula is usually ap-
plied. Ranulae contain a more or less transparent, gelatinous fluid, re-
sembling saliva. They are sometimes dilated ducts of the submaxillary
or sublingual glands, and at other times occur as dilatations of the ducts
of the mucous glands in the floor of the mouth. True hydatid cysts have
been found here, and the bursa above the hyoid bone has been known
to become enlarged, and resemble ranula. These cystic tumors are soft,
elastic swellings, which gradually increase in size. They sometimes be:
come so large as to push out the tissue of the neck below the jaw and
make a distinct bulging upon the exterior of the throat. Adipocere
and rice-like bodies have at times been found in ranulae. e
The treatment of these non-malignant growths consists in puncturing
the sac so that evacuation of fluid takes place, and then setting WP
sufficient irritation of the lining membrane to cause obliteration of the
cavity. This last object may be obtained by scraping the interior of
the sac with the trocar and canula with which its fluid contents have
been withdrawn, or by laying open the sac with a knife and mopping
T U M O R S OF T H E J A W. 557
out its interior with chloride of zinc or carbolic-acid solution. Some
surgeons prefer to operate by making, an opening in the cyst wall, and
keeping the orifice patulous by turning a portion of the wall inward
and stitching it with its internal surface toward the interior of the sac.
A seton may be passed through the sac, so as to evacuate its contents
and give rise to plastic adhesion of its walls. , Large cysts projecting
externally may require to be attacked by incision in the neck. After
evacuation, the cavity of the cyst is then stuffed with antiseptic gauze.
It is occasionally possible to dissect out the cyst by means of external
incision.
ALVEOLAR ABSCESS.
Abscesses of the alveolar process may be superficial, when they are
called gum-boils, or deep, when the pus originates in the tissues around
the root of a tooth. Abscesses occurring in the tooth sockets are usually
due to disease of the teeth, as, indeed, is usually the case in superficial
abscess. The pus in superficial abscess is not confined by bony tissue, as
in the deeper form, and is, therefore, the seat of but moderate pain. In
those cases in which the pus is confined in the dense walls of the tooth
sockets the pain is excruciating, and is only relieved when the pus is
evacuated either spontaneously or by drilling the bone or the tooth. Re-
moval of a filling which has been previously placed in a carious cavity
in the crown of the tooth by the dentist may afford exit to the confined
pus. Escape of the pus gives instant relief from pain. When the pus
does not thus find its way through the bone in which the tooth is lodged,
it may finally be evacuated alongside of the tooth after it has reached the
upper edge of the socket. Occasionally, the suppurative process gives
rise to a fistulous opening in the cheek or in the roof of the mouth, and
may even cause destruction of the palate bone and penetrate into the
nasal cavity.
The treatment of alveolar abscess consists in the use of leeches locally
to the gum ; painting the gum with tincture of aconite root ; the applica-
tion of heat and moisture, which is best accomplished by the use of a hot
fig or raisin applied to the gum; incision of the gum, and, in deep abscesses,
boring of the bone or tooth, in order to permit the escape of pus. In many
instances the tooth should be seen by a competent dentist, since removal
of the filling and treatment of the abscess cavity through the tooth may
hasten cure and preserve the structure.
Acute subperiosteal abscess may occur in connection with alveolar
inflammation, and lead to more or less extensive destruction of the bone
by necrosis. Early and thorough incision is the proper treatment.
TUMoRS OF THE JAW.
Growths involving the alveolar process of the jaw, but not the bone
Very extensively, have long been given the name epulis. This term,
however, should be discarded, since it has no strict definition, and many
cases of so-called epulis would be better understood and more effectively
treated if called tumors of the jaw and described by their proper adjec-
"We as fibromatous, sarcomatous, and carcinomatous. The common
growth to which the term epulis is applied is a fibrous mass, usually if
not always arising from the periosteum or bone, and presenting itself as
* Smooth, firm, elastic growth alongside of or between the teeth. It may
558 D IS E A S E S OF TH E M O U T H .
become ulcerated. These fibromas are more common in the lower than
in the upper jaw, and they appear to be due to the irritation caused by
decayed teeth. Such fibromas should be removed by operation within
the mouth in order that the scar may not appear upon the cheek. They
are ordinarily easily cut away with a strong knife or gouge, though it
may be necessary to extract one or more teeth in order to make the
extirpation complete. They are not apt to return. -
Malignant tumors of the jaw, whether occupying the alveolus, and
therefore being a form of epulis, or arising from the central portion of
the jaw-bone and gradually extending to the surface, should be removed
by very free incision through the soft tissue and bone. Such malignant
growths require total or partial excision of the jaw, the amount of bone,
removed depending upon the time at which the operation is done. In
Some instances it is sufficient to cut away the upper margin of the lower
jaw without making the section complete. Similar tumors affecting the
upper jaw may require its complete or partial resection.
Non-malignant growths of the jaws, as has been stated, may require
only partial excision of the bone, or possibly may be enucleated without
taking away much of the bone tissue. Malignant disease, however,
whether it involve the upper or lower jaw, should be removed by very
free incisions and by enucleating any of the lymphatic glands which may
be secondarily involved. Where it is impossible to get beyond the recog.
nized limits of the disease, operation may be unjustifiable, although some
instances seem to indicate that removal of the major portion of the
growth by means of a knife and the application of chloride of zinc solu-
tion to the surface left may be followed by prolongation of life.
Cystic, as well as solid, growths may develop within the antrum or
cavity of the upper jaw bone. Such tumors occasion great deformity as
the growth pushes the walls of the antrum into the neighboring fossae,
or outward upon the face. By this means the eyeball may be protruded
because the floor of the orbit is raised; the nasal chamber may be
occluded by the growth ; the hard and soft palate may be pushed down-
ward, and the face may be deformed by protrusion of the cheek. Diffi-
culty in breathing and difficulty in swallowing may result from such
antral growths. Cerebral complications may also occur, as well as blind-
ness and profuse nasal hemorrhage. Solid growths in the antrum are to
be distinguished from cystic growths by their firmness, and by the fact
that in the latter case fluid is evacuated when the antrum is tapped from
within the mouth above the canine tooth. Rapidity of growth occurring
in persons beyond the middle age and involvement of the submaxillary
and other lymphatic glands suggests that the tumor is malignant rather
than benign. This diagnosis is confirmed when rapid infiltration occurs
outside the bony walls of the antrum, because it indicates that the malig-
nant tumor has involved the bony walls and spread to the soft tissues,
Cystic tumors within the antrum may owe their origin to the abnormal
development of a tooth within the antral cavity. Such dentigerous cysts
are not uncommon.
NECROSIS OF THE JAw.
Necrosis of the jaw is not uncommon in those exposed to the fumes of
phosphorous acid in the manufacture of matches. It is probable that
this disease, called phosphorus necrosis, occurs only when the patient, is
the subject of diseased teeth. The necrotic portion of bone should be
IN FL A. M M ATION OF T H E TO N G U E. 559
removed by operation within the mouth so as to avoid a scar. This
should not be done ordinarily until the sequestrum has become detached,
because it is desirable to retain the integrity of the arch of the jaw-bone
which in earlier attempts at removal may be fractured. Where the
sequestrum is very large it may be necessary to make an external incision.
The application of artificial dentures to the defective bone after the
removal of such large portions may give a useful lower jaw.
Actinomycosis is a disease due to a parasitic fungus which has been
known to attack the jaws and to be the cause of necrosis. Necrosis also
occurs secondarily to some of the essential fevers, and as a symptom of
tuberculosis, syphilis, injuries, diseased teeth, and excessive mercurializa-
tion. Ankylosis and articular disease of the temporo-maxillary joint
have been discussed elsewhere.
DISEASES OF THE TONGUE.
When the fraenum of the tongue is abnormally short, preventing the
protrusion of the tip beyond the teeth, and limiting its movements within
the mouth, tongue-tie is said to be present. This condition sometimes
prevents a young child from suckling, and in older children interferes
with perfect articulation. Tongue-tie, however, does not prevent speech
and make a child dumb, as is sometimes supposed by the laity.
When tongue-tie exists to any marked extent it should be remedied by
clipping the edge of the franum with the scissors. The incision should
be about one-eighth of an inch deep. The surgeon's finger can then tear
the tissue and establish lingual movements. The ranine arteries lie in
the fraenum close to the lower surface of the tongue. Division of these
vessels is avoided by keeping the point of the scissors turned downward.
Reunion of the cut portions of the fraenum should be prevented by sepa-
rating them daily with a probe or with the finger. The edges of the
slight wound will have cicatrized in four or five days.
INFLAMMATION OF THE TONGUE.
Glossitis, or inflammation of the tongue, may be acute or chronic,
simple or specific. Simple or superficial inflammation of the mucous
membrane of the tongue occurs in connection with stomatitis or inflam-
mation of the mouth. Stomatitis is applied to inflammation of the
mucous membrane lining the cheeks, lips, and other oral structures. It
may arise from digestive disorders, the administration of iodine, mercury,
and other drugs, and as a lesion of secondary syphilis. Mucous patches
and erythema are the pathological conditions of the mouth most prone to
follow syphilis. It must be remembered that chancre itself may be fouud
in the mouth. Syphilis may be exhibited by mucous patches or gummy
deposits or ulceration in the tongue. General parenchymatous inflam-
mation of the body of the tongue of an acute kind occasionally occurs,
and is quite a serious condition. It may be due to wounds or to insect
bites, or it may occur without apparent cause. The tongue is swollen
and red and shows a smooth surface. Pain, which is great, is perhaps
increased during efforts at taking food. The flow of the saliva is abun-
'ant and the interference with respiration may be marked. The condi-
tion is occasionally followed by sloughing. -
Syphilitic glossitis requires constitutional treatment and local stimu-
560 DISE A SES OF THE MOUTH.
lating applications. Acute parenchymatous glossitis should be treated by
leeches applied under the jaw externally and the use of cracked ice in
the mouth, while the patient is nourished with liquid food. If these
means do not relieve the swelling and the inflammatory symptoms,
incision should be made in the tongue to the depth of one-half inch along
each side of the middle line, beginning well back upon the dorsum of the
tongue, and extending nearly but not quite to the tip. The relief from
tension and swelling given by this incision will usually be immediate.
Antiseptic mouth-washes should be freely used thereafter.
Injuries to the tongue and the impaction of foreign bodies in the organ
give rise at times to acute or chronic suppurative inflammation or abscess
of the tongue. If the puriform fluid lies deeply in the organ the chronic
abscess may be surrounded with infiltrated tissue sufficiently hard to
cause resemblance to a tumor imbedded in the lingual muscles. Such
abscesses of the tongue are treated by incision and the removal of more
or less inspissated puriform fluid with the curette. Chronic abscess is
probably tubercular in its etiology.
In addition to these forms of glossitis there occurs a chronic superficial
inflammation to which the names leucoma, psoriasis, and ichthyosis have
been applied.
EPITHELIOMA OF THE TONGUE.
Various benign and malignant tumors may occur in the tongue, but the
most common of all is epithelioma, which is a disease with distressing
symptoms. It is more frequent in man than in woman, is a disease of
rather advanced life, and apparently may at times arise secondarily to
superficial glossitis. Smoking, the immoderate use of spirituous drinks
and of condiments, irritation from jagged teeth, as well as syphilis, have
been suggested as possible predisposing causes.
Epithelioma of the tongue appears usually on one side of the middle
line toward the root of the organ. Superficial ulceration with indurated
base and edges is an early evidence of the disease. The pain is at first
slight, but the discomfort increases during eating and other movements,
until it becomes very great. The saliva flows more freely and the breath
becomes fetid. The floor of the mouth and fauces become involved, as
do also the lymphatic glands below the angle of the jaw. Slight or pro-
fuse hemorrhage may occur. Impaired nutrition, due to the difficulty in
feeding and the swallowing of foul secretions, is soon evident. If one of
the lingual arteries is opened by ulceration, fatal hemorrhage probably
supervenes, while death may also occur from Septic pneumonia, due to
inhalations of the Secretions from the malignant growth. &
The diagnosis between epithelioma of the tongue and ulcerative syphi.
litic gumma is at times difficult, but the doubt can easily be cleared up by
the use of mercury and potassium iodide in full doses. Specific disease
under this treatment will soon show evidence of improvement.
The only effective treatment for epithelioma of the tongue is early and
complete removal of the whole tongue and of any lymphatic glands below
the jaw, which may be involved, "Where the disease has progressed tº
the involvement of the floor of the mouth before the surgeon is consulted
it may be doubtful whether operation is justifiable. In such a case liga.
tion of both lingual arteries may possibly retard the development of the
growth, and excision of a portion of the lingual nerve on the side affected
may relieve pain. This nerve can be felt in the mouth lying underneath
E PIT H E L IO M A OF THE TO N G U E. 561
the mucous membrane at the angle of the lower jaw, vertically below the
second lower molar tooth. An incision through the mucous membrane
will enable the operator to take up the nerve by means of a hook and to
excise a portion of it. This neurectomy lessens pain and diminishes the
uncomfortable flow of the saliva. The pain which makes lingual move-
ments distressing may also be mitigated by painting the diseased tissue
with cocaine, about forty grains to the ounce. The patient may require
feeding by enemas, or by having a tube passed through the nostril into
the pharynx. CEsophagotomy may be available for feeding in cases where
the fauces are obstructed by the growth.
It has been proposed to perform tracheotomy in order to prevent inhala-
tion of the foul discharges which give rise to septic pneumonia. This
seems scarcely necessary, since the free use of antiseptics with frequent
powdering of the cancer with iodoform will preserve a fairly clean con-
dition of the ulcer.
The tongue can be entirely removed by dragging it forward while the
mouth is held open by a gag. A strong string passed through the organ
at its tip will give the operator control of it, and enable him to pull it
well out of the mouth, and by successive manipulations with the scissors
the organ can be cut away without difficulty, and the spurting vessels tied
as they are divided. It is well to have a ligature of silk passed through
the stump and brought out of the mouth after the removal of the organ,
in order that the patient may not be suffocated by the base of the tongue
falling backward into the pharynx. This danger does not exist after
twenty-four hours have elapsed.
It is often advantageous to split the tongue in the middle line antero-
posteriorly before attempting its complete removal with the scissors. So,
also, in cases where the écraseur is applied to extirpate the organ, it is
Well to operate upon the two halves successively. Operation with the
scissors, however, seems more surgical and accurate than that by means
of the écraseur, because the direction and extent of the incision can be
better regulated. The mouth should be well packed, after drying of the
stump, with iodoform gauze, which should be pushed into every irregu-
larity of the mouth, and retained several days until cicatrization of all
the surfaces has been accomplished. The patient should not be allowed
to talk or take food by the mouth for a week. Alimentation can be kept
up by the rectum.
If this radical operation is done early in the course of the disease, a
considerable prolongation of life is usually secured. It is, however, bad
. to attempt partial removal of the organ in cases of malignant
1Séa Se.
Access to the tongue, in order to accomplish its complete removal, may
be obtained by making a horseshoe incision in the throat under the lower
JºW, going through the floor of the mouth, or by making a straight cut
from the centre of the lip to the chin, accompanied by division of the jaw
bone With a saw at the symphysis. Ordinarily, however, the method first
described—namely, that of dragging the tongue out of the mouth—is
efficacious.
Subsequent to the removal of the tongue, the speech is not so imperfect
as Would be expected.
36
562 I) IS E A SES OF TH E M O U T H .
DISEASES OF THE TONSILs.
Tomsillitis, or quinsy, may go on to suppuration, and require incision
for the evacuation of pus. A sharp-pointed bistoury should be carried
through the swollen gland and the surrounding tissue until the pus col-
lection is entered. Usually the abscess is localized at the upper point of
the tonsil, where it joins the soft palate. The point of the knife must
never be carried outward, since the internal carotid artery lies just exter-
nal to the gland. Detergent washes should be used after the operation.
Relief is immediate. A solution of sodium bicarbonate has been highly
lauded as an application in quinsy prior to the stage of suppuration.
Syphilitic lesions and malignant tumors are at times found in the tonsil
glands.
Hypertrophy of the tonsils is a chronic condition, probably inflamma-
tory in its character, which is often seen in children. These enlarged
tonsils are frequently associated with recurrent attacks of inflammation of
the throat, and it is possible that they may have some relation to local
tubercular infection. The increase in size may be so great that the
enlarged glands extend to or beyond the middle line of the fauces, so
that the opposite growths come in contact and result in mutual pressure.
|Ulceration of the masses may be thus induced. The disease causes ob-
struction to breathing and swallowing, and compels the child to keep its
mouth open almost constantly, and to snore during sleep. When the
enlarged glands are attacked with acute inflammation, the difficulty in
breathing may approach Suffocation.
FIG. 365.
º:
|
) -..….: '.
--><sº:
ºe;=
Tonsillotome.
The medical treatment of enlarged tonsils consists in the use of astringent
gargles, the application of nitrate of silver, improved hygienic surroundings,
and the internal administration of good food, cod-liver oil, iodide of iron,
and other tonics. Surgical treatment is often demanded because of the
inefficiency of these measures. It consists in excision of a portion of the
enlarged gland by means of a guillotine or tonsillotome. The operatiº
is not a dangerous or painful one, and may be done to Very young chil-
dren without an anaesthetic. A solution of cocaine may be painted Pº"
the surface of the enlarged tonsils, if the child is very sensitive. Only
that portion of the growth which projects into the ring of the tonsillo-
tome, when it is laid over the organ, should be removed. Even when
only a comparatively small portion is cut away the operation is successful,
since atrophy of the hypertrophied mass is very apt to occur afterward.
The hemorrhage is only very slight usually, although cases have been
reported in which it has been profuse. In such cases, it is Pºpº to
seize the bleeding point with a hemostatic forceps, which should be left
in position for a few hours. Detergent gargles should be used after the
operation. e
When the circular knife, to which the name guillotine or tonillº
is applied, is not at hand, the hypertrophic tissue may be cut º W.
a probe-pointed bistoury, after the apex of the mass has been seized With





R. E. T. R O - P H A R Y N G E A L A BSC ES S. 563
a pair of toothed forceps. This method is less rapid, and more apt to
frighten the child, than the other.
SALIVARY FISTULE.
Fistules of the salivary ducts may be upon the inside or upon the out-
side of the mouth. If the abnormal opening is in the oral cavity itself,
it requires no treatment. If, however, the opening is so placed that the
saliva escapes upon the external surface of the face, it is necessary to
operate in order to turn the current into the mouth. Salivary fistules
are due to wounds, to abscesses, to calculi impacted in the ducts, or to
obstruction from inflammation of the ducts. The amount of saliva that
escapes from a salivary fistule during mastication may be as much as a
drachm within a few minutes. The fluid can be recognized as salivary by
the characteristic test with potassium sulpho-cyanide and with ferric
chloride. I once saw a case of inflammation of the parotid gland in
which a transudate appeared upon the surface of the cheek which seemed
to be saliva. This local escape of fluid in drops like sweat was lessened
by passing a probe into the duct from the mouth, and relieving the ob-
struction. Unfortunately, the patient passed out of my hands before I
was able to make a test to prove that the fluid upon the cheek was really
saliva.
The treatment of salivary fistule must begin with removal of the cal-
culi or other causative influence. A new opening must then be made
from the mouth into the duct behind the site of the external opening.
This can be done by inserting a probe into the external orifice, passing it
along the duct upward toward the gland and making its point push up
the mucous membrane in the mouth. An incision can then be made
upon the point of the probe and a comparatively large opening made
from the duct into the mouth so that the saliva will flow into the buccal
cavity. This new orifice must be kept open by means of daily insertions
of a probe from within the mouth. When the internal opening has been
permanently established the external fistule will soon heal; if not, this
may be accomplished by the application of caustics, or the orifice can be
closed by a plastic operation.
RETRO-PHARYNGEAL ABSCESS.
Retro-pharyngeal abscess is a collection of pus between the posterior
Wall of the pharynx and the anterior surface of the vertebral bodies in
the cervical region. It is not unusual in adults, but occurs especially
in children of unhealthy constitution. It may result from caries of the
Cervical vertebrae, from suppuration of the lymphatic glands behind the
pharynx, or from suppuration in some neighboring region burrowing
behind the constrictor muscles of the pharynx. At other times, however,
its cause is not apparent. Acute abscess is necessarily more dangerous
and more rapid in its course than a chronic tuberculous collection of
Puriform matter in this locality. The difficulty in breathing and swal-
lºwing associated with a soft, fluctuating swelling at the back of the
Pºynx makes the diagnosis evident. The abscess is not always in the
middle line and may give rise to some stiffness of the neck due to an
*tempt on the part of the muscles to fix the vertebral articulation and
P*Vent pain. In the event of spontaneous evacuation of the abscess
564 DIS E A SES OF T H E M O U TEI.
there is danger of the quantity of pus being large enough to suffocate
the patient from its entrance into the larynx. At other times the con-
tents of the abscess cavity pass into the stomach or are spat out. In
rare cases the pus burrows into the posterior mediastinum or along the
muscle sheaths and fascial spaces of the neck. Early and free evacuation
of the pus is the essential treatment. It is accomplished by making a
vertical incision through the posterior pharyngeal wall with the patient's
mouth wide open, and in getting rid of the pus, which is often very large
in amount, so as to obviate the possibility of the patient drowning. It
may be wise to evacuate the major portion of the pus by means of a
trocar and canula in order that the gush of fluid may not asphyxiate the
patient by getting into the larynx. Subsequently the cavity must be
freely opened with a knife. Astringent and disinfectant washes should
thereafter be used.
DISEASES OF THE CESOPHAGUS.
Wounds of the oesophagus, if external, are usually indicated by the
escape of food from the opening. Deglutition is accompanied by pain,
and emphysema of the cellular tissues of the neck may occur as a sec-
Ondary symptom.
Rupture of the oesophagus may occur, though rarely, as a result of
violent vomiting; and more frequently as a sequence of stricture or
malignant disease which has caused softening and thinning of the coats.
Feeding with liquids introduced by means of a tube passed through the
injured gullet is necessary in these cases if nutrition is not kept up by
means of rectal injections. External wounds should be sutured by means
of stitches passed through the oesophageal wall, and provision for drainage
externally should be made because of the dangers of pus collection in the
deep tissues of the neck. Such retained pus might very readily be the
cause of mediastinal abscess or pleural inflammation.
FOREIGN BODIES IN THE CESOPHAGUs.
Foreign substances swallowed may be caught in the pharynx or Oºsoph:
agus instead of passing into the stomach. Dental plates and artificial
teeth are not infrequently thus swallowed, and food sometimes becomes
impacted in the oesophagus, giving rise to trouble. Very rarely fruit
stones and substances which have previously entered the stomach have
become impacted in the oesophagus during vomiting. Bullets and other
missiles may enter the oesophagus through external wounds in the neck
and throat. Persons of hysterical temperament sometimes imagine that
foreign bodies are lodged in the gullet when no such condition exists.
Sharp pieces of bone may, during their passage through the gullet,
scrape the mucous membrane and cause irritation, thus giving the patient
the sensation of a foreign substance impacted in the canal after the Vuk
nerating body has actually passed into the stomach.
SYMPTOMs.-A comparatively large foreign body, lodged in the upper
end of the oesophagus or in the lower portion of the pharynx, causes a eel-
in g of suffocation, violent paroxysms of dyspnoea on attempting to swallow,
repeated and vigorous efforts at deglutition, retching, spitting of saliya, P0s.
sibly mixed with blood, bulging of the eyes, and great anxiety on the part
of the patient, accompanied with sweating and prostration. Pressure 9”
F O R. EI G. N. B O DIES IN T H E CESO PH A G U. S. 565
the larynx by, or a spasmodic condition of the glottis produced by irrita-
tion from, a foreign body may cause asphyxia and death. Loss of voice,
dysphagia, and pain are also symptoms. The combination of symptoms
seen varies with the size and character of the impacted body. Small and
sharp foreign substances will give rise perhaps to difficulty of respiration
without much actual interference with swallowing, but are apt to be
accompanied with blood expectoration. The position of the body also
causes change in the combination of symptoms. It is possible in some
cases to feel the obstructing substance by thrusting the finger into the
back part of the fauces and down the pharynx, or by palpation of the
throat externally. Auscultation of the oesophagus by means of the stetho-
scope, placed upon the exterior of the neck, sometimes gives aid in diag-
nosis, because fluids or other food swallowed are arrested or diverted in
their course by the impacted substance, and therefore produce sounds
which can be distinctly heard through the stethoscope.
Inflammation of the oesophagus followed by ulceration, perforation, or
abscess, may result from prolonged retention of a foreign body; and cica-
tricial contraction due to such inflammatory processes may cause stricture
of the oesophagus. Secondary to this stricture, dilatation above the point
of stricture and contraction of the normal tube below may supervene.
Perforation from a sharp foreign body or from abscess may involve the
pericardium, the heart, the trachea, the pleura, the mediastinum, or the
aorta. Such secondary lesions are more apt to occur and prove fatal
when the foreign substance is lodged low down in the oesophagus. The
presence of a foreign body in the gullet may often be proved by carefully
passing into the oesophagus a bougie or probang, which consists of an
olive-shaped tip attached to a long, flexible stem. Such a bougie may
push small foreign bodies before it into the stomach, thereby relieving
the existing condition. It may, however, pass by a small bone or similar
object without dislodging it, and without giving the sensation of having
passed an obstruction.
TREATMENT.-Masses of food and foreign bodies of moderate size may
be carefully pushed into the stomach by the oesophageal bougie. This
Operation should be very carefully attempted lest the oesophagus be
ruptured, or the mucous membrane scraped loose. Substances lodged in
the upper portion of the gullet may be extracted through the mouth by
the finger of the surgeon or by curved forceps. Several forms of instru-
ments to draw out coins and similar substances from the lower part of the
ºsophagus have been constructed. A very good method is to fasten a
Ty piece of a sponge on to the end of a rod of whalebone and pass this
beyºnd the obstruction. The sponge, after becoming swollen by the fluids
of the Gesophagus, fills the calibre of the tube, and on being withdrawn
brings up the obstructing substance. A somewhat similar instrument is
made of horse-hair, which after its introduction and passage beneath the
obstruction is distended until it fills the tube. Its withdrawal carries the
offending substances upward into the mouth.
Vomiting may be induced by hypodermic injections of apomorphia
(gr. i’s to gr. Pº), or by the administration of emetics by the stomach, to
$ºse ejection of the body in the oesophagus. Inversion of the patient's
body has sometimes been successful in causing expulsion of the offending
substance. There is, however, some danger in this procedure of causing
*Phyxia from the foreign substance becoming lodged in the upper por-
ºn of the oesophagus or at the opening of the glottis. Where the symp-
toms of dyspnoea are marked, either before the attempt at removal or
566 DIS E A SE S OF T H E M O U TEI.
during such effort, tracheotomy should be performed as a preliminary
precaution.
If the methods described are ineffectual in relieving the patient's con-
dition it then becomes necessary to open the Oesophagus. This operation
is called oesophagotomy. If the operation is done high up in the throat
the name pharyngotomy is applied. As it is only possible to open the
food tract in the upper portion of the neck, it is probable that what many
operators call osophagotomy is actually pharyngotomy. External oesoph.
agotomy or pharyngotomy is usually performed on the left side of the
neck, because the oesophagus is located a little to the left of the median
line. If, however, the body to be extracted is more prominent on the
right side, there is no objection to making the incision on that aspect. It
is only necessary to describe left-sided oesophagotomy, since that upon the
right side is done in a similar manner.
During the operation the head should be turned a little to the right.
An incision parallel to the anterior border of the sterno-cleido-mastoid
muscle should be made, beginning on a level with the upper border of the
thyroid cartilage and extending downward toward the sternum for four
or five inches. This incision should be carried through the tissue between
the sheath of the carotid artery and the sterno-hyoid and the sterno-thy-
roid muscles. The thyroid body and trachea should be pushed toward
the middle line and the sheath of the carotid vessels drawn outward. In
this space will be seen the omo-hyoid muscle which may be drawn aside
and divided. Care should be taken to avoid the inferior thyroid artery,
and also the recurrent laryngeal nerve. The latter structure lies in the
groove between the trachea and the oesophagus. When the gullet has
been exposed at the bottom of the wound, it is well, if the foreign body
does not make a projection, to pass a bougie with a large tip through the
mouth, in order that the gullet wall may be pushed up toward the surface
and be made easily accessible for incision. A silk ligature may be passed
through the oesophageal tissues by means of a curved needle, in order to
give the surgeon control and to enable him to lift the wall toward the
external wound. A small incision is next made into the oesophagus and
an exploratory finger passed into the opening, which is subsequently en-
larged in a longitudinal direction if necessary. The foreign body is then
extracted with forceps, the oesophageal wound is closed with sutures, and
provision made for drainage of the external wound, the edges of which
may be united by buried and superficial sutures.
TUMORS OF THE CESOPHAGUS.
PATHOLOGY..—Growths of benign character are quite rare in the
oesophagus, but primary malignant disease in this locality is not infre:
uent. Of the forms of tumor epithelioma is the most common, and it
usually attacks the oesophageal tube either at the upper or lower extrem.
ity. The affection is one occurring late in life, and more frequently, it
would seem, in man than in woman. Involvement of the surrounding
glands and tissues is quite common and ulceration of the growth usual.
The disease has a rather rapid course toward death, its average duratio"
being from four to sixteen months. The fatal issue occurs from hemOT-
rhage; from starvation, the result of the contraction caused by the growth
preventing the administration of food; from asphyxia, due to pressulº. 9"
S T R ICTU. R. E. O. F. T H E CESO PH A G U. S. 567
the trachea and the primary bronchi, and from secondary lung condi-
tions.
SYMPTOMs.-The symptoms are like those of non-malignant stricture
hereafter to be described, and consist of pain, difficulty in Swallowing,
regurgitation of food, offensive breath, delayed digestion, constipation,
inanition, and great debility. The gullet is apt to be dilated above the
site of the epitheliomatous stricture, and may become perforated by
ulcers in the neighborhood of the malignant growth. Symptoms arising
from pressure upon the neighboring viscera may be prominent, and in
some cases there is external evidence of tumor.
DIAGNOSIS.—The early stages of malignant disease of the oesophagus
may resemble hysterical stricture. A tumor outside of the oesophagus
pressing the wall inward will give similar symptoms, and at times render
diagnosis of the true condition difficult. Exploration of the oesophagus
with a flexible bougie, such as was described in the discussion of foreign
bodies lodged in the oesophagus, will prove the existence of a growth of
some sort if the contraction made by it is at all conspicuous. It may be
possible to differentiate the histological elements and to characterize the
nature of the growth by microscopical examination of the tissue scraped
off by the bougie.
Fibroid growths of the oesophagus give the impression of a smooth
surface when touched with the bougie, are much more resistant than a
malignant tumor, and do not bleed. Hemorrhage occurring after careful
manipulation suggests malignant tumor, as does, of course, the existence
of a purulent, bloody discharge.
TREATMENT.—If the disease is situated in the upper portion of the
tube, Oesophagotomy may permit the removal of the tumor if small, or
(esophagostomy, which is the formation of a permanent opening in the
Qºsophagus, will establish an opening by which food can be administered.
Removal of such growths by opening the gullet is only justifiable when
the disease is limited. In other cases a small bougie may be passed every
two or three days in the effort to keep the tube open and to allow the food
to be administered by the normal channel. If the operations suggested
are not deemed advisable the performance of gastrostomy will permit
feeding by fistule so made in the stomach. Gastrostomy is often delayed
too long until the patient is too weak to enjoy long the benefit of the
operation. In the event of these operative measures being impossible,
the surgeon can do nothing but render death easy by palliating measures.
STRICTURE OF THE CESOPHAGUs.
PATHOLOGY..—Diminution in the calibre of the oesophagus may be due
tº organic changes and contractions resulting from malignant disease
and the other conditions which have been mentioned, and to cicatricial
contraction following inflammation of the oesophageal coats. Swallowing
hot liquids or strong acids and alkalies with suicidal intent, or by acci-
ºnt, are frequent causes of such coarctations. Syphilis, tuberculosis of
he mucous and submucous tissues of the gullet, and wounds due to
foreign bodies may, in a similar manner, lead to obstruction in the
*Phagus. So, also, aneurism, foreign bodies in the trachea, and
*sses or tumors outside the oesophagus may, by pressure upon its
Walls, cause diminution of its calibre. The condition called Oesophagis-
* or spasm of the muscular coat of the oesophagus, which occurs at
568 D IS E A SES OF T H E M O U T H .
times in hysteria, gives rise to symptoms of stricture. A bougie can,
however, be readily passed through the contracted portion, and meets in its
passage with no perceptible resistance. Indeed, the successful introduc-
tion of Šuch a bougie will often convince the patient that no danger from
obstruction exists, and be thus the means of curing the symptoms. Aus.
cultation with a stethoscope, placed over the oesophagus on the left side
of the neck, is said to give information that the stricture is spasmodic
and not an organic one. In the former case food which has been swal.
lowed is regurgitated immediately; but in the case of true stricture
regurgitation of ingested materials is more slow. CEsophagismus, more-
over, is intermittent and not constant. The medical treatment of this
hysterical affection consists in curing the coincident nervous symptoms.
Fibroid or cicatricial strictures usually take place in the upper part of
the oesophagus or in the pharynx. The contraction may be due to a
puckering of the inner coats of the tube at the site of the scar, it may
consist in a crescentic ridge extending partly around the tube on its
internal surface, or it may be a cicatricial ring involving the entire cir-
cumference of the gullet. Abscess about the injured portion may be
present.
SYMPTOMS.–Difficulty in swallowing solid food is one of the early
symptoms of Oesophageal stricture. If the contraction increases, degluti-
tion of liquid foods soon becomes difficult. Regurgitation of food may
take place after it has reached this stage, and may be slight, or amount
to actual Oesophageal vomiting. The time at which regurgitation or
vomiting takes place, after the attempt at Swallowing food, gives an ap-
proximate idea of the position of the disease. The food when ejected
may be more or less putrid, and mixed with blood or smeared with mucus.
A discharge from the Oesophagus, having a coffee-color, is symptomatic of
malignant disease. The pain is usually slight at first, unless there is acute
inflammation accompanying the stricture; severe pain may then be ex-
perienced. It may radiate to the shoulders and to the epigastrium. The
location of the most severe and constant pain may indicate the seat of
stricture, which may be more or less certainly ascertained by the sense of
stoppage in the food-tract when the patient endeavors to swallow nutri-
ment. The use of the stethoscope may give the surgeon an idea of the
position of the disease, because he may thereby learn the point at which
food stops in swallowing, or the point through which the food passes with
difficulty. Palpation of the throat may at times reveal the mass which
has caused the obstruction. The lodgement of food which takes place
above the contracted portion causes dilatation and hypertrophy of the
wall of the gullet. Great debility and emaciation are later symptoms of
the disease and are particularly slow in their progress when the stricture
is a cicatricial one rather than a malignant one. º
The passage of an oesophageal bougie will give the surgeon information
as to the distance from the front teeth, and the length, number, and calibre
of the contracted portions. ©
TREATMENT.-The treatment of oesophageal stricture consists in giving
rest to the diseased organ, in nourishing the patient, and in dilating the
contracted tube. Rest is obtained by keeping up the patient's nutrition
through rectal injections of milk, broth, and other nutritious articles.
This procedure is of special value if there is great sensitiveness of the
cesophagus, since efforts at alimentation through the oesophagus then
cause great distress and depression of the patient. º
Dilatation of the contracted and contracting oesophagus is accomplished
STRICT U R E O F T H E CESO PH A G U. S. 569
by the introduction of bougies with conical tips, the size of which is
gradually increased. The bougie should not be passed oftener, as a rule,
than once in three days, but at one sitting two or three increasing sizes
may be successively introduced, each of which may be left in position
about ten minutes. Such intermittent dilatation should be made in a
gradual manner, since attempt to pass a large bougie after the passage
of a much smaller one, is liable to cause laceration of the tissues. Rapid
dilatation is not safe, even if it were possible to substitute it for slow
intermittent dilatation, which has just been recommended. Continuous
dilatation can be accomplished by the introduction and leaving in position
of tubes large enough to stretch the strictured portion slightly. Through
this tube, which may be allowed to remain for three or four days, food
can be introduced. At the end of this time the tube should be taken
out to be cleaned, and should then be reinserted or succeeded by a tube
slightly larger.
There are other oesophageal bougies which, after being placed in posi-
tion through the stricture, may be dilated with air or water. Again,
there are dilators which can be spread, after their introduction, in much
the same manner as instruments used for dilating strictures of the urethra.
Internal oesophagotomy, or division of the stricture, by a sharp blade
concealed in a sheath during its introduction through the mouth and
pharynx is dangerous because of the liability of dividing the wall of the
gullet as well as the stricture. It is good practice in certain cases to per-
form external Oesophagotomy just above or just below the stricture, and
then to make an internal oesophagotomy.
External oesophagotomy, or opening of the oesophageal tube from the
exterior of the throat may be useful, as has just been stated, to gain
access to the stricture in order that it may be dilated or incised, and also
for the purpose of obtaining an opening through which food may be
passed into the stomach. In the latter case the operation is called oeso-
phagostomy. Such operations, it is evident, can only be done when the
disease is situated high in the neck and gives room for an external inci-
sion above the clavicle. When the disease is situated in the lower portion
of the gullet the stomach should be opened through the abdominal wall
and a gastric fistule established for the introduction of food. This ope-
ration is called gastrostomy or “stomach-mouth * in contra-distinction to
gastrotomy, in which the stomach is opened for the removal of a foreign
body and immediately closed.
Introduction of the CEsophageal Bougie or Stomach-pump Tube.
Tubes or bougies may require to be introduced into the cesophagus
alone or into the cavity of the stomach for purposes of diagnosis, for the
treatment of stricture, for the evacuation of poisons which may have en-
tered the stomach, for washing out the stomach, and for feeding. It is
*Portant, therefore, that the surgeon should be familiar with the method
ºf using these diagnostic and therapeutic instruments. The patient
should be seated with his head thrown well back, in order to bring the
*9 th and the long axis of the gullet in the same line. The mouth,
Which should be wide open, may or may not be prevented from closing
Y means of a gag between the teeth. This is seldom needed, except in
obstreperous patients. The surgeon, standing in front of the patient,
should then pass the instrument, which has previously been well oiled and
570 I) IS E A SES OF T H E M O U T H .
warmed, through the mouth backward toward the posterior wall of the
pharynx. This portion of the operation should be done without touching
the patient's tongue. With his left forefinger the operator next guides
the instrument above the epiglottis and downward into the upper portion
of the oesophagus. Pressure slowly applied then pushes the instrument
downward toward the stomach. If any obstruction is felt the instrument
should be slightly withdrawn and again gently pushed forward. The
patient will soon discover that he can breathe notwithstanding the pres-
ence of a foreign body in the food-tract, and he will suffer little or no
inconvenience. Care must be taken, however, not to push the instrument
into the trachea, which is likely to occur if the tube be a small one. If
the surgeon prefer, he may stand behind the patient and, steadying the
latter's head against his chest, introduce the bougie or tube from this po-
sition. In this method, however, the surgeon's forefinger cannot be used
to insure the slipping of the instrument over the epiglottis. It therefore
requires a little more dexterity on the part of the surgeon. -
When the tube of the stomach-pump is thus introduced for washing
out the stomach, about two pints of warm water should be allowed to
flow through the tube. This may be done by pouring water into a funnel
attached to the outer end of the tube, or by attaching to this extremity
some form of a pump. When the fluid is withdrawn from the stomach
it is wise not to permit all to come out, as the mucous membrane lining
of the stomach may be sucked into the opening at the gastric extremity
of the tube.
C H A P T E R X. X. I.
DISEASES OF THE ABDOMEN AND PELVIS.
THE foetal canal extending from the bladder to the umbilicus may
remain patulous after birth. This tubular canal may then permit the
discharge of small quantities of urine at the umbilicus. In rare instances
such an unobliterated urachus has been laid open in performing abdomi-
mal section for the treatment of abdominal disease. Cystic tumor, abscess,
and other pathological processes may occur here. Urinary calculi have
been found in a patulous urachus.
Wounds of the abdomen, when fatal, have probably caused injury to
the solar plexus, or to some one of the glandular or hollow viscera; which
injury will be revealed by an autopsy. Death occurring without discov-
able lesion is very infrequent. Contusions or wounds of the abdominal
wall have no special importance except when associated with rupture of
the viscera or some other internal lesion. They are treated, when uncom-
plicated, as are wounds in other regions. When there is a probability of
visceral lesion as a complication, the necessity for abdominal section and
exploration is often imperative. *
Wounds of the abdomen are of extreme importance, because of the
probability of injury to the contents of the abdomen and pelvis. Gun-
shot or stab wounds of the belly are so liable to be complicated with
intestinal lesions that abdominal section is very often required, in order
to secure the patient from death by reason of internal hemorrhage or
fecal extravasation into the peritoneal cavity. It is often doubtful
whether a bullet or a cutting instrument has actually penetrated the
intestines, because at times the vulnerating instrument does not travel the
entire thickness of the wall, or is deflected by the muscular fascias. The
hydrogen test of Semn consists in inflating the intestinal canal with hydro-
gen gas introduced through the rectum by means of a rubber tube con-
nected with a reservoir or rubber bag filled with gas. The hydrogen
distends the intestinal canal, escapes through any perforation that has
been made in it, and after filling the peritoneal sac escapes through the
external opening. Its presence at this point is detected by holding a
lighted taper to the wound when the gas, as it escapes, becomes ignited.
Such ignition is a positive evidence of a wound in the intestines. Unfor-
tunately, however, the absence of the escape of hydrogen is not positive
proof that no orifice exists in the gut.
If a doubt exists as to the propriety of opening the abdomen for the
Purpose of discovering and repairing visceral damage, it is usually wise
to give the patient the benefit of the doubt and to operate. Carefully
done, aseptic abdominal section is almost free from danger, whereas intes-
final wounds have a large death-rate from peritonitis. The exploratory
lºgision should be made in the median line, after which the whole length
ºf the intestinal tract should be carefully examined, unless the wound in
he wall has shown that the wounding of the stomach or intestine has
been impossible.
572 D IS E A SES OF T H E A BD O M E N A N D P E L WIS.
METHOD OF OPERATING WITHIN THE ABDOMEN AND PELVIS.
Before describing the various operative procedures demanded by abdom-
imal and pelvic diseases and injuries, it is necessary to discuss the general
method of performing surgical operations in these cavities. Fluids occur-
ring and accumulating in the abdominal cavity as a result of irritation
are very liable to septic changes. Therefore, the most absolute asepsis is
important, since the large absorbent surface furnished by the peritoneal
membrane makes the occurrence of septic processes in this cavity ex-
tremely dangerous. Twisted silk is usually preferred for ligatures by
abdominal surgeons, while plaited silk or silkworm-gut is ordinarily
deemed most Satisfactory for suturing purposes. Catgut, however, is avail-
able. These and all instruments and sponges should be rendered abso-
lutely sterile. The use of antiseptic solutions within the abdominal cavity
is usually deprecated, because of the danger of these chemical solutions
even when weak causing undue irritation. Experience has proved that
water sterilized by boiling does not possess this disadvantage, and of course
is perfectly safe. The frequency with which the external wound has been
sutured when instruments and sponges have been left in the abdomen is
sufficient reason to demand that all instruments and sponges shall be
counted before and after operation.
The abdominal incision, which should usually be made in the median
lime, should be large enough to permit good work. It is, perhaps, wise
to begin with a small incision, varying with the character of the operation
to be performed, and to enlarge it as necessity becomes evident. In opera-
tions for appendicitis and other conditions about the caecal region, an inci-
sion to the outer side of the right rectus muscle is often preferable to one
in the middle line. *
Tumors within the abdomen sometimes become adherent to the anterior
wall, and the incision will, therefore, reach them before the surgeon enters
the abdominal cavity. Such adhesions of the growth may be suspected if
there is much bleeding from the muscular incision, or unusual pinkness of
the deep muscular fascias and the subperitoneal fat. In all cases, the
surgeon should be careful to get within the abdominal cavity before work-
ing along the wall from the incision. If he does not be careful in this
regard he may separate a large sheet of peritoneum from the inner surface
of the muscles, and think that he is detaching an ovarian cyst or other
growth adherent to the internal surface of the abdominal wall.
During operation the intestines should be kept out of the way as much
as possible by packing flat, warm, aseptic sponges around the field of
operation, so as practically to shut it out from the rest of the peritoneal
cavity. These sponges should be squeezed out, or substituted by clean
ones when they become saturated with blood, serous fluid, or pus. If it
is necessary to allow the intestines to escape from the cavity temporarily;
they should be wrapped up in a warm, moist, aseptic towel, which will
not allow particles of lint to be detached from it.
The adhesions and attachments of morbid growths and diseased strug-
tures to be removed should be separated by means of the finger, as the
tearing thus performed is not very liable to be followed by bleeding. The
attachments, if vascular, should be cut only after firm ligation, or Comº
pression of the stump by haemostatic forceps. Points likely to bleed must
be ligated before the forceps are removed. $.
By the toilet of the peritoneum, is meant the removal of all blood and
OPERATING WITH IN THE ABDO MEN AND PEL WIS. 573
other fluids by irrigation or by sponges which have been pushed into the
pelvic or lumbar, fossae. This may require them to be seized by long
forceps, so as to give them a sort of handle. If the fluid is gelatinous or
purulent, it will be necessary to wash out the cavity with sterilized water
of a temperature of 105°, poured into the cavity from an ordinary pitcher,
or from the tube of a fountain syringe. By this means any unrecognized
bleeding is discovered, because the water returns stained, and shreds of
tissue or lymph are effectively removed. It is not necessary to insist upon
the removal of all such sterilized water which has been used to flush the
cavity, because it is harmless and is soon absorbed.
Whenever it is believed that a purulent cavity has not been perfectly
cleansed, and that purulent material remains, it becomes necessary to leave
a drainage-tube in the wound at the time of adjusting the sutures. Healthy
peritoneum absorbs aseptic fluids rapidly, but a diseased peritoneum does
so very slowly. In such cases, and where there is very great transudation
of fluid subsequent to operation, Douglas's pouch becomes the receptacle
in which such fluids accumulate; and disastrous inflammation is liable to
occur because of the possibility of septic changes occurring there. Hence
drainage is often desirable in such cases. If the hemorrhage has not been
entirely stopped, or bleeding subsequent to the operation is feared, the
insertion of a drainage-tube is wise. Any excess of fluid accumulating
after operation may then be removed by introducing a long-nozzle aseptic
syringe through the tube at frequent intervals. The occurrence of sec-
ondary hemorrhage will be indicated by the escape of blood through the
drainage-tube, and will thus be susceptible of prompt treatment. These
circumstances render it probable that in cases of doubt as to the necessity
of drainage, the surgeon had better use a drainage-tube, since, if the asepsis
is perfect, it can scarcely do harm. In cases where the operation has been
simple and uncomplicated, however, and when no pus has previously
existed, complete closure of the wound without drainage is the proper
procedure. A straight or curved glass tube, having a calibre of about a
FIG. 366.
*Revº
Glass abdominal drainage-tube.
half inch, with an opening in its abdominal extremity, and with a ridge
or shoulder at its cutaneous end, is the proper sort of tube to be employed.
A piece of rubber tubing will answer the purpose nearly as well. It is
rather objectionable to have lateral openings in the tube near its outer
ºnd, because fluids entering the tube at its lower end may escape from
these lateral openings and becoming septic if the dressings are imperfect,
infect the wound in the abdominal wall. The tube, as a rule, should be
*bout six inches long, and descend into the pelvis or one of the lumbar
fossie. Under rare circumstances it becomes necessary to introduce two
* three tubes, in order to allow free drainage or irrigation in distinct
regions of the abdomen.
Suction with a syringe will remove fluids which accrue in the tube.
he escape may be so great as to require this cleansing of the tube every


574 DISE AS ES OF THE ABDO MEN AN D PEL WIS.
few hours, or even oftener. The insertion of a small quantity of absorbent
cotton, twisted into a rope and put into the tube, will increase the drainage
and remove the fluid by capillarity. A sort of wick of absorbent gauze wäi
be efficacious in the same way. It is essential that the abdominal cavity be
kept dry and free from fluid when oozing of blood is going on after closure
of the wound, because moisture seems to encourage the flow of blood.
It goes without saying, of course, that all recognizable bleeding points
should be secured by ligatures, or by the application of the cautery, before
the abdomen is closed.
FIG. 367.
Tait's syringe.
The abdominal wound should be brought together by sutures of silk,
catgut, wormgut, or wire, carried through the entire thickness of the
wall, including the peritoneum. Interrupted sutures should be used.
If a drainage-tube is to be employed, the suture at the point where the
tube comes out should not be tied, so that when, at the end of the second
or third day, the tube is removed, the wound may be brought together by
this suture and the pain of using a needle avoided. An ordinary gauze
dressing, either aseptic or antiseptic, is then applied, and a many-tailed
flannel bandage carried around the loins, and secured in such a way as to
make equable pressure upon the abdominal wall. If a drainage-tube is
used, its external end should be thrust through a small opening made in
the centre of a piece of strong rubber tissue about eight inches square. A
ligature should then be thrown around the tube in such a way as to tie
the rubber material close to the tube. This is to prevent the possibility
of fluid escaping from the tube and running down its outside and coming
in contact with the wound. By placing a mass of absorbent cotton, or a
sponge, over the orifice of the tube, and folding the edges of the rubber
dam around it, a little bag is formed in which the escaping fluid is retained,
and thus prevented from coming in contact with the wound, which, there-
fore, heals by first intention. This rubber bag, as it practically is, can be
opened several times a day, if necessary, to suck out the tube with a
syringe, and to remove the saturated cotton or sponge. This can all be
done without disturbing the main dressing.
The after-treatment of cases of abdominal operation is very simple:
unless some complication arises. Beef tea, thin arrowroot or oatmeal
gruel, given in small quantities about every two hours, is probably the
best food. Milk is believed to be improper food, because of its supposed
tendency to induce flatulency. As a rule, it is well to give no food for the
first twenty-four hours. During this time it is usual to administer only
small amounts of water. Most foods are perhaps better digested if peptor

OPERATING WITHIN THE ABDO MEN AND PELVIS. 575
nized. Thirst is relieved by rather copious injections of waterinto the rectum,
which is better, perhaps, than swallowing large draughts of water by the
mouth or sucking ice. Very frequently the catheter will not be demanded;
occasionally, however, it is required. Morphia should not be given unless
absolutely required, and then in small amounts. It may sometimes be
administered hypodermically. It, and all opiates, tend to constipate the
patient, to disturb digestion, and to mask symptoms of danger. Vomiting
is liable to occur within the first twenty-four hours as a result of the
anaesthesia. If it exists, or begins on the third or fourth day, it is prob-
able that it is caused by incipient inflammation of the peritoneum.
The dangers to be feared in abdominal cases are protracted vomiting,
tympanites, and peritonitis. The two former are often associated, and are
usually indicative of incipient peritonitis. Vomiting is often an effort to
get rid of flatus, and is therefore to be looked upon as salutary. Copious
vomiting induced by the administration of warm water as an emetic will
often aid in the eructation of a large amount of wind, and be of other
service. If the distention of the abdomen from flatus is great, it should
be relieved by allowing the patient to lie upon his side, or by the intro-
duction of a tube in the rectum. A large rubber catheter, or the tube of
a stomach pump makes a good rectal tube for this purpose, and may be
left in the rectum for many hours at a time.
Incipient peritonitis, as has been suggested before, is liable to cause
vomiting and distention of the abdomen. Relief of the vomiting and of
this tympanites will frequently be followed by rapid improvement of the
patient. It is probable, therefore, that the early removal of these symp-
toms prevents the occurrence of destructive peritonitis. The administra-
tion of a saline cathartic, such as Epsom salt, Rochelle salt, or Seidlitz
powder, so as to produce free evacuation of the bowels, will often give
this desirable result. The administration of opium in such cases of oper-
ative peritonitis is decidedly harmful and should not be adopted. Turpen-
time injected into the rectum, about half an ounce of turpentine to the
quart of soap-suds, will be of service in similar manner by promoting the
discharge of gas and the evacuation of the intestinal contents.
The purgative treatment of incipient peritonitis probably owes its value
to the prevention of distention and to the draining of the abdominal
organs of their serum. Carminatives, such as ether and peppermint, can
be administered by the stomach as adjuvants, but will not very often be
required. When vomiting is marked, nutrition should be kept up by
rectal feeding, which is best done by the use of peptonized foods in a
diluted state.
Traumatic Peritomitis.
. Peritomitis, occurring after operations done in the manner just described
is rare. If the early symptoms of peritonitis are met by the administra-
tion of Saline purgatives and if abstinence from the use of opium is en-
forced, it is probable that active peritoneal inflammation will not often
Occur. Should it take place it demands active treatment, such as opening
of the abdomen in order to wash out and drain from the pelvis the accu-
mulated fluid which has become septic. The continued use of salines in
laxative doses and the avoidance of tympany are the essentials in the
medical management of this disease. Traumatic peritonitis commonly
follows wounds which have not been at once submitted to aseptic or anti-
Septic treatment. The vulnerating instrument is often a dirty.one, and
576 D IS E A SES OF T H E A B D O M E N A N ID P E L VIS .
the clothing of the patient and his surroundings may cause septic inflam-
mation before he reaches the surgeon's hands.
A circumscribed peritonitis occurs, however, in some cases both in
operative and accidental wounds. If there is absence of septic infection
the lymph exuded seals the wound and healing rapidly occurs. By such
an exudation of lymph even a septic peritonitis is sometimes circum-
scribed and then may not do much harm, because the septic focus has
been shut off from the rest of the abdomen by the plastic exudate. It is
the diffused septic inflammation of the peritoneum, which gives rise to a
large quantity of turbid serum or pus within the peritoneal cavity, which
is so fatal.
The symptoms of traumatic peritonitis are vomiting and flatulency with
more or less pain and rapid breathing. It must be recollected that pain
may be almost absent, however, and that high temperature is often not
present. The cause of the peritonitis should always be sought for, and
this search will usually demand opening of the abdomen. Intussuscep-
tion of the intestines, rupture or inflammation about the vermiform appen-
dix, or the pouring out of pus into the pelvic cavity from a ruptured,
suppurating Fallopian tube, will often be found to be causes of what was
supposed to be traumatic peritonitis following a slight injury. Pus in the
abdomen, from whatever cause, demands incision of the abdominal wall
and free drainage.
The treatment of traumatic peritonitis will be better understood when
the methods of dealing with visceral lesions have been discussed. Tuber-
cular peritomitis and distention of the abdominal cavity with large quan-
tities of serous fluid have been treated effectually by abdominal section,
evacuation of the peritoneal fluid, and drainage.
Tapping the Abdomen.
Withdrawing fluid from the peritoneal cavity with a trocar and canula
or with an aspirating needle is called paracentesis abdominis.
An incision through the abdominal wall for the purpose of exploring
the abdominal contents, or to gain access to the organs in order to perform
operations upon them, is called abdominal section or laparotomy.
Paracentesis of the abdomen is seldom employed at the present time,
except for the evacuation of serous fluid in the peritoneal cavity, due to
cirrhosis of the liver or to disease of the heart or kidneys. Unless the
ascitic fluid which distends the abdomen is known to be due to disease of
these organs it is better for the surgeon to make a small incision through
the abdominal wall and to introduce his finger. By this means not only
is the fluid which is causing the distention evacuated, but certain infor:
mation as to the cause of the accumulation of the fluid is obtained. One
or two fingers introduced through a median incision an inch long, midway
between the navel and the pubes, will be able to explore the pelvis and
the abdomen almost as high as the liver. It is readily seen that tumors
and other obscure conditions can be examined in this way and informa-
tion obtained which will be a valuable guide to operative procedure, or
other methods of treatment to be subsequently adopted. *
The old practice of tapping the abdomen whenever it is distended with
fluid without reference to the location and cause of the distention is now
looked upon with disfavor. Ovarian cysts should not be tapped but
OPERATING WITH IN T H E A BD OMEN A N D PEL WIS. 577
removed by laparotomy. Many other conditions of a similar character
which were formerly tapped are now treated by radical means.
Paracentesis, therefore, is reserved for cases in which a diagnosis of
ascites from disease of the liver, kidney, or heart of a medical kind has
been made. In obscure conditions it is proper to make an exploratory
incision, since tapping for the evacuation of the fluid gives no information
of a definite kind.
Before tapping the abdomen the bladder should be emptied and the
possibility of pregnancy considered. The patient during the operation
sits upon the edge of the bed, or is propped up in a semi-recumbent posi-
tion by means of pillows. A trocar and canula, not more than an eighth
or a quarter of an inch in diameter, is then thrust through the belly wall
in the middle line about two inches below the umbilicus. The forefinger
of the surgeon should be placed about an inch from the point of the
trocar as a guard, in order that the instrument may not be thrust too deeply
into the abdomen. The instrument should be thrust through the tissues
with a quick motion and with a little rotation, which causes less pain
than a slow puncture, and insures the entrance of the instrument into the
peritoneal cavity. The trocar and canula should, of course, be aseptic.
It is wise to percuss previously the point at which the perforation is to be
made, in order to see that no portion of the bowel lies against the inner
surface of the abdominal wall. Occasionally an adhesion between the
intestine and the parietal peritoneum at this point may have occurred, and
a resulting injury to the bowel from the point of the instrument will
occur, unless by percussion giving a resonant note the surgeon suspect
such adhesion and selects a point dull on percussion. The possibility of
such an adhesion makes it wise to adopt a different point of puncture if
paracentesis is repeated at a subsequent date because of the recurrence of
the fluid.
A broad, four-tailed bandage placed around the waist in such a way as
to permit the escape of the fluid from the canula may be employed to
compress the abdomen as the fluid escapes. If the bandage should be
applied before the tapping is performed a hole may be cut in it to expose
the skin at the point where the perforation is to be made. The four tails
being crossed at the back enables the assistant or surgeon to draw the band-
age more and more tightly as the belly collapses. If the canula becomes
plugged by a portion of omentum or lymph being washed into it, or lying
against its end, an aseptic grooved director pushed in will cause the fluid
to flow anew. After the withdrawal of the canula the wound needs no
other treatment than the application of a piece of aseptic gauze. If
90%ing of serum continues from the wound a suture may be employed;
this, however, is not often required.
Abdominal and Pelvic Abscesses.
There are many different positions in the abdomen and pelvis in which
fºcuses of suppuration may occur. Abscess within the layers of the ab-
dominal wall is not very unusual. The spaces, or loculi, formed by cir-
*mscribed peritonitis causing adhesions between the abdomen and the
other viscera, or between the viscera and belly wall, may contain pus.
Piffused peritonitis is not uncommon. This is not strictly an abscess,
"t it is discussed at this point because its treatment and symptoms are
those of abscess. It is strictly a purulent effusion into the peritoneal
37
578 D IS E A S E S OF T H E A B D O M E N A N D P E L V I S.
cavity; because an abscess is an abnormal cavity containing pus, whereas
the peritoneum is a normal cavity. Hence free pus in the peritoneum is
a purulent effusion.
Abscesses may exist in the parenchyma of one of the solid viscera,
such as the liver and spleen. The Fallopian tube may become distended
with pus and give rise to the condition called pyosalpinx.
Again, suppurative processes may occur behind the peritoneum, in the
space occupied by the kidneys and other retro-peritoneal organs. Abscess
is also possible between the layers of the mesentery; while suppuration
around the vermiform appendix and caecum is quite common.
Parietal abscess presents symptoms similar to abscess in other locations
and is to be treated in a similar manner by evacuation of the pus. It
derives its importance from the fact that it, and especially cheesy or tuber-
cular deposits, or the accumulation of cheesy pus in this region, may simu-
late an abdominal tumor. I recently operated upon a case in which the
caseous mass was so hard and irregular in outline that I was quite sure
that I had a tumor within the belly to deal with until an incision revealed
the true character of the condition.
Localized suppurative peritonitis, with the adherent viscera, may resem-
ble tumor within the abdomen. The proper treatment is laparotomy,
with evacuation of the purulent collection and the insertion of drainage-
tubes. The escape of pus into the peritoneal cavity should if possible be
prevented during the operation. Thorough irrigation of the general peri-
toneal cavity is demanded if any pus accidentally flows into it. Thorough
drainage is essential in all cases of visceral abscesses, whether of liver,
spleen, or ovary. Abscess behind the peritoneum, or within the layers
of the mesentery, should be subjected to the same operative treatment.
Pus in the Fallopian tubes should be treated by removal of the tubes
without rupture of them during the operation, since in this männer con-
tact of pus with the peritoneal surfaces is obviated. If the tube becomes
ruptured during its forcible separation from the adjacent, structures to
which it has become adherent, the pelvis and abdomen should be well irri-
ated and a drainage-tube left in the wound.
Abscess of the vermiform appendix and caecum should be treated in the
same way as pelvic abscess associated with Fallopian suppuration.
Removal of the appendix and thorough drainage of the pus cavity are
indicated.
DISEASES AND INJURIES OF THE STOMACH.
Physical exploration of the stomach is accomplished by inspection,
palpation, percussion, and auscultation of the epigastric region. The
contents of the stomach removed by a stomach-tube will, at times, afford
valuable information as to the condition of disease. The stomach is
usually distended in obstruction of the pylorus, while depression of the
epigastric region occurs when the ingress of food is prevented by obstruct
tion at the cardiac orifice. The movements of the stomach may be seen
at times when it is dilated. Abnormal growths may often be seen and
felt, while these and other conditions often give rise to local pain or ten-
derness on pressure.
Tumors of the wall of the stomach are examined with difficulty, espe:
cially if situated on the left side of the organ. There is a tendency for
gastric tumors to be displaced downward by gravity; hence they are seen
and felt at a lower level than would be thought possible if this fact Werº
D IS E A S E S A N D IN J U R I ES OF T H E S TO M A C EI. 579
not remembered. Percussion of the stomach gives a tympanitic note.
This may, however, be identical with the note elicited by percussion over
the colon. A diagnosis may at times be made by causing the patient to
drink a little water, when the stomach loses its tympanitic note, which,
however, the colon retains. The lower border of the stomach is situated
about midway between the sternum and the umbilicus.
Some information of the gastric condition is obtainable by stethoscopic
examination, by which various splashy and gurgling sounds are heard
during swallowing and digestion.
Foreign Bodies in the Stomach.
Coins, artificial teeth, and other indigestible substances are liable to be
swallowed and become lodged in the stomach or bowels. It is not wise
to give a purgative in such cases, but it is proper to delay the passage of
the foreign body through the digestive tract by feeding the patient on a
diet which is bulky and which will surround the foreign body with a mass
of fecal matter. An exclusive diet of potatoes has been recommended
with this object in view. If the foreign body is too large to pass with
safety through the intestine it is necessary to remove it by operation, pro-
vided there is certain evidence by palpation or by the history that the
foreign body is actually lodged in the stomach or intestines. Opening
the stomach after laparotomy is called gastrotomy, and is to be distin-
guished from gastrostomy, in which a permanent orifice is made. These
operations will be discussed hereafter. Opening the intestine is called
enterotomy.
Wounds of the Stomach.
Rupture of the stomach, incised or gunshot wounds of the stomach, and
perforating ulcer of the stomach present symptoms similar to the same
lesions of the intestines, with the addition of haematemesis or vomiting
of blood. The treatment is practically the same as that for the corre-
Sponding lesions of the intestines, namely: abdominal section with sutur-
ing of the gastric wall (gastrorrhaphy). Before such operations are under-
taken it is usually wise to wash out the stomach with sterilized water by
means of a stomach-tube. If a portion of the stomach has been injured
sufficiently to lead probably to local gangrene, it is often best treated by
pushing the injured portion toward the interior of the stomach and
drawing the neighboring healthy tissue over it by sutures. This is done
in order to prevent extravasation of the gastric contents into the peri-
toneal cavity when the sloughing occurs. Lembert's suture, which will
be described under Intestinai Wounds, effectually accomplishes this object,
and is the proper method of suturing to be used in closing wounds or a
rupture of the gastric wall.
Operations wbon the Stomach.
g It becomes necessary to define the various terms used to describe opera-
tions upon the stomach.
. Gastrostomy is the formation of a permanent opening from the exte-
*or of the epigastrium into the stomach, by means of which food may be
580 I) IS E A SES OF T H E A B D O M E N A N D P E L VIS .
introduced. It is performed in cases of oesophageal stricture and of malig.
mant disease of the cardiac orifice of the stomach.
Gastrotomy is an incision into the stomach; and is performed for the
removal of foreign bodies, for the purpose of dilating a strictured condi.
tion of the pyloric or cardiac orifices, and for the removal of tumor in-
volving the walls of the organ.
Gastrorrhaphy is suturing of the stomach wall, and is demanded in
wounds or rupture of the stomach, and in the treatment of perforating
ulcers of the stomach.
Pylorectomy is a term used to express excision of the pyloric end of
the stomach for malignant disease, just as gastrectomy is applied to opera-
tions for the removal of any portion of the stomach.
Gastro-enterostomy is the operation in which an opening or fistule is
made between the stomach and a neighboring portion of the intestine. It
is employed when the contents of the stomach cannot be passed into the
duodenum because of the obstruction of the pyloric orifice or of the duo-
denum.
Gastrostomy.
Gastrostomy, as is seen from its derivation, signifies a mouth in the
stomach. It is performed by attaching the stomach to the anterior belly
wall, and making a permanent opening by which food can be introduced
into the stomach. The operation is performed in order to prolong life in
malignant disease of the oesophagus, and to effect what may practically
be a cure in cicatricial stricture of the oesophagus due to injury. The
object of the operation, of course, is to prevent starvation, which is the
only cause of death in cicatricial stricture. The operation is somewhat
more readily performed when the stomach is distended. In cases of ob-
struction in the oesophagus such as demand gastrostomy the stomach is
apt to be collapsed; hence, if the patient can swallow a few ounces of
water, it is, perhaps, judicious to have him do so before the operation is
undertaken. There is not, however, sufficient advantage gained to insist
upon repeated attempts at distention of the organ if it gives the patient
annoyance or pain.
The incision should be made parallel to the costal border of the lower
ribs on the left side, and should be about an inch from that border, and
from an inch and a half to two inches long. The fistula which is to be
made to serve as an artificial mouth should be in the angle between the
lower lobe of the liver and the costal cartilages, about one inch from the
ribs and one inch from the lower border of the liver.
When the incision through the abdominal muscles has been made, the
stomach should be carefully distinguished from the colon, and that part
of it selected for the orifice which can be attached readily and well with:
out making traction upon the sutures. It is always wise to allow the
stomach to become adherent to the belly wall before the former is opened;
hence, the gastric wound should not be made until four or five days have
elapsed after the stomach has been sutured to the abdominal parieteş.
This precaution prevents extravasation of the contents of the stomach
into the peritoneal cavity, and should be insisted upon, except in those
rare cases where the condition of the patient from starvation is so grºVº
that immediate opening of the stomach for the introduction of food is
demanded. &
After the abdominal wound has been made and the stomach recognized
D IS E A SES AND IN J U R I ES OF THE ST O M A C H. 581
two harelip pins should be thrust through the integument, and outer
tissues at the edges of the wound and then through the peritoneal and
muscular coats of the stomach, so as to fasten that organ against the peri-
toneum covering the inner surface of the abdominal parietes. These pins
should be passed transversely to the line of the external abdominal
wound. As a rule, these two pins will be all that is required to hold the
stomach in contact with the abdominal surface. If, however, the condi-
tion of the patient is such that incision of the stomach may be demanded
within a day or two, a few additional sutures of silk may be employed.
When immediate opening of the stomach is required, a more complicated
system of suturing is necessary, but, if possible, it is wiser to allow four
or five days, at least, to elapse before the perforation of the stomach itself,
since even this short time will permit a valuable degree of adhesion to
occur between the gastric and abdominal surfaces.
FIG. 368.
When immediate operation upon the stomach is to be done, the harelip
pins are not used. Two silver-wire sutures are passed through the perito-
neal and muscular coats of the stomach by means of a round-pointed needle,
which is preferable for most forms of abdominal work to the bayonet-
pointed needle. These loops of silver wire, which are transverse to the
external abdominal wound, serve to draw up the stomach into contact
With the inner margins of the abdominal incision, and to give the sur-
geon control of the organ. A long silk suture is then passed through
the two outer coats of the stomach in the manner shown in the diagram,
so that the ends of the loops project upon the exterior of the organ.
. By means of a needle fixed in a handle, and with a hook near its point
instead of an eye, the abdominal wall is perforated opposite these loops,
and each loop by means of the needle is drawn through until it reaches
the exterior abdomen a little beyond the wound. A piece of rubber drain-
*ge-tube is carried around the external opening of the abdomen, and
slipped through the loops made by the silk sutures. By drawing the silk
loops tightly down upon the tube and tying the ends over the tube, elastic
Pressure is made around the whole circumference of the wound. Thus

582 DIS E A SES OF T H E A B D O MEN A N D P E L WIS.
the gastric and internal abdominal surfaces are held closely in contact, so
that no leakage from the stomach, which is about to be opened, can take
place into the general peritoneal cavity.
The wire suture which has been used to draw up the organ during these
manipulations, can be slipped under the tube and bent over its upper surface,
to make the fixation more perfect.
It is to be remembered that in passing the sutures through the stomach
wall the mucous coat is not to be perforated. This is in accordance with
the method of introducing sutures in operations on the intestines. If the
stomach is not to be opened for several days, ordinary antiseptic gauze is
º over the wound until the surgeon is ready to make the gastric
Ol’ITICG.
When the time arrives for the performance of the gastric incision,
whether it is to be done as a part of the original operation or as a secondary
step, a very small orifice is made through the wall of the stomach by punc-
turing it with a knife or scissors. A rubber catheter is then slipped into
the interior of the organ. The orifice should be very small, and no food
should be introduced for some time; then small quantities of liquid food
at a temperature of 100°, given every four hours, is proper. Peptonized
milk, beef-tea, and similar nourishment should be used. After the first
few days, six or eight ounces at a time may be allowed to flow slowly into
the stomach.
The catheter is held in place by threads passing through it, or tied
around it and fastened to the abdominal skin by adhesive strips. Subse-
quently the orifice may be enlarged. After a time, solid food may be
allowed. It may be masticated by the patient before being put into the
tube which leads to the stomach. This method of feeding is only adapted
to cases in which the gastric opening has been dilated and increased after
the patient has recovered from the original operation.
An absorbent pad is kept over the opening in the intervals of feeding.
Gastrotomy.
This word was formerly used to denote what is now more properly
called abdominal Section, or laparotomy.
It is used here to signify incision into the stomach which is subsequently
to be closed, and differs, therefore, from gastrostomy, in which the opening
made into the stomach is permanently maintained. Gastrotomy is per-
formed for the removal of foreign bodies that are of such shape that they
cannot pass through the intestinal tract; for the purpose of dilating the
cardiac orifices which have become contracted by reason of malignant
growths or cicatrices of wounds or ulcers; and also for the removal or
curetting of malignant tumors involving the inner surface of the stomach;
The operation is, perhaps, best done after the stomach has been washed
out with a weak solution of bicarbonate of sodium (five grains to the
ounce), introduced through the mouth by means of a stomach-tube. If
this fluid escapes into the abdomen during the operation it can readily be
sponged up, and is not liable to irritate the peritoneum. *
The external incision should be about two or three inches long, and is
made parallel to the costal cartilages on the left side, or over the promº,
nence made by the foreign body in the stomach, if there be any external
evidence of it. The fingers of the surgeon are then carefully introduced
into the abdomen to feel for the stomach. The area of operation is Surº
D IS E A SES A N D IN J U R I ES OF T H E S TO M A. C. H. 583
rounded with aseptic sponges, and two sutures are introduced into the
stomach wall so as to draw it up. These sutures should be parallel to the
proposed gastric incision, which, of course, should be in the same direction
as the external wound. A round needle passed so as not to perforate the
mucous coat, should be used here as in the operation for gastrostomy. An
incision is then made into the cavity of the stomach, subsequently the
foreign body is removed by the fingers or forceps, dilatation of the pylorus
or of the cardiac orifice effected, or other operation contemplated performed.
The gastric wound is then closed with twisted silk sutures after the manner
of Lembert. A sponge attached to a ligature should be pushed inside
the stomach, so as to draw up the edges of the gastric wound. None of
the sutures should be tied until all have been properly placed, when the
sponge is withdrawn and the sutures tied securely. A second row of sutures
may be placed between the Lembert sutures. These should be introduced
through the peritoneum only, and taken as ordinary interrupted sutures.
The patient must be supported for three or four days by nutrient
€I16D08.S.
Suturing gastric wounds, whether accidental or operative, is called
gastrorrhaphy.
Tumors of the Stomach.
The tumors found involving the stomach walls are usually, though not
necessarily, malignant.
Malignant conditions of the stomach occur usually at the pyloric or
cardiac orifices, but other portions of the stomach may be the seat of
such conditions. The diagnosis of gastric tumors belongs to medicine
rather than to surgery.
The existence of a tumor may be discovered by palpation of the abdo-
men ; but its relation to the stomach must be determined by the digestive
and other symptoms accompanying it.
Malignant disease involving the pylorus, or diseases of a similar nature
occurring primarily in organs adjacent to the pyloric portion of the
stomach, give rise in many instances to stricture of the pylorus. When
the growth does not actually involve the pylorus it may lessen its calibre
by external compression. Non-malignant stricture of this orifice may
also occur. It is stated that there is more anorexia in malignant than in
non-malignant stricture of the pylorus. Disappearance of hydrochloric
acid from the gastric juice is believed by some writers to occur in gastric
Cal'Cln Olna.
Excision of the pylorus, or pylorectomy, is at times undertaken for the
removal of the pylorus for malignant disease.
The term partial gastrectomy is employed to denote this, or, indeed,
any operation which removes a portion of the stomach.
efore excision of the pylorus is attempted the stomach should be
Washed out with a solution of boro-glyceride, or with some other non-
Pºisonous antiseptic, so that the stomach may be empty as well as aseptic.
he incision should correspond with the long axis of the stomach and
should be about two inches long. The pyloric end is then to be separated
from the Surrounding structures by means of the finger. It is possible
that some adhesions may require to be cut by the scissors, after ligatures
have been applied to prevent hemorrhage. The diseased portions of the
*ºmach and of the neighboring duodenum are then removed with the
*Sors, and the remaining portion of the stomach sutured to the duode-
584 D IS E A SES OF T H E A B D O M E N A N D P E L VI S.
num in much the same manner as is done after excision or resection of
the intestines. On account of the stomach at the point of excision having
greater calibre than the duodenum, it becomes necessary to diminish th.
lumen of the former in order that it may join the duodenum without
causing leakage. This may be done by cutting out a V-shaped portion of
the muscular and peritoneal coats of the stomach, which narrows its ori-
fice.
In pyloric disease it will sometimes be better for the surgeon to make a
permanent opening between the stomach above the pylorus and the intes.
tine below the duodenum by Senn's method of intestinal anastomosis
(gastro-enterostomy).
Stricture of Gastric Orifices.
A strictured condition of the pyloric or cardiac orifices may be due to
malignant disease, to cicatricial contraction after ulceration in these re-
gions, and perhaps to simple fibrous hypertrophy, similar to that causing
fibrous stricture of the rectum. In these cases the symptoms may be ame.
diorated or cured by opening the stomach, as in gastrotomy, and stretching
the contracted opening by means of the fingers or some form of dilating
instrument.
The incision should be in the median line of the abdomen. In pyloric
stricture the stomach should be opened about an inch from the pylorus
and about midway between the greater and lesser curvatures. After one
finger has been inserted through the contracted pylorus a second finger
may be introduced and sufficient stretching applied to bring the fingers
an inch and a half to two inches apart. The distance, of course, depends
upon the character of the contraction and the peculiarities of the indi-
vidual case.
In operating upon a contracted cardiac opening the gastric incision
should be near the cardiac end of the organ. If there is difficulty in
reaching the cardiac orifice with the fingers, a pair of dilating forceps,
similar to those used for dilating the rectum, may be employed.
In malignant strictures dilatation may add greatly to the patient's
comfort and is far less dangerous than gastrectomy.
DISEASES AND INJURIES OF THE INTESTINEs.
Foreign Bodies.
Foreign bodies in the intestines may require the operation of enterotomy,
or incision into the bowel, for their removal. The abdominal opening
should be made in the median line, and the bowel opened opposite its
mesenteric attachments. After the removal of the foreign body the in-
testinal wound is closed by Lembert sutures.
Rupture, Wounds, and Perforating Ulcers of the Intestines.
Rupture of the intestines occurs from blows, and is particularly liable
to take place when the gut is greatly distended with gas at the time of
injury. The symptoms are collapse in varying degree, according to the
extent of the injury, burning pain, feeble and irregular pulse, and Yomi',
ing. After the contents of the stomach have been ejected, blood and
DIS E A SES AND IN J U R IES OF THE IN TEST IN ES. 585
bile may be vomited. Tympany usually but not necessarily occurs later,
after which more marked symptoms of traumatic peritonitis supervene,
and are followed by death. If the hemorrhage, extravasation of feces,
or shock is very great, death may be immediate.
Typhoid fever ulceration, giving rise to perforation of the intestine,
causes a similar set of symptoms, but these are developed, of course, during
or after the existence of typhoid fever. In “walking” typhoid fever
collapse from perforation may be the first serious symptom noticed.
Rupture, and perforating ulcer of the intestines are uniformly fatal.
There is but one rational treatment—immediate laparotomy followed by
suturing at the point where the solution of continuity has occurred. The
chances of saving life are far greater in traumatic rupture than when
perforation has occurred in typhoid fever. Small perforations or tears
in soft and almost gangrenous gut, made during abdominal operations,
may not be amenable to suture because of the friable condition of the
intestinal coats. Here life may at times be saved by simply making the
intestinal tube straight, and preventing by mild laxatives the accumula-
tion of feces in the diseased gut. Thus strain is removed from the region
of the perforation, and fecal extravasation may not occur. A drainage-
tube should be placed in the external wound. This sort of surgery may
be safer than resection, which is a prolonged operation. It is only admis-
sible perhaps in such perforations.
In all wounds of the abdominal wall which have penetrated into the
abdominal cavity there is danger of death occurring from septic peri-
tonitis due to infection from the instrument at the time of the injury, or
to extravasation of feces.
Gunshot wounds and stab wounds made with a long knife almost always
Wound the hollow or solid viscera. It is probably best, therefore,
always to open the abdomen for the purpose of rendering aseptic any
wound which is not accompanied with visceral injury, and to repair the
damage to the intestines or other organs in cases where such dangerous
traumatisms have been produced. &
Intestinal wounds are dangerous because of the fecal extravasation
which occurs always, unless the wound is quite small, and because the
Warmth of the abdominal cavity encourages bleeding from injured ves-
sels. In all cases of presumable intestinal wound, abdominal section
With examination of the entire length of the intestine is the wisest pro-
cedure. If done in a perfectly aseptic manner, according to the princi-
ples laid down in the paragraph on abdominal surgery, it is accompanied
With no very great risk. If no injury to the viscera is found, the peri-
toneal cavity should be simply washed out with sterilized water, or some
Very weak antiseptic solution, and immediately closed.
If from the character of the vulnerating instrument it is probable that
Septic infection has occurred, a corrosive sublimate solution may be used,
but not stronger than 1 to 20,000.
The hydrogen test of Senn, already described under Abdominal Wounds,
Will often give evidence that the intestine has been perforated before the
belly wallis incised. Unfortunately, however, an intestinal wound may
exist, and the hydrogen gas not show it, because of mucous membrane
plugging the wound and preventing the escape of the gas.
After the abdomen has been opened and intestinal wounds found and
šutured, additional wounds will sometimes be discovered with great ease
by applying the hydrogen test. Formerly the treatment of abdominal
Wounds varied a good deal with the occurrence or non-occurrence of pro-
586 D IS E A SES OF T H E A B D O M E N A N I) P E L WIS,
trusion of the viscera. At present very little stress is laid upon protru-
sion, since in all cases the peritoneal cavity must be rendered aseptic and
all complications treated on general aseptic principles.
The cardinal rules are to make the abdominal cavity aseptic, stop
hemorrhage, and close the perforated intestine with sutures. All of these
procedures demand as a rule immediate laparotony, which in no instance
should be delayed beyond a very few hours. Promptness here is more
important than in almost any other field of surgery.
Enterorrhaphy, or suturing of the intestine, is the proper treatment for
wounds, whether caused by gunshot or other injury. Lembert's method
of placing the sutures is uncomplicated and most effective, and is the one
now usually employed. The peritoneal and muscular coats at the two
sides of the wound are punctured and drawn together by the suture, while
the edges of the wound are turned into the interior of the intestine. By
this means rapid occlusion of the wound is obtained because the peritoneal
surfaces rapidly adhere by plastic exudation. Round needles are better
for this purpose than bayonet-pointed needles, because there is less bleeding
from the punctures. The mucous membrane should not be included
in the stitch. Either catgut or fine twisted silk may be used. All feces,
blood, and serum should be washed out of the abdominal cavity according
to the rules adopted for abdominal operations. -
FIG. 369. FIG. 370.
Lembert’s suture. Lembert's suture. a. serous, b muscular, and
(AsHHURST.) c. mucous coat. (SMITH,)
If the bowel is divided across its calibre the ends must be united by
circular suturing, or fastened to the belly wound so as to form an artificial
anus. If the bowel or mesentery is so riddled with wounds as to render
its preservation improper, resection of intestine (enterectomy) may be:
come necessary. The cut ends may be united by immediate circular suture
of the intestine, or if the patient's grave condition contra-indicates this
long operation, the two ends of the divided intestine may be attached aſ
the point of incision, so as to form an artificial anus. This may be closed
some months afterward, when the patient has recovered from the dangers
incident upon the original injury. Such a procedure, although not *
ideal operation, will often be the means of saving the patient's life, sinº
there is less danger of fecal extravasation occurring into the peritoneal
cavity, and the patient's strength is not exhausted by the prolonged
manipulation rendered necessary by circular enterorrhaphy, which would
be the case if resected ends were at once sutured. Portions of the intº
times which have been subject to contusion or laceration occasionally

DISE As Es AND IN J U RIES OF THE INTESTINES. 587
slough, and from the perforation so produced extravasation of feces
occurs secondarily. Death may occur from such pathological perforation
after other portions of the intestines which have been subjected to sutur-
ing for wounds have satisfactorily healed. Areas of gut which are very
likely to slough had better, therefore, be turned into the lumen of the
gut by Lembert sutures passed beyond the slough margins in a manner
identical with that which would be necessary if the contained area of
tissue were actually a perforating wound.
Small orifices in the bowel, due to gangrenous inflammation, which are
at times found during abdominal operations, do not necessarily cause fatal
peritonitis by extravasation of feces. If the portion of gut so perforated
is placed in a straight position—that is, without curves—there will be
little strain in the weakened wall, and often no escape of feces will occur.
Fecal extravasation occurring in an abdomen which is left opened so as
to permit free drainage and washing is not at all necessarily fatal.
Intestimal Obstruction.
DEFINITION.—By intestinal obstruction is meant such a condition of
the intestinal calibre as prevents the passage of fecal matter through it.
The term is not applied, however, when the obstruction is due to strangu-
lation of a hernia, although the conditions are practically the same.
Obstruction of the intestine is acute or chronic, although the acute
form may assume chronic characteristics and the chronic form may become
aCute.
CAUSES.–The bowels may be obstructed by being filled with gall
stones, intestinal calculi, or indigestible materials which have been swal-
lowed; by the process of invagination or intussusception, where one portion
of the intestine is pushed into the other, as the finger of a glove may be
thrust backward into itself; by stricture of the intestinal coats; by adhe-
sions between the intestinal coils; by puckering of the mesentery; by in-
flammation or malignant disease involving the bowel walls; by twisting
and bending of the intestinal tube (volvulus); by bands of inflammatory
tissue strangulating the intestine; by pressure from tumors or abscesses;
and by the intestines being pushed through congenital or abnormal holes
in the mesentery or omentum, or elsewhere, or through orifices made by
inflammatory deposits.
, SyMPTOMs.--The symptoms of obstruction vary as it is acute or chronic
in character. In acute obstruction the pain is commonly marked and is
often localized in a particular region of the abdomen, but this locality
does not necessarily have to correspond with the seat of the obstruction.
Pain from strangulation of the intestine by a band or other similar stric-
ture is usually sudden, intense, localized, and continuous, though it may
be somewhat relieved by external pressure. In stricture of the intestines
pain is said to be more intermittent in character; while in volvulus it is
more diffused than localized. Collapse and actual syncope is marked in
many cases of intestinal obstruction, while vomiting, first of the contents
of the stomach and subsequently of bile, is usually present. Constipa-
tion, tenderness, swelling, and distention of the abdomen are marked
Symptoms. The rolling of the distended intestines over each other from
interference with normal peristaltic action causes at times marked gur-
gling. If the abdomen is thin the hands placed upon its surface may feel
the motion of the intestines, and at times even locate the seat of the ob-
588 DIS E A SES OF T H E A B D O M E N A N D P E L V IS.
struction. Exhaustion, peritonitis, and gangrene are the usual causes of
death. In acute intestinal obstruction death occurs in from one to seven
days.
In intussusception the portion of the gut which is pushed into the
adjoining part of the intestine may slough off, because of the constriction
made upon it by the sheath which grasps it, and be discharged from the
anus. The continuity of the calibre of the intestine may be reëstablished
in this way, because during the stage preceding sloughing the walls while
in contact have become united by inflammatory adhesions.
In chronic obstruction of the bowels pain and vomiting are often not
very marked, but obstinate constipation is a prominent sign. Tympan-
ites does not occur early in such cases, but when it occurs it is marked.
Spontaneous recovery sometimes takes place, while death, which is a
common result, does not occur until after six or eight weeks.
DIAGNOSIS.–In making a diagnosis of intestinal obstruction the possi-
bility of impaction of feces in the rectum, and of strangulated hernia
must be excluded. The surgeon should remember also that constipation
of an obstinate kind may occur in enteritis and peritonitis, and also in
inflammation of an undescended testicle.
It is important to determine the cause of the obstruction and to learn
whether the case is of an acute or chronic character. Lead colic may
mislead the careless examiner.
A short consideration of the special symptoms of the various forms of
intestinal obstruction will here be proper.
Intussusception, or prolapse of one portion of the bowel into the lumen
of an adjoining portion, occurs most commonly in children, and is the
most frequent form of intestinal obstruction. The invaginated portion,
or intusussceptum, usually is above the portion into which it passes, which
is called the intussuscipiens, or sheath. Occasionally, however, invagina-
tion takes place upward.
FIG, 371.
receivin. g
pendrºling
sº
Watwrcil opening &/
ſº of intussuscepted -
Ile win.
Diagram ºf § Y
inliussuscepte a ºv
I lettºm,
Rectivn1. Ileavin
laid open
Intussusception; with a diagram showing the entering, returning, and receiving
layers of ileum into colon. (BRYANT.)
Polypus of the intestine, worms, or undigested food may be a cause of
intussusception. It is believed by some writers that many cases of colic
in children are instances of intussusception, which have corrected them-
º before inflammatory adhesion of the invaginated coats has taken
place.
The sheath, or intussuscipiens, having grasped the invaginated portion,
forces it along by peristaltic action, gradually “sucking in ’’ or “swallow-
ing ” more of the intestine, just as a mass of feces is pushed along the
intestinal canal. Epithelioma is at times found involving the invaginated












DISE As Es AND IN J U RIES OF THE IN TEST IN ES. 589
gut. It is a question in these cases whether, the disease has occurred
after the process of invagination, or whether the malignant mass was the
origin of the process of invagination.
The most prominent symptom of intussusception is a constant desire to
go to stool. With this is associated a discharge of mucus and blood from
the rectum. Fecal vomiting is not so often present as in some other forms
of obstruction. A sausage-shaped mass may at times be felt or seen
through the abdominal wall. This is more frequently found on the left
side of the belly. In children it is not uncommon to feel the invaginated
portion by the finger introduced into the rectum. The accumulation of
feces, which takes place above the seat of obstruction, is occasionally
perceived by palpation. . It is apt to be upon the right side of the abdo-
men, and can be indented or pitted by the fingers pressed upon the exterior.
This symptom is almost pathognomonic. Invagination may occur without
obstruction to the passage of the feces, unless swelling of the mucous and
other coats causes obliteration of the lumen. Otherwise obstinate consti-
pation supervenes. When these symptoms do not occur, a certain amount
of patency to the canal is retained.
Internal strangulation by inflammatory bands, or by orifices in the mes-
entery,..or omentum, or by rings caused by foetal structures which have
remained within the abdomen, is often called internal hernia. Its most
marked symptom is intense prostration or syncope. It does not often
occur in infants or in the aged. It presents, of course, the symptoms
which have been described as indicative of obstruction.
Twist of the bowel (volvulus), occurs particularly in old people, and
usually at the sigmoid or ileo-caecal region. Actual knotting of the bowel
has been discovered. The prostration, however, is not so extreme as in
internal strangulation. The abdomen is often unevenly distended, one side
being rather flattened, while the other is remarkably tympanitic. It is the
right side which most frequently shows flattening, because the sigmoid
portion of the colon is the most frequent seat of trouble. The accumula-
tion of gas in the intestines is rapid and great.
Obstruction from stricture or tumor is usually chronic, and affects the
lower bowel more frequently than the upper. A history of gradual con-
stipation can at times be obtained, and thus aid in the differential diag-
nosis. Acute symptoms, however, may suddenly become engrafted upon
such a condition of chronic obstruction, and thus add to the difficulty of
accurate diagnosis.
DIAGNOSIS.–Obstruction in the small intestine is more apt to be rapid
in course, and accompanied with greater pain, than is the same condition
in the large intestine. Early vomiting is more conspicuous in obstruction
of the small than of the large intestine. In other words, acute symptoms,
except in the case of volvulus, are apt to be associated with obstruction of
the small intestine, while chronic symptoms are usually due to obstruction
of the colon. Less urine is secreted, it is said, as the stricture is tighter.
Sºme writers, however, believe that the diminution of urine is connected
With the position in the intestinal tube at which the obstruction occurs.
The nearer the stomach the obstruction takes place, the less, it is stated,
is the secretion of urine.
TREATMENT—The treatment of obstruction should be prompt, but
should never consist in the administration of purgatives. If the diagnosis
has been made before inflammation of the peritoneum and distention of
the abdomen have taken place, and before the patient has been exhausted
by the disease, or his condition made more hazardous by the administration
590 D IS E A SES OF T H E A B D O M E N A N D P E L WIS.
of purgatives, the possibility of relief is much increased. All cases are
exceedingly dangerous, but the danger is often increased by injudicious
attempts at purgation. The existence of hernia at any of the usual situa-
tions, or the presence of impacted feces in the rectum, must first of all be
excluded. When this has been done, and enteritis and peritonitis as a
cause of the symptom can be set aside, abdominal section should be per-
formed as an exploratory measure within a few hours after the occur-
rence of obstruction; provided that attempts to relieve the obstruction by
large enemas have failed.
Enemas of warm water or oil should be given by means of a long tube,
introduced preferably when the patient is in the knee-elbow position. This
position will allow gravity to act, and will aid in the introduction of very
large quantities of liquid into the bowel. The hydrostatic pressure may
be increased by raising the fountain syringe, or other reservoir, several feet
above the patient. This can be done by the surgeon mounting a chair or
step-ladder. Such large enemas are of value in softening fecal accumula-
tion, and are capable of altering the abnormal positions or twists in the
bowel which are causing the symptoms. Inflation of the intestine with air
forced in by means of a long tube, connected with a stomach-pump and
introduced into the rectum, has its advantages. *
If these means fail, a median incision into the abdominal cavity should
be made, and two fingers introduced to explore the peritoneal cavity and
determine the cause of the obstruction. A short distance below the
umbilicus is usually the most advantageous point for the section, unless
palpation gives evidence of a higher point in the median line being prefer-
able. Usually the distended intestine will be discovered forcing its way
through the incision. The most dilated portion should be seized and the
bowel followed along in the direction of the greatest distention and the
greatest congestion. This will usually lead to the point of obstruction.
Greig Smith states that this method is more satisfactory and more practi-
cable than attempts to find the most constricted portion, and to follow it
to the seat of obstruction.
If a foreign body is found, the gut should be opened and the body re-
moved. If it is a gall-stone it will, perhaps, be possible to split it up into
fragments by introducing a needle through the intestinal wall. A volvulus
or internal strangulation may be relieved by untwisting the coils of gut or
cutting through the constricting bands. A stricture of the gut may be
treated by opening the intestine and dilating the stricture by means of the
fingers, as has been described in the treatment of strictures of the gastric
orifices. If it is impossible to deal with the stricture in this way, the dis-
eased portion may be excised, or the intestine may be opened above the
obstruction and stitched to the external abdominal wound so as to form
an artificial anus. It may be preferable in some cases to form a commu-
nication between the intestine above the seat of the disease and that below
it, by means of intestinal anastomosis.
In intussusception the invaginated portion may perhaps be withdrawn
from the sheath or intussuscipiens. If this is impossible, the establish-
ment of an artificial anus, the performance of lateral anastomosis, or
resection of the bowel will be proper.
This line of treatment is that which should be adopted in cases of acute
intestinal obstruction. t
In chronic cases the adoption of operative measures is not so vigorously
demanded, but the case should be watched. No purgatives should be
given and large enemas should be used. The patient should be kept
DIs E As Es AND IN J U RIES OF THE INTEST IN E S. 591
upon concentrated food given in small quantities. In this manner, the
strength is retained without the formation of large quantities of fecal
matter. After this treatment has been carried on unsuccessfully for about
a week, abdominal section, with the performance of such intra-abdominal
operations as may be suitable for the condition discovered, is proper.
In patients that have been allowed to suffer until their strength is ex-
hausted and their general condition exceedingly bad, the administration
of general anaesthesia may be ill-advised. Greig Smith wisely suggests
in such cases that an abdominal incision should be made under local
anaesthesia by means of cocaine. A quick exploration of the abdomen
should then be made and the bowel opened at any convenient point and
stitched to the abdominal wound in order to establish an artificial anus.
This rapid operation will cause but little shock, and will relieve the im-
mediate symptoms. Several weeks after, when the patient has attained a
better general condition, the artificial anus should be dealt with and more
radical measures adopted.
In all cases of intestinal obstruction it is important that the great dis-
tention of the intestines which exists should be relieved at the time of
the operation for the treatment of the obstruction. This is best done by
drawing out of the abdomen a coil of the distended gut, receiving it upon
a warm antiseptic towel and making an incision into it through which the
gas and fecal matter may be forced out by manipulation of the adjoining
coils. The incision, which should not be more than three-fourths of an
inch in length, should be transverse to the axis of the bowel and upon
the side opposite to the mesentery. After the large quantities of gas and
all fecal matter in the vicinity have escaped the intestinal wound is closed
by Lembert sutures and the intestine replaced.
Tumors of the Intestines and Omentum.
Tumors of various kinds occur in the intestinal walls. Malignant
growths are more frequent than other solid tumors in this site, and are
more common in the large than in the small bowel. The omentum may
also be the seat of solid growths, as, indeed, may be the mesentery. Hy-
datid tumors are not very infrequent in the abdominal organs in certain
portions of the world. º
The symptoms of tumor connected with the bowel or the adjacent tis-
Sues are pain, ascites, intestinal obstruction, and subacute peritonitis.
The symptoms, however, vary with the character of tumor and its loca-
tion. The abnormal massis often detectable by palpation of the abdomen,
especially if the examination is made previous to the occurrence of ab-
dominal dropsy due to obstruction of the venous current occasioned by
pressure on the portal vein and its branches.
The treatment of such growths consists in laparotomy, followed by
drainage or excision in the case of cystic tumors, and by such operations
as will effect the radical removal of solid tumors or overcome the condi-
tions induced by them. Resection of the intestine or the establishment of
a new route for the intestinal contents by means of intestinal anastomosis
or the creation of an artificial anus, will be the proper procedure in
selected cases.
Operations on the Intestines.
Opening the small intestine for the removal of a foreign body, or for
*ny other cause, is called enterotomy. Resection of the small intestine is
592 D IS E A S E S OF T H E A B I) O M E N A N D P E L VI S.
enterectomy; while suturing of a wound of the small intestine is enteror.
rhaphy.
Colotomy should, in the strict sense of the term, mean opening the
colon, but it is frequently employed to designate the formation of a per-
manent opening between this intestine and the external air. This should
really be called colostomy. Colectomy is the excision or resection of a
portion of the colon.
Enterotomy, enterectomy, and enterorrhaphy are often used to designate
operations on either the large or small intestine.
Artificial Anus.
An artificial anus is a permanent opening between the intestinal canal
and the air, through the abdominal wall, by means of which the feces are
extruded. The opening may lead into either the small or the large intes-
time. When only a small portion of the feces escapes through such an
orifice, and the remainder is evacuated at the normal anus, the communi-
cation between the external air and the intestinal canal is more accurately
called a fecal fistule. Such openings are made intentionally, in order to
save life during the performance of some abdominal operation; or they
are the result of sloughing of the intestine after it has become adherent
by inflammation to the parietes of the abdomen. Sloughing of the knuckle
of the gut in strangulated hernia is quite frequently the cause of artificial
all Uls.
The bowel around the seat of the opening is adherent to the parietal
peritoneum at the margin of the opening. In accidental cases the orifice
or fistule is usually distorted and depressed, while the surrounding skin
is the seat of eczematous inflammation. There may be two parallel
intestinal tubes with their adjoining walls adherent at the seat of the
artificial anus, or there may be but a small opening in the bowel which
is attached to the belly wall without any bending of the intestine. In
the former case the artificial anus is due to the sloughing away of the bent
portion or knuckle of intestine which formerly connected the two tubes,
now lying parallel to each other. The upper portion of the gut, that is
the portion nearest the stomach, is usually dilated, and from it the feces
escape; while the lower portion of the gut is collapsed. This lower por-
tion of the gut may, rarely, be situated at the upper portion of the ab:
dominal opening. By rotation it has become uppermost, and then adhered
to the upper part of the belly wall before the sloughing occurred. We
employ the term upper in a technical sense to mean the portion of the
intestine which is furthest from the rectum. t
Usually, there is a spur or partition between the two tubes, which ls the
remains of the adjoining walls of the normal intestine at the point of
flexion. It is this spur which tends to cause extrusion of the entire fecal
contents through the abnormal anus. If this is absent the contents of the
bowel may continue down the tube and escape in the normal manne,
with very little escape occurring through the abdominal orifice; which is
then a fecal fistule rather than an artificial anus.
Operation may be demanded to repair such an artificial anus Or. fecal
fistule. It is important that it be undertaken before the lower portion of
the gut has become so shrivelled or atrophied as to be quite different *
calibre from the upper tube. If the artificial anus has occurred high up
in the ileum or jejunum, the chyle escapes from the intestinal tract and
DIS E A SES AND IN J U R IES OF THE IN TEST IN ES. 593
causes the patient to suffer from partial or complete starvation. The con-
dition then demands operative interference because of the difficulty in
nourishing the patient, as well as on account of the disagreeable nature of
the disease.
FIG. 372.
Diagram showing various relations of upper (U) and lower (L) portions of
intestime with spur. (GREIG SMITH.)
The introduction of hydrogen gas through the rectum, already described
under Wounds of the Abdomen, is a means of proving the relative locality
of the opening. If the artificial anus is in the large intestine, the gas will
escape from the abnormal orifice very soon after being introduced into the
rectum, and there will be no gurgling heard, such as is produced when the
gas passes the ileo-caecal valve. The time elapsing before the gas escapes
from the abnormal opening, if it be in the small intestine, will indicate
the relative situation of the opening in the small gut.
Simple means of closing an artificial opening should be adopted before
the more complicated and dangerous procedures are undertaken. When
there is no spur, or when only a very small orifice exists, it is possible to
ºre the condition by the application of the cautery; by paring the edges
of the fistule and suturing them together; or by covering the opening by
º, flap of skin dissected from the surrounding surface after the edges of
the ºpening have been freshened and stitched together.
When a spur directing the fecal matter through the opening exists, it
§ necessary to remove this partition by pushing it downward, or dividing
it, so as to restore the continuity of the intestinal calibre. Mere removal
ºf this obstruction may cause spontaneous closure of the artificial anus.
simple method of depressing the spur is to push into the opening a piece
ºf stiff rubber tubing, which is bent into a sort of horseshoe. The two

38
594 D IS E A SES OF T H E A B D O M E N A N D P E L V IS,
ends are thrust into the opening of the tube, and by their tendency to
separate the spur is pressed downward. The bent tube can be removed at
any time by means of a string which has been attached to it. When the
spur is large and thickened it becomes necessary to divide it. This is best
done by an enterotome, which, in brief, is a long, two-bladed clamp, by
which the spur is grasped and held for several days, until the pressure
causes sloughing of the portion of the spur between the jaws. If the clamp
cuts too rapidly, there is possibility of a perforation extending into the
general peritoneal cavity, particularly if the blades grasp a portion of the
intestinal walls at the base of the spur which have not previously been
adherent to each other.
The best form of enterotome is that in which the blades have ring-like
extremities. This instrument causes sloughing in a circle and, therefore.
removes a disk of the spur, instead of making a simple incision through it.
F1 G. 373.
a, Enterotome; b, enterotome applied. (AsHHURST.)
The opening upon the surface of the abdominal wall is to be closed by
a suitable plastic operation, unless spontaneous closure occurs soon after
restoration of the line of the bowel by the removal of the obstructive .
SOU! I’.
} Resection of the intestine on both sides of the artificial anus, and imme,
diate suturing of the two ends of the gut thus obtained, is a method of
treating artificial anus seldom adopted, because of its greater danger than
the method just described. It is justifiable, however, in certain cases
when milder measures fail.
Appendicitis and Typhlitis.
PATHology.—Inflammation of the caecum is called typhlitis; inflam-
mation in and around the caecum perityphlitis, and inflammation of the
vermiform appendix appendicitis. *
The terms typhlitis and perityphlitis formerly included all inflamma-
tions in this region, but it is now believed that the majority of cases *
instances of appendicitis.
Foreign bodies, which may have been swallowed, may become impacted
in the vermiform appendix. Small, masses of hardened feces, grape seeds,

DISEAs Es AND IN J U RIES OF THE IN TESTINES. 595
and small bones are quite often the cause of inflammation of the appendix
and the structures in the iliac fossa. It is not unusual for perforation of
the appendix to occur subsequently to such impaction and irritation, Or,
perhaps, from simple ulceration of its coats. . Such perforatiye, appen-
dicitis is acute and gives rise to violent general peritonitis. If the con-
dition, however, is a chronic one, adhesions occur about the appendix and
shut off the suppurative focus from the general peritoneal cavity. The
symptoms thus caused are less rapid, though often fatal.
Repeated attacks of sub-acute inflammation in this region are seen in
not a few patients. It is probable that the recurrence is due to patho-
logical changes associated with appendix disease. It is now believed that
such disease of the appendix is a source of risk to the patient, and opera-
tions are done to remove this worm-like organ during the stage of quiet
after a second or third attack of inflammation.
SYMPTOMs.-The differential diagnosis between typhlitis, perityphlitis,
and inflammation of the colon above the caecum is not very easy to make,
except in the typical cases where the localization of symptoms and their
acuteness indicate the portion of intestine involved.
Sudden perforation of the intestine gives rise to pain and profound col-
lapse, vomiting, tympany, suppurative peritonitis, and death. This ma
occur to a patient, to all appearances, previously in perfect health. Ordi-
marily, however, perforation does not occur except after previous inflam-
matory symptoms.
In chronic cases there is pain, more or less severe in character, in the
iliac region, with reflected pain in the groin, hip and front of the thigh.
Great tenderness upon pressure in the caecal region is apt to be present,
and, from spasm of the psoas muscle in the effort to avoid pain, the thigh
is usually flexed on the pelvis. The bowels may be bound, but some-
times they are actually loose, so that a condition of diarrhoea is present.
At other times impaction of the feces occurs, causing a hard mass to be
felt in the caecal region.
The symptoms are those, therefore, of localized peritonitis, with corre-
sponding constitutional phenomena. A hard, doughy mass, the size of a
fist, may be found on palpation of the abdominal surface. This indura-
tion may also be discovered by rectal exploration with the finger or the
inserted hand. Resolution may take place after two or three weeks'
illness, or evidences of suppuration may supervene. Rigors, high tem-
perature, especially at night, and other hectic symptoms are not unusual.
If the pus burrows under the peritoneum covering the lateral and pos-
terior wall of the abdomen, the symptoms are not so startling as when
pus effects an entrance into the general peritoneal cavity. Even in
appendicitis the pus may be walled in and prevented from entering the
peritoneal cavity by a chronic adhesive inflammation which has been
produced about the seat of perforation.
TREATMENT.-In chronic cases of such inflammation the patient should
be put to bed and given saline laxatives, but not active purgatives. Mor-
phia and atropia combined, and in moderate doses, may be given to
relieve pain, though the use of these remedies is to be deprecated, as their
tendency is to mask symptoms and thus to prevent early operation in
*PPropriate cases. Leeches may be applied locally, or a blister used for
99Unter-irritation. Abundant enemas of warm water, introduced by
*ans of a long rectal tube, are very valuable. Too great pressure, how-
*Ver, should not be employed lest the inflamed and softened intestine be
596 D IS E A SES OF T H E A B I) O M E N A N D P E L W I S.
ruptured. Perforation due to repeated or over-zealous examination of
the iliac fossa with the fingers has occurred. t
In sub-acute cases the line of treatment just mentioned should be insti-
tuted, but preparations for laparotomy should be made so that no delay
need occur after the advent of acute symptoms indicating perforation.
In acute perforation immediate laparotomy should be done without
waiting for the development of fatal peritonitis.
In chronic cases delay of operation is wise, but if local oedema, rise in
temperature, and fluctuation give evidence of the existence of pus, an
exploratory operation should be performed.
It often happens that a patient will have inflammation of the iliac
fossa, which never again is repeated, but in other instances inflammatory
symptoms supervene at irregular intervals without apparent cause, or sub-
sequently to violent exertion, or to indiscretion in diet. As such repeated
attacks cause a condition of chronic ill health, it is proper during one of
the periods of quiet to open the abdomen and remove the appendix, if it
is found to be diseased, as will nearly always be the case.
Chronic pain in this region has been relieved, it is stated, by removing
an apparently healthy appendix, which, however, on being opened revealed
the existence of ulceration of its mucous surface.
The incision to reach the appendix or caecum should be from two to
four inches long, and a little outside of the right seni-lunar line with its
lower extremity about an inch above Poupart's ligament. Every pre-
caution should be taken, by surrounding the field of operation by flat
sponges, to keep the pus from the general peritoneal cavity. The appen-
dix will be found at the bottom perforated, gangrenous, or inflamed.
A silk ligature should be tied around its base, after which the appendix
should be excised. Its stump may be pushed into the wall of the caecum
in such a manner as to invaginate it, though this is not an essential. If
the dimple made by invagination of the stump left after removal of the
appendix is a large one, the serous covering of the caecum may be drawn
over the stump by Lembert sutures of catgut.
If general peritonitis exists the peritoneal cavity must be washed out
and drainage-tubes inserted. In some cases it will be better not to attempt
to complete the operation in this manner, but to be satisfied with thor-
oughly laying open the part and making provision for thorough disinfec-
tion and drainage.
If an opening be found in the caecum or colon instead of in the appen-
dix, it should be closed by drawing the serous covering over it by Lem:
bert sutures, as in the case of appendix excision.
The operation of removing the appendix during health is simple. The
stump should be invaginated and the peritoneum of the caecum drawn
over it.
Colotomy.
When an artificial opening into the colon is established for the purpose
of giving exit to the feces, the operation is termed colotomy, though, as
previously stated, colostomy would be the more strictly accurate term.
A new anus may be made upon either side, and in the lumbar region 0.
in the groin; the former is called lumbar colotomy, the latter inguing
colotomy. The term laparo-colotomy would be better for the last named,
since at times the artificial anus is made in the median line between it
and the groin. The transverse colon is not often opened, the operation
DIS E As Es A ND IN J U RIES OF THE IN TESTINES. 597
being usually done upon the sigmoid flexure or cacum, as would be sup-
posed from the fact that the loin or the inguinal region is usually the
place elected for operation.
Colotomy is performed for the relief of imperforate anus, for stricture
of the rectum to afford an exit for the feces, and in ulceration of the
rectum and recto-vesical fistule in order to put the rectum at rest.
Lumbar colotomy, often called colotomy by Amussat’s method, is ac-
complished by making an incision in the loin. The colon is then opened
at the place where it is not covered with peritoneum, but is attached to
the posterior abdominal wall by loose cellular tissue. The patient is
placed in the prone position with the side to be operated upon elevated by
means of a hair pillow placed under the belly. This makes the loin
prominent. The anatomical position of the colon is half an inch behind
a vertical line drawn upward from the middle of the crest of the ilium.
The incision is from two to four inches long and is made midway between
the lower rib and the crest of the ilium with its centré over the colon,
the position of which has previously been marked on the skin. The inci-
sion is made obliquely downward and outward, which makes it nearly
parallel to the ribs. The dissection is carried toward the abdomen until
the lumbar fascia and the edge of the quadrate muscle is reached. The
former is divided and the edge of the latter may be incised if necessary
to get room. By tearing through the transversalis muscle and fascia the
colon is found in the line previously marked on the skin, a little in front
of the border of the quadrate muscle. It is recognized by the feces,
which can be felt in it, or by the longitudinal bands of fibrous tissue
which characterize the great intestine. If there is not an impassable stric-
ture of the rectum present the intestine may be distended with air by
means of an ordinary syringe, the nozzle of which has been passed
through a plug fitting the anus. This distention may be a great aid to the
recognition of the colon. It is often seen distinctly, however, without
such assistance. The nozzle of the syringe may be passed through the
centre of a roller bandage made conical. This makes an exceedingly
good plug to prevent escape of the air pumped into the rectum by the
Syringe. w
Care must be taken that the peritoneum bulging into the wound be not
mistaken for the colon. If the peritoneum should be unwittingly punc-
tured, the edges of this serous membrane should be held together by
means of one or two hemostatic forceps, and ligatures of catgut or silk
tied around the opening.
The operation is performed on the right side if the obstruction is above
the sigmoid flexure. A curved needle should be passed into the wall of the
colon and a suture carried through in order to have the ends of the suture
for drawing the gut up to the surface of the wound. The colon is then
carefully stitched fast to the edges of the wound and opened at once, or
after the lapse of two or three days when it has become adherent. The
latter method is safer, since the possibility of feces escaping into the tissues
around the colon is avoided. The opening may be made without anaes-
thesia, since the intestinal tissue is not very sensitive. In either event
the deep portion of the wound should be carefully sutured and drainage-
tubes put in both the upper and lower extremities of the deep wound.
Absorbent dressings to catch the discharging feces should be applied
*nd frequently changed. This is especially necessary if an artificial anus
has been made at the time of the original operation. Some prolapse of
the mucous membrane often occurs in cases of colotomy, but it does not
598 DIS E A SES OF TH E A BID OME N A N D PEL WIS.
usually become very marked. Indeed, an artificial anus often shows a
tendency to contract, and dilatation is required to keep it sufficiently
patulous.
The patient usually has no great inconvenience from an artificial amus
and soon learns to dress it so as to catch any fecal matter which may
escape at inconvenient times. Absorbent pads are often more comfort.
able than any form of plug or receptacle made by instrument-makers. A
portion of the feces may in certain cases pass beyond the opening and get
into the bowel below. This is due to the fact that when the intestine was
brought to the surface it was not sufficiently bent upon itself to make a
spur or partition. Various operations have been devised to prevent or
remedy this occurrence. In making the artificial anus the surgeon should
º to secure a good spur between the upper and lower portions of
the tube. º
Laparo-colotomy.
When an artificial anus is established in the inguinal region (often
called Littré's method), and when the incision and the abdominal opening
is made in the middle line, the operation is called laparo-colotomy. This
operation has some advantages over lumbar colotomy. The bowel is
more easily found, and a more accurate exploration of the condition for
which the operation was done is possible. These advantages are partic.
ularly marked if the median instead of the inguinal incision is made. If
it is found that an opening in the descending portion of the colon would
not be serviceable in relieving the obstruction, it is possible to make at
once an opening in the ascending colon. This has distinct advantages
over the lumbar incision, in which, of course, the large bowel can only
be opened upon the side corresponding with the external wound. The
anterior operation, moreover, is less serious and troublesome in its perform-
ance than the lumbar method, and puts the artificial anus at a place
where it can be easily attended to by the patient.
Laparo-colotomy, if done in the inguinal region, requires a two-inch
incision, which should be parallel to Poupart's ligament, beginning an
inch inside of the anterior-superior spinous process of the ilium. It
should be situated a short distance above Poupart's ligament. After the
parietal peritoneum has been sutured to the skin the sigmoid flexure is
drawn through the opening, and a piece with a rather long mesentery
selected. Two silk sutures are then carried through the mesentery close
to the bowel, but on opposite sides, and their ends brought out through
the skin by means of a needle. These ligatures or sutures should be
about three inches apart. The lower ligature is attached to the skin
nearer the end of the incision than is the upper one. These ligature;
when tied hold the bowel against the inner aspect of the abdominal
wound. The protruding portion of intestine is then sutured with care 9
the edges of the wound. The ligatures retain the gut in a flexed condi-
tion so that a spur is made between the upper and lower portion of the
tube. Antiseptic dressings are then applied, and if three days, have
elapsed before the opening is made into the colon, inflammatory adhesion
between the intestine and the belly wall will have occurred. Incision is
then made into the bowel without anaesthesia.
The intestinal wound should correspond with the long diameter of the
bowel and should be about half an inch in length. The edges of th;
wound may subsequently be trimmed away so as to make a good sized
DISE A SES AND IN J U RIES OF THE IN TESTIN ES. 599
opening. The operation in the median line is conducted on the same
principles.
Resection of the Intestine.
Resection or excision of intestine is the removal of a portion of the
bowel; and is often followed by immediate suturing of the ends of the
tube thus left. The word enterectomy is often used to include operations
of this sort upon the large as well as upon the small intestine. Strictly,
it should be employed only for resection of the small intestine, while
colectomy should be used when a portion of the large bowel is cut away.
Resection of the intestine is adopted in gunshot and in stab wounds, when
the bowel is too much injured to admit of simple suturing ; in malignant
and other strictures of the bowel; in gangrene of the intestine ; and in
some cases of incurable artificial amus. After gangrenous hernia resection
may be necessary at the inguinal canal. At other times it is done after
making a preliminary abdominal section, which is usually made in the
median line.
The operation is divided into three stages: Separation of the bowel,
excision of the intestinal tube, and suturing together of the cut ends.
Adhesions between the portion about to be excised and other intestinal
loops, or between it and the solid viscera, are a contra-indication to ope-
ration. The portion to be operated upon must be movable enough to be
brought to the surface of the abdominal wound in order to permit the
necessary manipulation.
In performing resection of the bowel the removal must include sufficient
of the intestinal tube to reach healthy tissue above and below the seat of
the disease. The intestinal contents, whether feces or gas, should be
pressed out of the portion of the tube to be operated upon, and clamps
should be placed above and below the field of operation.
FIG. 374.
Clamp for resection of bowel.
The bowel is then cut loose from the mesentery and the clamps succes-
sively released in order that the feces and gas retained beyond the clamp
may be allowed to escape. In cases of obstruction the amount of mate-
rial which will thus flow out is, of course, great. Much care should be
taken that this material does not come in contact with the general peri-
toneal cavity, which may be separated from the field of operation by
packing large, flat sponges into the abdominal wound. The portion of
gut which the surgeon is about to cut off may, after it is detached at the
lower end, be used to conduct away this accumulation of fecal matter into
* Vessel held alongside the patient. After the portion to be excised has
been separated from the mesentery some surgeons prefer to cut out of the
mesentery a V-shaped piece in order to get rid of the redundant mesen-
ºric tissue. If this is done it is necessary to unite carefully the edges of
the mesentery by overlapping them and applying sutures. It is not neces-
*y, however, to make this V-shaped incision, since the redundant mesen-
ºric tissue can be folded up by means of sutures and attached behind

600 I) IS E A SES OF T H E A B D O M E N A N D P E L WIS .
the junction of the two ends of the intestine after they have been sewed
together. This adds somewhat to the strength of the union.
Bleeding from the small vessels of the intestimal wall will follow ex-
cision of the diseased portion, and should be stopped by means of fine
ligatures. Care must be taken not to devitalize the intestinal coats by
compression of these vessels with large haemostatic forceps, which grasp
a great deal of tissue. Small-pointed arterial forceps should be used, and
only the vessels enclosed in their grasp.
The most important and tedious step in enterectomy is stitching
together the cut tube, which must be well done in order to prevent ex-
travasation of feces into the general peritoneal cavity after the abdominal
wound has been closed. Fine twisted silk makes the best sutures. They
should be carried through the peritoneal and muscular coats, but should
never perforate the mucous membrane so as to enter the lumen of the bowel.
If any sutures are inserted for the purpose of uniting the mucous mem-
brane, they must be tied on the inside of the gut, and not come through
to the peritoneal surface. The Lembert suture is probably the best form
FIG, 375. FIG. 376. FIG. 377,
Quilt suture.
applied to intestine.
to use after resection of the intestinal tube. After the insertion of these
sutures the continued suture may be used as an additional means of Sup-
port at any dangerously weak spot in the bond of union. The quilt suture
is another satisfactory method.
The sutures may be inserted while the clamps are upon the intestines, or
some liquefiable cylinder, such as a long plug of cocoa-butter, may be
inserted into the cut ends of the tube, and the sutures placed while the
bowel is thus distended. A rubber bag, which can be distended with air,
will answer the same purpose. Such devices are, however, not absolutely
necessary. - tº
The least point of leakage at the place where the enterorrhaphy is made
will, of course, destroy the success of the operation, and will probably
give rise to fatal peritonitis. In order to make the point of union still
more perfect, Senn has proposed taking grafts of omentum and applying
them along the suture line. He cuts out a small strip of omentum about
two inches in width, and long enough to go around the gut. He keelº
this in a warm antiseptic solution (sublimate, 1 to 2000), until he is ready
to apply it around the junction as a sort of collar. The ends of the graft
are stitched to the mesentery; and as the graft is asepticit becomes uniº
to the gut at the seat of operation. To make the graft more readily
adhere, the peritoneal surface of the bowel may be slightly scratched with
a needle point to cause rapid exudation of lymph.

DISE ASES AND IN J U RIES OF THE IN TEST IN E S. 601
The bowel thus prepared and sutured is returned into the abdominal
cavity, for these manipulations have been done, of course, outside the ab-
domen, and the wound closed in the ordinary manner. If there is any
doubt about the perfection of the enterorrhaphy, it is well to stitch the
repaired gut to the edge of the wound. Then, if one of the sutures be-
comes untied, or a leak occurs, it will be at once discovered ; when opening
of the abdomen, irrigation and drainage may be promptly instituted.
ºf º
f
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;|
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f
º
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W
W
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i.
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ift iſ #|||||||||III;
º #H#Hº
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Drawing to show method of suturing bowel after resection. (GREIG SMITH.)
If it is impossible to complete the resection in a case where this has
been attempted, an artificial anus must be made by attaching the wounded
intestine to the abdominal wall. If colectomy is anticipated when the
9Pºration is begun, it may be better to make a lateral rather than a median
laparotomy. After such lateral opening has been made, which may be
















(302 D IS E A SES OF T H E A B D O M E N A N D P E L V IS.
small for exploratory purposes, it is not improper to do the operation
through another incision, made in the median line, if the lateral one is
found disadvantageous.
Intestinal Anastomosis.
This term signifies the construction of a permanent orifice between two
portions of gut, so as to exclude the intervening portion from conducting
the feces. When intestimal anastomosis is established between the
jejunum and the ileum, the term jejuno-ileostomy is used. Ileo-colos-
tomy is the construction of an orifice between the ileum and the colon,
while gastro-enterostomy is applied to the creation of an opening between
the stomach and a portion of the small intestine.
Intestinal anastomosis is indicated in obstruction of the intestines and
in such malignant strictures as cannot be overcome or removed with
safety. Apposition of the tubes between which the orifice is to be made
is maintained by decalcified bone plates with central openings, or by ellip-
tical rings of catgut or rubber. After these have served their purpose in
keeping the serous surfaces in contact, they are either dissolved in the
FIG. 379.
|
... -- * * * *.
* *
*
|
e”
º
... -- - - - - - -
* *
*
s
º
* * ,
*
*
**s*.
:
º
&
§
s
$g
*~,
;
&
tº sº. sº
- e.g.: = *
**ś
***
*
Diagram of method of using decalcified bone plates of Senn. (GREIG SMITH."
intestinal fluids, or, as in the case of rubber rings, pass through the bowels
and escape from the anus undigested. In using the rubber rings, it
is customary to cut them at one point and unite the cut ends with
catgut, which becomes dissolved and allows the rings to pass through the
bowel straightened out and not as a cylinder. The use of plates or rings
adds greatly to the safety of the operation of intestinal anastomosis. In
suturing the apposed tubes a preliminary scratching of the peritoneum
with a needle point will add to the certainty of the results.
Spring clamps are put upon the intestine above and below the seat of
















L) I S E A S E S A N ID IN J U R I E S OF T H E L I W E R . 603
operation after the intestinal contents have been squeezed out, as in resec-
tion. A point must be selected which will not cause dragging upon the
mesentery or the bowel when the surfaces are put together. An incision
from two to two and a half inches long is made in each portion of the
gut, corresponding with its long diameter, and on the side opposite to the
mesentery. Through these are passed into the lumen of the bowel the
catgut or rubber rings, to each of which four sutures are attached or
fastened. The lateral threads are carried through all the coats of the
intestinal wall, while the threads at the end of the elliptical rings come
through the wound. The ends of the corresponding threads are then
tied upon the peritoneal surfaces of the apposed coils of gut. The open-
ing in the centre of the ring prevents obstruction of the intestinal flow
from one coil to another.
Intestinal anastomosis may be employed instead of a circular suture
after resection. In this case the two cylinders are laid side by side, and
the walls at the cut ends are turned in and sutured in a straight line
across the extremity. After this a new opening is made and the apposi-
tion rings adjusted.
FIG. 380.
| N T E S T | NE
P-S-E-3
*327%
WALL OF
|NT EST INE
TURNED IN AND
SECURE D BY
LEMBERT stitchEsé | N T E S T | NE
* •
*~ *
SECTION OF R | N G
Diagram showing position of decalcified bone plates in intestimal anastomosis after
resection of bowel.
The mere slit, made for the insertion of the rings and for the new orifice
between the intestinal tubes, seems at times to give too small an orifice for
the ready passage of feces. It probably contracts during cicatrization.
It is possible that trimming away the edges of the intestinal incision. So
as to make an elliptical hole in each cylinder of gut will obviate this
condition.
DISEASES AND INJURIES OF THE LIVER,
Lageration and other wounds of the liver may be indicated by local
Pºin, jaundice, clay-colored stools, bilious vomiting and sugar in the urine.
The Symptoms vary with the locality and extent of the injury. The
treatment is immediate abdominal section with suturing of the liver, and
ligation or the use of the actual cautery to stop bleeding.
Abscess of the liver is especially frequent in tropical countries, but is
also met with elsewhere. The Suppurative process not infrequently gives
.* to multiple abscesses. The pus which may originally be formed at some
distance from the surface of the liver, may be evacuated spontaneously
*to the chest, abdomen, or bowel, or u pon the exterior of the body. The













604 DISE A SES OF THE ABDO MEN AND PEL WIS.
symptoms are rather negative, but increased hepatic dulness associated
with pain and tenderness is suggestive of the possibility of abscess.
Hydatid cysts give rise to symptoms similar to abscess. The peculiar
fremitus, which is so characteristic of the presence of this form of cyst,
is often absent in hepatic hydatid cysts. Suppuration of these cysts is
not uncommon. Then the symptoms are identical with abscess from
other causes. Fluctuation is only perceptible in abscess and hydatid dis-
ease when the collection is large and near the surface.
The best treatment of hepatic abscess is laparotomy followed by incision
of the abscess (hepatotomy) and drainage by a tube left in the wound.
It is unwise to wait for the occurrence of adhesions between the liver and
the belly wall with the idea of incising or aspirating the abscess through
the parietes, because fatal rupture may take place before adhesion occurs.
Moreover, there is often no means by which the surgeon can be sure of
the existence of adhesion between the liver and abdominal wall. An
abdominal incision should be made over the tumor if there be one. If
adhesions of the liver to the belly wall are found to exist after this
incision has been made, it is wise to close the exploratory wound and to
open the abscess by a new cutaneous cut carried through the adherent
area. In other cases the abscess is punctured, a finger inserted, and the
liver drawn up to the abdominal wound in order that the abscess cavity
may be evacuated without pus escaping into the peritoneal cavity. When
this abscess has been emptied the finger should explore its interior and
rupture any neighboring abscesses, so that all will empty themselves
through the original opening in the liver. A weak antiseptic solution is
used to wash out the suppurating cavity, after which the edges of the
abscess wound are stitched to the skin, and a large drainage-tube of
rubber inserted. The peritoneal cavity should be thoroughly washed out
with warm sterilized water if it has been soiled, and the usual dressings
applied. Pus should be sucked out of the abscess cavity by means of a
syringe every day, and possibly irrigated with a weak antiseptic fluid.
Hydatid cysts should be treated by incision and suturing to the belly
wall in the same manner as abscesses.
Malignant Diseases of the Liver.
A malignant tumor of the liver, if single, may be removed by lapal-
otomy. It is unusual, however, to find a single malignant nodule, since
the symptoms are scarcely prominent enough to suggest exploratory lapan.
otomy until the disease has advanced far enough to cause multiple tumors
or large and immovable growths.
DISEASES AND INJURIES OF THE GALL-BLADDER.
Rupture and wounds of the gall-bladder, because of the inflammatiº
caused thereby, are nearly always fatal unless treated by surgical,meº
The exudation of plastic lymph as a concomitant of a localized peritoniº
may occasionally circumscribe the inflammation and thereby prolong life,
or even prevent the fatal issue.
The treatment, however, is clear. It consists in opening the abdomen
and stitching the edges of the wound in the gall-bladder to the skin, “”
the ordinary operation of cholecystotomy.
DISE A SES AND IN J U R IES OF THE G ALL-BLA DDE R. 605
Cholecystotomy.
Cholecystotomy, or incision of the gall-bladder, is performed for the ex-
traction of gall-stones, for the treatment of dropsy and empyema of the
gall-bladder, for obstruction of the common bile-duct, and in cases of rup.
ture or wounds of the gall-bladder. Gall-stones give rise to attacks of
hepatic colic, the pain of which is often agonizing. Inflammation, suppu-
ration, and gangrene of the gall-bladder may occur as a result of the
presence of stones in the bladder, while their passage into and arrest in the
biliary passages may cause obstruction of the cystic, hepatic, or common
bile-duct. Such obstruction, if involving only the cystic duct, gives rise
to local symptoms, such as distention of the gall-bladder, followed, per-
haps, by inflammation, gangrene, and the occurrence of biliary fistule.
By sloughing of the wall of the gall-bladder and surrounding tissues,
gall-stones may pass into the lungs, bowels, and peritoneal cavity. Fatal
peritonitis is a complication which may be thus excited. If gall-stones
become impacted in the common bile-duct, jaundice and cholaemia result
in addition to local pain and inflammation.
Stones lying in the gall-bladder and not becoming entangled in the
duct, may give rise to no special symptoms and remain unnoticed for
€8.1°S.
y Dropsy, or empyema, of the gall-bladder is usually due to stones, but
may be caused by hydatids or intestinal worms plugging the duct, or to
pressure from some tumor connected with the neighboring viscera. The
distention may be so great as to cause the bladder to fill nearly the entire
abdomen. In such cases the walls are apt to be thinned.
Stricture from inflammation of the mucous membrane of the duct may
give rise to purulent distention of the gall-bladder. Thickening, ulcera-
tion, and perforation of the walls may occur as a result of suppurative
inflammation within the gall-bladder.
The diagnosis of these pathological changes in the gall-bladder is made
by the existence of a tumor in the right hypochondriac region. It may
be fluctuating, or so tensely distended as to be hard. It may be pear-
shaped or globular, but usually increases in size in an oblique direction
from the hypochondrium toward the umbilicus. Jaundice is frequently
absent, because the common bile-duct is unobstructed.
The diagnosis between distention of the gall-bladder, cystic tumor of
the kidney, movable kidney, and inflammation about the pylorus or head
of the pancreas is difficult.
The operation of cholecystotomy is demanded in wounds, dropsy, and
empyema of the gall-bladder. It is often required in cases of gall-stones,
but in this condition should not be performed until the frequency of
hepatic colic, the exhaustion of the patient from cholaemia, or the evident
existence of a greatly distended bladder filled with stones indicates its
necessity.
The operation is more successful in cases in which jaundice is not
present, because bile in the blood (cholaemia) depresses the patient's forces
and renders the bleeding more profuse. The operation, however, must
often be done in cases where jaundice exists. Opening the gall bladder
and simply stitching its wall to the abdominal parietes is the operation
called cholecystotomy. Removal of gall stones after such an incision is
gholelithotomy, while, if it is necessary to crush the stones before remov-
ing them, the procedure is termed cholelithotrity.
606 D IS E A SES OF T H E A B DO MEN A N D. PEL WIS .
The incision should be made over the fundus of the gall-bladder, which
corresponds with the tip of the cartilage of the tenth rib on the right
side, or it may be made over the tumor, if one exists. The incision should
be vertical. If the bladder is greatly distended some of the fluid may be
drained away by an aspirator before an incision large enough to permit
insertion of a finger is made. Care should be taken, by packing wet
sponges around the seat of the operation, to prevent the bile flowing into
the peritoneal cavity. The gall-stones should be removed with a scoop
or forceps, or crushed with appropriate forceps.
FIG. 381.
=rºsse
Tait's cholelithotomy forceps.
The surgeon must recollect that the walls are thin and easily torn.
If laceration occurs it may be necessary to remove the entire bladder
(cholecystectomy). If the stone is immovably fixed in the duct it may be
nibbled away with Tait's forceps. Possibly it may be broken up by
thrusting a needle into it. After the stones have been removed, or the
dropsical fluid or other contents evacuated, the gall-bladder must be
sutured to the edges of the belly wall. The stitching should be by a con-
º suture of silk and pass through the skin, peritoneum, and bladder
wall.
A drainage-tube, preferably of rubber, should always be inserted and
the belly wound closed around it. The bile which flows from the tube
may be conducted into a bottle lying alongside of the patient. A piece
of rubber dam may be fixed around the orifice of the tube so as to pre-
vent the bile coming into contact with the wound, and a mass of absorb-
ent material placed over the orifice. If all stones have been removed so
that the bile flows through into the intestine, the fistule made by the ope-
ration will finally close. If such is not the case it may become necessary
to make a permanent opening between the intestine and bladder by sub-
sequent operation. Such an operation is entero-cholecystostomy.
Biliary fistules from spontaneous evacuation of the bladder contents
will not close unless the bile is conducted into the intestine by this same





D IS E A S E S A N I) IN J U R IES OF T H E U T E R U S. 607
operation; after which plastic operations upon external openings may be
made if closure does not take place.
DISEASES AND INJURIES OF THE SPLEEN.
Rupture or wounds of the spleen should be treated by abdominal sec-
tion and suturing. When the damage done is very great, removal of the
spleen (splenectomy) may be demanded. Cyst of the spleen is to be
treated by laparotomy and incision followed by drainage. The operation
of incision into the spleen is termed splenotomy. Excision of the spleen
or splenectomy, may be required in some cases of movable spleen, in
hypertrophy of the spleen, when it is not leucocythaemic, and in tumors.
The operation is performed by an incision through the left semilunar
line. The attachments of the organ are divided and ligated, clamps in
some instances being required before the adhesions are cut. Hemorrhage
is the great danger, hence it is necessary that each stump should be tied
separately.
DISEASES AND INJURIES OF THE PANCREAs.
Abscesses and cysts of the pancreas should be treated by laparotomy,
incision of the abscess or cyst, and the establishment of a fistule by at-
taching the edge of the sac to the abdominal incision. This is done
because of the necessity of providing for the escape of the pancreatic fluid,
which would otherwise flow into the peritoneal cavity. The incision
should be made over the tumor.
DISEASES AND INJURIES OF THE UTERUS AND ITS APPENDAGES.
Injuries of the abdomen seldom involve the uterus unless it be pregnant,
or in cases where the injury is so extreme as to do damage to many of the
abdominal and pelvic organs. A pregnant uterus has by error been
tapped for abdominal dropsy. The wound in such cases is apt to cause
abortion. If serious symptoms or peritonitis should arise from this, or any
other uterine injury, abdominal section should be performed, and the con-
dition found treated on general principles, such as suturing of the wound,
irrigating the peritoneal cavity, and drainage.
Fibro-myomatous tumors of the uterus are quite common growths,
especially in the negro. They are often called fibroids because they re-
semble fibromas. They are, as a rule, however, largely myomatous in
their histological features; and are the most common of uterine tumors.
If they develop beneath the peritoneum they are called subserous, or sub-
peritoneal fibro-myomas; if under the mucous membrane of the uterus,
submucous fibro-myomas; while those developing within the substance of
the uterus are called interstitial or intra-mural tumors.
These tumors are interesting, surgically, particularly when they are
developed under the peritoneum, as then they may be confounded with
other growths until the abdomen is opened. A uterine fibro-myoma gives
*e to pain, uterine hemorrhage, and a hard irregular tumor, which can
often be felt through the abdominal wall.
Ergot is given for the relief of the hemorrhage and to cause uterine
9ntraction, by which it is hoped the growth may be gradually forced
through the uterine cavity toward the vagina, where it is more accessible
608 D IS E A SES OF T H E A B D O M E N A N D P E L WIS.
to removal. The submucous form sometimes has quite a long pedicle. If
this is the case the growth may be removed by the écraseur, introduced
through the vagina, Sessile growths of this sort are treated by scraping
away with a spoon having a saw-like edge, after a preliminary dilatation
or incision of the os has been performed, so as to facilitate the intra-uterino
manipulation. The intra-mural fibro-myomas may also, at times, be
enucleated by scraping or incising the internal uterine wall after dilatation
or incision of the os.
Subserous tumors are amenable to operative treatment only by abdom-
inal section. The growth may then, perhaps, be enucleated from the uterine
tissue; or the uterus, if occupied by enormous or numerous growths, ex-
tirpated (hysterectomy).
Apostoli and others have earnestly advocated the treatment of these
uterine tumors by the application of galvanism. Removal of the ovaries
to bring on the menopause, and thereby stop the monthly congestion of
the uterus, which aids in the growth of these tumors, is often adopted.
Fibro-cystic disease of the uterus is a rare condition, and need not be
discussed.
Malignant disease of the womb is most frequently met in the neck.
For its treatment, amputation of the neck by the introduction of instru-
ments into the vagina, is often performed. The diseased portion may be
eaten away by chloride of zinc or other caustics. The best treatment,
probably, is removal of the entire uterus by the operation called vaginal
hysterectomy. In this operation the uterus is pulled down by toothed
forceps, and an incision made through the vaginal mucous membrane in
front and behind, so that the operator's fingers can be carried into the
peritoneal cavity to drag down the entire organ. The broad ligaments
are then ligated, or clamped with large haemostatic forceps; and the uterus
cut loose. The peritoneum and mucous tissue at the top of the vagina
fall together as the uterus is withdrawn. If clamps are used to control
the vessels of the broad ligament, they are taken out at the end of twenty-
four or thirty-six hours. *
Tumors of the Ovary.
PATHOLOGY..—These growths are of importance to the surgeon, because
a diagnosis is often required to be made between them and other abdominal
conditions; and because the abdomen has often been opened for some
other condition, and an ovarian cyst or tumor unexpectedly found to be
the cause of the symptoms.
Ovarian tumors are most commonly cystic, which may be unilocular,
or multilocular. What are called unilocular cysts are not infrequently
multilocular cysts with one cyst greatly developed. Sometimes such
cystic tumors are in part solid. Tumors which are dermoid cysts, wholly
or in part, are not very rare in this locality. Tumors of the broad liga-
ment, called parovarian tumors, may be cystic or solid. Solid tumors of
the ovary are rare, and when found are usually malignant.
SYMPTOMs.-Ovarian cysts when small produce no symptoms. If they
increase in size they displace the uterus forward, or backward, or laterally:
and probably depress it a little. This takes place when the tumor is small
enough to be contained in the pelvis. When, from increase in size, it rises
into the abdomen, such changes are not apt to be present. º
The symptoms of ovarian tumors, which are now to be described, arº
not very reliable, for similar symptoms may occur in other diseases, and
D IS E A SE S A. N. D. IN J U R IES OF T H E U T E R U S. 609
ovarian cysts may be present without giving rise to them with sufficient
distinctness to be of value in diagnosis. A small, rather globular mass,
either firm or fluctuating, and probably movable, is found sometimes on
one or other side of the belly. As it increases in size a feeling of discom-
fort, frequent urination, constipation, and oedema of the limbs from com-
pression of the veins may arise. Pain from pressure on the sacral or
lumbar plexus may occur and be reflected down the legs. Nausea, vomit-
ing, colicky pains, and, perhaps, diarrhoea, are not improbable. Ascites
from interference with circulation in the portal vein is quite usual, and
hemorrhoids from a similar interference with the venous return are annoy-
ing complications. Albuminuria also may be present, and dyspnoea from
abdominal distention due to the bulk of the tumor, and from the peritoneal
dropsy just mentioned, may be very distressing.
When the cyst becomes large enough to distend the abdomen, greatly
and particularly when the cyst is unilocular, it very much resembles peri-
toneal dropsy, or ascites occurring from visceral disease. A differential
diagnosis is then a matter of great importance. Multilocular cysts are
not so liable to make a diagnosis difficult, because they usually have an
irregular surface, and because fluctuation is more marked in some places
than in others. The fluctuation wave does not cross the whole abdomen,
but is limited to various portions of it, unless one of the cysts in the multi-
locular growth is very much larger than the others. A unilocular cyst
FIG. 382. FIG. 383.
}
Diagrams showing development of areas of dulness in ascites (Fig. 382) and in ovarian
tumor (Fig. 383). The darker shading indicates an earlier stage of disease. (GREIG
SMITH ) w
has a smooth outline, is elastic, and gives a fluctuation wave over its
Whole extent. This last symptom is very like that given by ascites.
Dulness On percussion exists over the tumor whether it is unilocular or
multilocular. In ovarian dropsy, a term often used to signify an ovarian
%t, the area of dulness is circular, with the convexity of the circle
directed upward near the middle line, with resonance extending downward
upon each side. *
In ascites the dull area gives a crescentic line with the concavity upward,
While resonance is notably situated between this line and the stomach.
The dulness of ascites is changed by turning the patient on her side.

39
610 D IS E A SES OF T H E A B D O M E N A N D P E L VI S.
This does not take place in ovarian dropsy, where the line is practically
unchanged by such movement. It should be remembered that when an
ovarian cyst is accompanied with ascites, due to pressure of the cyst
upon the venous trunks, there may be dulness in the flank, fluctuation
across the whole abdomen, because of the complicating ascites. This will
destroy the outline of the resonant area indicative of ovarian cyst.
In ovarian cysts there is often a peculiar heaping up, as it were, in the
middle line, which is due to the greater distention in the middle portion
of the abdomen; but in ascites gravity acting on the unconfined fluid
causes distention at the sides of the abdomen and flattens the front of
the belly. In ascites, moreover, there is apt to be evidence of disease of
the heart, or of the kidney, liver, or some other abdominal organs, with
perhaps oedema of the arms and face. CEdema of the legs does not aid
much, because, though frequently occurring in cardiac, renal, and liver
disease, it also exists in cystic tumor of the ovary, from pressure of the
growth on the caval and iliac veins. When abdominal dropsy exists in
addition to the ovarian cyst, the diagnosis of a tumor in addition to the
ascites may sometimes be made by quick and forcible pressure of the
fingers upon the abdominal wall. The sudden pressure or tap causes the
peritoneal fluid to be pushed aside and the fingers come abruptly upon
the ovarian cyst or other growth. This would not occur if ascites alone
existed, nor if a large ovarian cyst without accompanying ascites were
present. The fluid of ascites is usually thin yellow serum. The fluid of
ovarian cysts is frequently brownish in appearance.
Encysted dropsy of the peritoneum is difficult to diagnose from ovarian
cyst. A differential diagnosis is often impossible. Cysts of the broad
ligament resemble ovarian tumors in their symptoms, and in their treat-
ment, except that tapping is sometimes curative in the former. Ovarian
cysts should seldom, if ever, be tapped, and then tapping is not curative.
As other growths, cysts of the ovary may become adherent to the intes-
tines, solid viscera, and abdominal wall. The presence of adhesions cannot
with certainty be made out before the abdomen is opened.
Rupture of an ovarian cyst may occur, and the fluid, if it escapes
through a small opening, may give rise to no special symptoms; but if it
is suddenly evacuated into the peritoneal cavity in large quantities, col-
lapse and death may occur at once. In any case, the escape of fluid may
give rise to peritonitis; this it is sure to do if the contents be purulent.
Twisting of the pedicle may occur from rotation of the tumor, and inflam-
mation and gangrene of the growth take place as a result.
TREATMENT.-The only treatment for ovarian cyst is removal by
laparotomy, which, at the present day, is exceedingly safe if the operation
be properly done. Tapping the cyst, so often employed formerly, is not
justifiable as a general course of treatment. It may be employed to
prolong life, when removal of the tumor is impossible; or it may be
done in order to make the patient comfortable until the operation, then
unadvisable, can be done. For example, the existence of an acute diº
ease may render immediate ovariotomy impossible. Then temporary
relief from tapping may be justifiable. There is no advantage in it in
order to make an examination of the fluid as a means of diagnosis, Slſº
such examination is fallacious. Since the only proper treatment canº"
be undertaken without opening the abdomen, exploratory incision, ſº
lowed by immediate removal of the ovarian cyst, if one is found, is the
correct surgical procedure.
Peritonitis, due to rupture of a cyst, or to the occurrence of suppu"
D IS E A SES AN ID IN J U R IES OF T H E U T E R U S. 611
tion within the cyst, indicates immediate operation. Ovarian cysts have
been successfully removed while the patient was pregnant.
The incision for removal of an ovarian cyst should be about three
inches long in the middle line and midway between the navel and the
ubes. It is wise to go no nearer to the pubes than two inches, to make
sure that the bladder be not injured. The incision can always be enlarged
upward with safety at any stage of the operation. If the surgeon carries
the abdominal incision above the navel it is best to carry it around the
outside of the navel on one side rather than to go directly through
it. All hemorrhage of the abdominal wound should be stopped before the
FIG. 384.
Tait's ovariotomy trocar.
peritoneum is opened. The cyst is then tapped with a trocar before the
adhesions, if there be any, are broken down, and the contents of the cyst
allowed to flow through the trocar. The wall of the sac should be drawn
out of the wound to prevent extravasation of the cystic
fluid into the peritoneal cavity. FIG. 385.
... The adhesions are then gradually torn through with
the fingers, or, if very firm, are divided with a pair of
scissors, perhaps after previous ligation. Every precau-
tion to prevent hemorrhage is taken. The wound made
by the trocar in the sac should be closed with a T-shaped
hemostatic forceps, to prevent the escape of cystic fluid
into the peritoneal cavity.
Injury to the bowels must be carefully avoided by
detaching the adhesions from the intestinal wall with
Caution. Vascular adhesions must be ligated in a way
similar to that adopted for tying a pedicle. The pedicle
ºf the growth is found after the sac has been separated
from its adhesions and drawn through the wound, and
must be ligated before the sac is cut away. This is best
done by transfixing the pedicle with a blunt needle
and thereby carrying a double silk ligature through it,
9 by thrusting a pair of closed hemostatic forceps
through the pedicle, by which the ligature is seized
in the middle and drawn backward through the opening d
made by the forceps. An aneurism needle does Very Thornton's T-shaped
Well for this purpose. The loop of the suture is then forceps.
% leaving two portions of silk lodged in the pedicle.
fier a twist around each other has been given to the threads at the
Pºint where they perforate the stump, each half of the stump is tied sepa-


612 D IS E A SES C F THE A B D O M E N A N D PEL WIS .
rately. One of the ligatures is then carried around the whole pedicle,
making the ligation more secure, and the ends, by means of needles
threaded upon them, may be carried through the base of the pedicle on
the side away from the tumor, and tied in such a way as to anchor the
whole ligature. This prevents the possibility of its slipping from the
stump when the tumor is removed.
Various forms of interlocking ligatures have been devised for use upon
the pedicle. One of the best is the Staffordshire knot. It is made by
carrying a double ligature through the middle of the pedicle, bringing the
loop, which is on one side of the pedicle, over the tumor, so as to be on
the same side as the two free ends, and then passing one end through the
loop. One end is thus placed over, the other under, the loop. The two
ends are then pulled, until the loop is tightened, and then tied with a flat
knot. The cyst is then cut off outside the ligature, and the ligated stump
dropped into the belly. The toilet of the peritoneum must be carefully
performed. Drainage should be instituted, if there is necessity for it by
reason of pus escaping from the sac into the cavity, or because of oozing
of blood from many small points which cannot be ligated.
Solid tumors of the ovary should be removed by laparotomy and
excision. The handled screw of Tait may be inserted into the mass in
order to render its manipulation convenient.
DISEASES OF THE FALLOPIAN TUBEs.
Tubal disease may arise as a consequence of uterine and pelvic inflam-
mations and of gonorrhoea. Inflammation of the tubes is called salpin-
gitis. Suppuration within the tubes is usually, it is believed, a sequence
of gonorrhoea, and is called pyosalpinx. Injury of the Fallopian tube,
or obstruction to the escape of menstrual fluid from the vagina or uterus
may give rise to distention of the tube by blood (haemato-salpinx). A
collection of serum in the tube causes the condition called hydro-
Salpinx.
Tubal disease is of importance to the surgeon because it is often the
cause of pelvic and abdominal suppuration. Purulent peritonitis is often
on examination found to be due to rupture of the Fallopian tube, which
has been the seat of suppurative inflammation.
The symptoms of tubal disease are pain, especially severe upon exertion
or coition, tenderness in the ovarian region, painful and irregular men:
struation and various distressing symptoms referred to the pelvis and
uterus. Symptoms formerly attributed to pelvic cellulitis were probably
in the majority of cases indicative of tubal disease. Pelvic cellulitis
without disease of the uterine appendages is now believed to be rare. In
disease of the tubes vaginal examination will probably reveal the pres:
ence of a fluctuating oblong tumor through the roof of the vagina. Such
a tumor may exist upon one or both sides, and may be movable 0.
adherent. The elongated shape of a distended tube differs from that of
a small ovarian cyst. Pyosalpinx sometimes gives rise to rigors and
febrile conditions. º
The treatment of diseased tubes is largely operative. Haemato-salpinº
may, perhaps, be excepted from the rule that diseased tubes should be
removed by abdominal section. When the tube contains pus there *
great danger of spontaneous or accidental rupture, and of thus creating
H E R N IA . 6.13
purulent peritonitis. Hence removal is demanded. The excision of tubes
distended with serum is usually judicious treatment.
The operation of salpingectomy, or removal of the tubes, is a simple
one, and consists in making a two-inch incision in the middle line of the
abdomen, through which one or two fingers are introduced. The adhe-
sions, which are often present, are carefully torn and the diseased Fallopian
tube drawn through the abdominal incision. The ovary should be brought
out along with the tube and afterward the pedicle secured and tied with
silk. Great care must be exercised in operating for pyosalpinx to avoid
rupture and escape of pus into abdomen or pelvis. If this accident hap-
pens, as it may, because of the firmness of the adhesions, the abdominal
and pelvic cavities must be well irrigated, and subsequently drained by
a glass or rubber tube being left in the wound. An interlocking ligature
about the broad ligament which forms the stump is probably the Safest.
Oöphorectomy, or removal of the ovaries when not the seat of cystic
disease or other gross lesion, has been employed in the treatment of
ovarian neuralgia, and of insanity, epilepsy, and menorrhagia accompany-
ing fibro-myomatous tumors.
The term ovariotomy is usually employed to indicate removal of ovaries
which are the seat of cystic or solid tumors. It will be seen, however,
that oëphorectomy, which etymologically means removal of the ovaries,
has the same signification, though the terms are usually used with a dis-
tinction. Normal ovariotomy is sometimes employed instead of oëphorec-
tomy. The student should observe that the latter word is not pronounced
as though its first syllable was “ou.”
HERNIA.
DEFINITION.—Hernia, or rupture, is a protrusion of any portion of the
abdominal or pelvic contents through an abnormal opening in the wall
of these cavities, not a recent penetrating wound. The tumor is usually
covered with integument. Such is not the case, however, in hernia through
the diaphragm, nor in hernia into the vagina or rectum.
The term “hernia” is sometimes applied to a protrusion of other struc-
tures through an opening, such as hermia of the brain, which is a protru-
Sion of cerebral and inflammatory tissue through an opening in the skull,
and hermia of the iris, which is a protrusion of the iris through an opening
in the cornea.
When the word hernia is used alone it refers to a protrusion of the
abdominal and pelvic contents.
CAUSES-Hernia is apt to occur where the wall of the abdomen or
Pelvis is weakened by the passage of some normal structure, such as the
*Pººrmatic cord, the round ligament, the femoral vessels, or by a cicatrix
left after a wound. A protrusion through a recent wound is not called a
hernia, but a protrusion occurring at the cicatrix of an old wound is a
€l'Illa.
The predisposing causes of hermia are a long mesentery, a patent funic-
ular portion of the Vaginal tunic or canal of Nuck, congenital defects
in the wall of the belly, relaxed muscles from pregnancy or emaciation,
and cicatrices.
he exciting causes are muscular exertion, such as occurs in lifting
*WY Weights, straining at stool, and in the repeated compression of the
"*"a which occurs in stricture of the urethra, phimosis, stone in the
614 D IS E A SES OF T H E A BID O M E N A N D P E L VI S.
bladder, and chronic cough. These conditions give rise to hernia because
the muscular contraction involved causes a diminution of the cubical
space in the abdomen and pelvis and tends to thrust the contents of these
cavities through any weak portion of the wall.
PATHOLOGY..—The ordinary seats of hernia are the inguinal canal, the
femoral canal, the umbilicus, and cicatrices left after laparotomy or
accidental penetrating wounds of the abdomen. Hernia at the obturator
foramen, at the great sciatic foramen, or through the diaphragm into the
chest is rare. A diaphragmatic hernia may occur through any of the
normal openings in that muscle, or through a congenital defect. Hernia
in the lumbar region, into the perineum, or into the space between the
vagina and the ramus of the ischium is rare, as is also hernia into the
rectum and vagina.
A hernial tumor usually pushes before it the parietal peritoneum,
which is stretched or undergoes interstitial growth by force of the descend-
ing tumor, and forms a sac. The contents of the sac are usually intestine
or omentum, but almost any of the abdominal or pelvic organs may be
contained in the hermial protrusion. Outside of the sac are found the
fascias and muscular structures pertaining to the region in which the
hernia occurs.
When hernia occurs into the vaginal tunic of the testicle because the
funicular portion in the inguinal canal has not become obliterated, the con-
dition is called a congenital hernia. Here there is no true hernial Sac or
protrusion of the parietal peritoneum, since the canal of peritoneum already
existed as an unclosed foetal structure.
The sac of a hernia has a body, a neck, and a mouth or orifice, through
which the hernia enters the sac. The sac is usually pear-shaped or glob-
ular, but may assume almost any form. It may be divided by partitions
into separate chambers, and in one or more of these chambers there may
be serous fluid. The sac walls of old hernias are often very much thick-
ened; sometimes they are irregularly thinned in places. The neck of the
sac in a recent hernia is more or less folded or plaited, but in old cases it
usually has become smooth, indurated, and thickened by inflammatory
deposits.
When the contents of a hernial sac consist entirely of intestine the
hernia is called an enterocele. A hernia consisting of omentum is all
epiplocele; while one in which the contents are both intestine and omen-
tum is known as an entero-epiplocele. e
The ovaries and bladder and portions of the solid viscera are found in
some large hernias, but usually it is the small intestine with or without a
portion of the omentum which is found in the hernial sac. In rare cases
only a portion of the calibre of the knuckle of intestine enters the her-
nial sac, which in this case of course is small.
An untreated hernia may become exceedingly large, until several feet
of gut lie outside of the abdominal cavity. The intestine, the mese tº
and the omentum of an old hernia usually become hypertrophied, and
more or less adherent to each other and to the sac wall. A limited
amount of serum is often found in the sac, and occasionally rice-like
bodies composed of inflammatory lymph are present. If a hernia has been
kept within the abdomen for a long while by a truss, the neck of the Sac
may become obliterated and the sac remain as a cyst filled with Serous
fluid. *
When the protruded viscera can be pushed back into the Cavity of the
abdomen the hemia is said to be “reducible.” When such is not *
H E R N I A . 615
case, and the protruded viscera cannot be reduced by manipulation, the
hernia is called “irreducible.” The word “incarcerated * is sometimes
employed to indicate the condition of irreducibility; unfortunately it is
also used occasionally as synonymous with “obstructed” hernia. The
latter use of it seems to me improper.
A “strangulated ” hernia is one in which the protruded viscera are so
tightly grasped that it is impossible to push back the mass into the ab:
dominal or pelvic cavities, and in which circulation of the part protruded
is so impeded that inflammation or gangrene takes place. If the hernia
which is strangulated contains intestine, the passage of the feces is also
prevented by the compression of the gut.
In an “obstructed" hernia the intestine is obstructed with a mass of
undigested food, or feces. It is irreducible, and occurs especially in old
persons. The liability of such hermias to become strangulated or inflamed
is very great.
An “inflamed ” hernia is one in which the sac contents are in a condi-
tion of inflammation. This pathological condition is most common in
small irreducible hernias, and is due to wearing an ill-fitting truss, or to
violent exercise or injury. An inflamed hernia is apt to become stran-
gulated.
In reducible hernia the hermial contents often return into the belly
spontaneously when the patient lies upon his back. The sac, in recent
cases, sometimes goes back at the same time that the intestine and
omentum do. In most cases, however, the sac remains adherent to the
surrounding structures after its contents have spontaneously, or by manip-
ulation, been returned to their normal site.
A hernia becomes irreducible because of changes in the vicinity of the
ring, in the protruded tissues themselves, or in the sac. The ring or open-
ing may have become inflamed, and thereby contracted; the neck of the sac
may have become elongated and its walls thickened; the protruded struc-
tures may, from growth or inflammation, have increased in size below the
neck after their extrusion; adhesions may have occurred between the con-
tents of the sac and the sac wall, or between various portions of the hermial
mass; and, finally, bands of inflammatory tissue developed within the sac,
. the fluid contained in it may interfere with the reducibility of the
€I’Illa,
A recent hernia may be strangulated by suddenly being forced through
a small opening which instantly exerts great constriction. An old hermia
may become strangulated by a sudden protrusion of a new portion of the
Intestine or omentum in addition to the previous mass; by swelling from
inflammation of the omentum or of the mucous membrane of the intes-
ºne, or by increased size of the gut from obstruction with gas or feces.
The constriction causing strangulation may be at the outside of the sac at
the hermial ring, in the neck of the sac itself, or within the sac. In the
last gase the strangulation may be caused by inflammatory, bands, or by
9penings between two portions of the hernia within which another portion
may have become constricted. Strangulation may be acute or chronic in
*...ourse, according to the mechanism which produces it.
he compression of veins by the strangulation gives rise to venous con-
8°stion, followed by inflammation and gangrene. The paralysis of the
*ścular coat, which sometimes occurs, may interfere with peristaltic
*ion and cause obstruction to the passage of the feces, although the
lºmen of the intestines is not entirely closed by the pressure. Strangula-
tion may occur also in Littré's hernia, although the entire calibre of the
616 D IS E A SES OF T H E A BID O M E N A. N. D. I? E L VIS .
intestine is not constricted in this form of hermia. It is easily understood
that the greater the swelling the greater the constriction, and that, at the
same time, the increase of constriction thus caused tends to produce a
further increase of swelling. A strangulated knuckle of bowel usually at
first becomes red, then of a dark color, and finally black or gray. This
last condition is often accompanied with ecchymotic spots. The swollen,
sticky, and Oedematous coats of the intestine exhale a fecal odor, and
exude a dark fluid. Sloughing and perforation of the intestinal wall
occurs as a later step, and is followed by fecal extravasation into the sac,
which, if the patient lives long enough, ends in fecal abscess, and in the
formation of a fistule between the gut and the external surface. Peri-
tonitis occurs quite early after strangulation has taken place. The intes-
tine soon becomes glued to the belly wall surrounding the hernial ring,
and, therefore, in cases of fecal abscess, the extravasated feces are not
apt to escape into the general peritoneal cavity. In the majority of cases,
death takes place from exhaustion and peritonitis before fecal abscess and
fistule have occurred.
SYMPTOMS.-A feeling of weakness is often experienced by the patient
before the hermial protrusion takes place. A fulness in the part is per-
haps perceptible, and suggests the occurrence of hernia because it is at the
locality where hernia is likely to occur. If the disease is gradual in its de-
velopment, a small tumor, not larger than a finger-tip, may at length be
noticed at the seat of this fulness, and is accompanied by a subjective sensa-
tion of weakness. When the patient lies down the tumor spontaneously dis-
appears, because the protruded bowel or omentum slips back into its normal
position. In other cases, sudden and painful protrusion occurs at one of
the ordinary seats of hernia during straining at stool or violent exercise.
The hermial tumor is usually round or oval, and rather smaller at its
base, which represents the seat of the neck of the sac. It is enlarged
when the patient stands or coughs, but disappears under gentle pressure
or when he lies down. Coughing causes an impulse in the tumor, which
is very perceptible to the hand when grasping it. If the hernia consists
of intestine alone, the tumor is smooth, elastic, tympanitic on percussion,
and slightly gurgling when compressed. The impulse on coughing is
marked. Rumbling from intestinal gases is present, and the patient has
a dragging sensation at the seat of the tumor. Reduction is accompanied
by a distinct gurgling, due to the escape of gases and liquid feces, and
by a sudden peculiar croaking sound as the gut slips back into the belly.
If the hernia contains only omentum, the tumor is apt to be irregular
and to have a doughy feeling; it shows less impulse on coughing, and
when being reduced slips back gradually without any gurgling or croak-
ing sound.
The symptoms of irreducible hernia are not unlike those already de;
scribed, except in so far as these symptoms pertain to the possibility of
the protrusion being pushed back into the abdomen. Colicky pains alſº
rather characteristic of irreducible hernia. In some cases, where both
intestine and omentum are contained in the sac, the gut is reducible, while
the omentum is irreducible.
Strangulated hernia gives rise to very characteristic symptoms. The
tumor becomes painful, tender, and tense, and a tympanitic note is g|V%"
if intestine is contained in the sac. Impulse on coughing is lost. Pain
is usually referred to the umbilical region, which is the reason that stra"
gulated hernia has been so often mistaken for ordinary colic. If the Conſ
striction is not relieved the skin overlying the gut, which has become
H E R N IA . . 617
gangrenous, assumes a dark hue and gives rise to a fecal odor. The sen-
sation of pain is apt to cease if gangrene occurs. To the uninitiated this
appears to be a good omen. The surgeon, however, knows that it is a
sign of grave pathological change. The intestinal obstruction due to
strangulation causes obstinate constipation and vomiting. Constipation
is complete except that the lower bowel may be emptied of its contents
during the earlier hours of the disease. In Littré's hernia constipation
is not, as a rule, complete. Vomiting is violent and gushing without much
retching. The vomited material is at first the contents of the stomach,
then bile and the other fluids found in the upper part of the small intes-
time are ejected. Finally the ejection of a brownish-yellow fluid with
the odor of feces indicates that the contents of the lower portion of the
small intestine are being thrown up. This fluid is indeed feces, and to
such vomiting the name “stercoraceous vomiting” is given. There is no
flatus discharged from the rectum, but the contents of the large bowel
may be evacuated either voluntarily or after the administration of an
enema. The face becomes pinched and anxious; the pulse is frequent
and weak and perhaps irregular; the tongue is furred and brown. There
is profund collapse, and, later, exhaustion and death take place. Recovery
after the formation of a fecal abscess and fistula due to gangrene of the
gut does occur, but it is rare. In young persons and in recent hernia
strangulation usually gives rise to acute symptoms, while, occurring in the
irreducible hernia of old people, the strangulation symptoms are apt to
be more chronic in their course.
TREATMENT.-The palliative treatment of reducible hernia is the
application of a compress of gauze, or other material, to hold the intes-
time within the abdomen until a properly fitting truss can be obtained
from the instrument-maker. A hernial truss consists of a pad held in
place over the hernial ring by a spring around the pelvis. The truss
varies in shape and size in accordance with the seat and character of the
hernia, and should be made to fit comfortably, and to make only such
pressure over the hermial opening as will retain the structures which are
liable to protrude. If the patient can be seen by the instrument-maker
a properly fitting truss is generally readily obtained. When, however,
the patient lives at a distance from a large city the surgeon should send
the instrument-maker the girth of the pelvis midway between the crest of
the ilium and the great trochanter, describe the kind of hernia, tell on
FIG. 386.
º 㺠CG was RANTED". .. : . * * * * *
Truss for inguinal hernia.
which side it exists, give the sex and age of the patient, and express his
°Pinion as to the relative strength of the spring required. The truss
should be adjusted while the patient is recumbent and the hernia reduced.
It should always be worn when in the erect position, and should never

618 DIS E A SES OF T H E A B D O M E N AN D P E L WIS.
be taken off until he is recumbent. Many patients can go without their
trusses at night because there is little tendency for the hernia to recur
while they are lying down. Others require to wear a truss at night, but
then it is not necessary for the spring to make as much pressure as during
the daytime. Hence a weaker truss may be used. A truss at night is
wise when the patient suffers from a cough. It usually takes some
time for the patient to become accustomed to wearing the support, as
is the case with those wearing an artificial limb or spectacles for the
first time. The annoyance, however, is only temporary.
FIG. 387.
Truss for femoral hermia. This form is applied across the pelvis from the sound side.
FIG. 388.
tº Tº
V. º
Truss for umbilical hernia.
A properly fitting truss should permit the patient to go up and down
stairs, and jump off a chair, for example, without permitting escape of
the hernia.
If the pad of the truss irritates the skin, as it often does, the cutaneous
surface may be sprinkled with lycopodium powder and bathed frequently
with whiskey and alum.
The radical treatment of hernia consists in reducing the protrusion,
obliterating the sac, and closing the ring. In young persons with small
hernias, wearing a truss may induce sufficient inflammation of the peri-
toneum forming the sac to cause the latter's obliteration. This is espe-
cially true of congenital hernia, in which the unobliterated portion of the
vaginal tunic very readily becomes adherent from the irritation caused by
pressure of the truss. *
In other cases the radical cure is only possible by operative inter.
ference. The radical treatment is especially employed in inguinal
hernia. An incision is made over the tumor, the sac separated from the
surrounding tissues, and the protruding viscera returned to the abdomen,
Various means are employed for dealing with the sac so emptied and
separated. Some operators invaginate it into the inguinal canal and
sew the columns of the ring and sac together, thus making a sort of plug
in the inguinal canal. Other surgeons carry a ligature around the neck
of the sac, tie it after having reduced the hernia, and then cut off the
sac below the ligature and sew the columns of the ring together. The
sac, on the other hand, may be folded up into a plug or twisted into a


H E R N IA . 619
rope and thrust into the canal, where it is stitched to the columns of the
ring. In these operations the peritoneum lining the inner surface of the
abdomen around the internal ring should be separated from the parietes
for a short distance from the circular margin of the ring. This is done
in order to insure solid closure of the ring by preventing the formation
of a concavity at its former site, which tends to allow the pressure of the
intestines to start the formation of a new hermial sac and to stretch the
closed plug. In most of these operations the stump of the sac or the
ring made by the old sac is supposed to be stitched behind the ring, thus
making a sort of pad within the abdomen at that point.
After dealing with the sac according to any one of the methods
described, the internal ring is closed by means of silk sutures carried in
various ways through the abdominal aponeuroses and margins of the
opening. Then the wound is closed.
In one of the operations for the radical cure of hernia the external
wound, instead of being closed, is plugged with antiseptic gauze because
healing by granulation is thus effected and a more solid cicatrix pre-
sumably made. This offers more resistance to protrusion of the intestinal
contents than a cicatrix made when union takes place by first intention.
At least such is the theory.
Excision of the sac may be employed for the cure of femoral and
umbilical as well as for inguinal hernia. The borders of the ring in fem-
oral hernia cannot, however, readily and satisfactorily be sewed together,
because the margins of the ring are too rigid. -
Ventral hernia occurring after laparotomy is treated by a bandage,
pad, or truss; or by excision of the sac and stitching the borders of the
opening together.
Radical operations for hernia, although comparatively safe when done
with antiseptic precautions, are attended with a certain, though limited
amount of risk, and in the majority of cases do not effect a truly radical
cure. A return of the hernia is quite frequent, though the recurrent
hernia may be smaller and more manageable by a truss than was the
original. Radical operation is justifiable in reducible hernias which are
very large and in those which a truss will not properly control.
Irreducible hernias frequently give great discomfort from their bulk or
from the dyspeptic symptoms produced by their existence. In irreduci-
ble hernias the operation for radical cure is more serious than in reducible
hernias, because the sac has to be opened in order to effect the reduction
of the hernia. The intestinal adhesions have to be released and portions
of omentum perhaps excised in order to accomplish a return of the pro-
truded viscera. The congenital forms of hernia are more amenable to
permanent cure by radical operation than other forms, but they are also
more amenable to cure by truss.
Irreducible hernias often become so large that they are a burden to
the patient; and they are dangerous because they are liable to inflamma-
tion, strangulation, and obstruction. An attempt should be made to
protect them from injury and to prevent their increase in size by wearing
a suitable bag-shaped truss or supporter. If a hernia has recently become
irreducible it is proper to attempt to render it reducible. This may be
accomplished by rest in bed, the administration of saline laxatives, and
the application of ice to the surface of the tumor. Such measures are of
no avail unless resorted to shortly after the advent of irreducibility.
620 D IS E A SES OF T H E A B D O M E N A N D P E L VIS .
Strangulated Hermia.
When a hernia becomes strangulated the reduction must be made at
Once, since every hour adds to the danger of the condition and increases
the inflammatory changes in the gut or omentum which is subjected to
pressure. Purgatives to relieve the constipation are useless and extremely
harmful. Prolonged and forcible manipulation of the tumor in the hope
of reducing the protruded mass is equally unjustifiable.
The word “taxis.” is employed to describe the series of manipulations
used in reducing a strangulated hernia.
When strañgulation has occurred taxis should at once be attempted,
but the surgeon must remember that the manipulations must be gentle
and continued for but a few minutes. If reduction by taxis is not ac-
complished in this manner, the use of enemas to empty the lower bowel,
and of ice locally to the tumor, and the internal administration of mod-
erate doses of morphia may be adopted. Ether has been recommended
as a local application because of its refrigerant effect. In some kinds of
hernia this line of treatment will cause the tumor to become reducible,
and gentle taxis employed at the expiration of three or four hours will
effect reduction of the strangulated gut. A hot bath is sometimes appa-
rently efficacious, though in strangulation of femoral hernia it appears
to be valueless. If these measures fail, immediate resort to operation for
the relief of the strangulation is proper.
In attempting to reduce a hernia by taxis the surgeon seizes the tumor
with one hand and slightly lifts it, exerting at the same time a little pres-
sure upon it with his fingers. The pressure on the constricted knuckle
causes, if the calibre be not entirely closed by the constriction, the expul-
sion of gas and feces, and thereby reduces the bulk of the hernia. With
the fingers of the other hand he slightly compresses the protrusion at the
neck of the tumor to prevent the contents from bulging over the ring
when pressure is being made with the other hand. It is often well to
draw down the tumor a little with the right hand in order to pull out a
little more intestine and thus disengage the protruded portion from the
grasp of the ring through which it has escaped. It is clear that the
portion of the hernia which has escaped from the abdomen last must be
the first to be pushed back. Hence the part near the neck must be
“coaxed ” into the belly before the lower part can be reduced. During
these manipulations the pelvis should be slightly raised. In femoral
hernia the thigh should be flexed and rotated a little inward in order to
relax the fascia lata which forms the external femoral or saphenous open-
ing. The pressure exerted during taxis should be gentle and steady.
The site of the hernia causes a variation of the direction in which the
pressure should be exerted, for it is easily understood that the gut must
follow the same route in reduction as it took in protrusion, though in the
opposite direction. Hence the line of pressure proper in an inguinal hermia
is not suitable for the reduction of an umbilical or femoral hernia. In the
discussion of Special Hermias the direction in which taxis should be em-
ployed in each variety will be given.
When strangulation is relieved and the hernia slips back into the abdo-
men, a peculiar croak is heard if there be gut in the tumor. If the re.
duction is not readily effected by such gentle taxis, the surgeon, mus
desist, since force or too long employment of taxis may cause bruising ºf
the intestine, and sometimes actual rupture. Two minutes is probably
H E R N IA . 621
long enough to continue the efforts in a small, tight femoral hernia, and
about five minutes in other hernias, whether femoral, inguinal, or um-
bilical.
Taxis is more successful in relieving strangulation of recent hernias
than of old hernias. It is also more effective in inguinal than in femoral
hernias. Anaesthetics should always be resorted to after the first efforts
at taxis have been ineffectual. It is usually best to gain the consent of
the patient to operation before administering the anaesthetic so that the
surgeon may proceed at once to radical measures if taxis under anaes-
thesia proves unavailing. If any other surgeon has previously made
protracted efforts to relieve the strangulation by taxis, or the hernial
tumor is tender and inflamed, it is unwise to make repeated efforts at
reduction. When fecal vomiting has existed for some time and hiccough
has occurred, and especially so in femoral hernia, it is not wise to make
efforts at taxis. The danger in these cases lies in the fact that injurious
pressure may be made upon an already inflamed and gangrenous intes-
time, which will be followed by rupture of the gut or fatal peritoneal in-
flammation. Operation is in such cases to be undertaken without running
the risk of causing damage by taxis.
The operation for relief of strangulation of a hernia is called herniotomy,
or kelotomy.
Hermiotomy or Kelotomy.
Herniotomy is undertaken for the purpose of liberating the constricted
bowel or omentum, so that the protruded structures may be returned to
the abdominal cavity. If the protruded organs are gangrenous, so that
their return would be followed by serious consequences, their excision, the
establishment of an artificial anus, or the resection of intestine, with or
without immediate suturing, is accomplished.
The incision in hermiotomy is made in the long axis of the tumor, and
the coverings of the hernia down to the sac are carefully divided in
the same direction, or are torn apart by means of the fingers, forceps, or
the handle of a scalpel. By this procedure the hernial sac is exposed.
Care must be taken that the sac is identified, because if it is opened un-
wittingly, the intestinal wall may be mistaken for the sac and incised.
Characteristics of the sac are its tense, smooth appearance, and the
longitudinal direction in which its vessels run. The blood vessels of the
intestines run around the gut in a direction transverse to its long axis.
Often the sac may be picked up from the contents of the hernia in such
a way that the bowel may be felt to slip away from between the fingers
holding the sac. In some instances in which the sac is distended with
fluid, the sac wall is so thin that the coils of intestine or omentum may
be distinctly recognized within. The sac usually does not feel as thick as
the intestine, when pinched between the fingers.
Under certain circumstances, it is wise to divide the stricture without
opening the sac, because opening the sac is to expose the intestine to con-
tact with air, and to invade the general peritoneal cavity, which, of course,
is in direct connection with the cavity of the sac. This method of reliev-
ing a strangulated hernia is called the lesser operation for hernia, or the
method of Petit. In it the neck of the sac, which has just been exposed
by the incision, is thoroughly separated from its surroundings, and the
Surgeon's finger-nail carefully insinuated under the edge of the constrict-
ing band. This is then divided with a blunt-pointed bistoury, or hernia
622 D IS E A SES OF T H E A B D O M E N A N D P E L V 1 S.
knife. Sometimes the finger's tip can be insinuated under the band which
strangulates, and the constriction relieved by stretching or tearing the tense
tissues. If a knife is used, two or three small notches are better than one
deep one, since there is then less danger of wounding the surrounding
structures. Gentle efforts at taxis will then reduce the hernia, after which
the edges of the hernial ring are stitched together, and an ordinary gauze
dressing applied.
Herniotomy, without opening the sac, should not be performed when
there is danger of the gut being in bad condition because of the length of
time that strangulation has existed, nor when the hernia is known to have
been previously irreducible. It is very evident that in cases where rup-
ture of the gut from forcible taxis is suspected, that it is necessary to open
the Sac in order that the exact condition of affairs may be ascertained In
other cases it becomes necessary to open the sac because attempts to relieve
the strangulation without laying open the sac have been abortive.
When, therefore, it becomes necessary to open the sac, either because
the strangulation cannot be relieved otherwise, or because the suspected
condition of the hermia makes a full investigation imperative, the sac is
picked up at one point with a forceps, and its wall punctured by means of
a knife held horizontally. The small opening thus made is enlarged until
the whole interior of the sac is exposed to examination. It is often possi-
ble to tear through the thin sac with the finger-mail. This is safer than
using a knife. Ordinarily, however, there is not much danger of injury
to the gut, because in many cases there is fluid to fill the space between
the intestine and the sac wall. Occasionally, however, the gut lies in im-
mediate contact with the sac wall; then considerable care is necessary to
avoid injuring it.
If the fluid within the sac is simply yellow serum, the condition of the
contents of the sac may be considered good. The escape of bloody or
turbid fluid, however, and especially if it exhales a fecal odor, is indicative
of inflammatory and gangrenous intestine or omentum. The stricture is
next sought for with the finger, and at the same time any adhesions be-
tween the intestine and omentum, or between these structures and the sac,
are broken down. The finger-naikis then slipped under the strangulating
band, and the blunt-pointed bistoury or hernia knife carried along the
pulp of the finger until it lies beneath the constriction. The knife should
be pushed under the band lying flat upon the finger. After it has been
put in proper position, the edge is turned against the tight band and used
so as to make two or three shallow nicks, which are better than a single
deep one. After division of the stricture, taxis is undertaken.
FIG. 389.
W. W - \ \ W w tº: º::===== ºff/ f | º º: º:
G = ºrºstas º #
# § É *23%. 22g.º. *-º-s º ~ §§ §§ § sº
&
Lewis’s notched hernia, director.
If sufficient division of the stricture has not been performed, as indi-
cated by the impossibility of reduction, the strangulated band should be
divided or torm a little more. In those cases in which the strangulation
is too tight to permit the entrance of the tip of the finger, a hernia
director should be carefully inserted under the tense band. One of the
best forms is the Levis notched hernia director, which catches the strangu-




































HERN IA. 623
lating band in a notch and holds aside the intestines, so that their injury
with the knife is almost impossible.
If the intestine is found to be gangrenous, the constricting band should
be notched, and nothing more done; since breaking up the adhesions is
to permit access to the general abdominal cavity of the fetid fluid con-
tents of the hermial Sac. After the constriction has thus been relieved an
incision should be made into the calibre of the gangrenous intestine, to
ermit the escape of feces. An artificial anus or fecal fistula will then be
established at the site of the operation. This may be treated by operation
some weeks later, when the patient has recovered from the immediate re-
sults of the strangulation.
In some cases of omental hernia, a small knuckle of gut is wrapped up
or covered by the omentum. This should be sought for before the omental
hernia is returned, since the whole mass may be returned with the hidden
intestine still strangulated.
In many cases of operation for strangulated hernia it is difficult to de-
cide whether the intestine is in condition to be returned. The question is
easy enough of determination in cases where actual gangrene has occurred,
and in instances where there is not a great deal of inflammation ; but
there are many border-line cases which require serious consideration. If
the fluid in the sac is serous, and the intestine, though congested, still has
a shiny surface, it is proper to return it. If its walls are ashy-gray in
color, and show no evidence of elasticity, it is equally clear that gangrene
has taken place, that the mass should not be returned, and that an artificial
anus should be established. If the intestine is extensively diseased, resec-
tion of the gangrenous portion should be performed. In such an event
the open ends of the bowel should be stitched to the external wound, in
order that the fecal contents may escape upon the surface of the body.
If the gut is purplish in color, shows ecchymotic spots, and is covered with
Sticky lymph, it is not always clear whether it should be returned. If a
large coil presents this condition, it may be left in the hernial sac after
the strangulation has been relieved, so that in the event of sloughing the
extravasated feces and the contaminating fluids from the diseased struc-
tures may be kept outside of the abdominal cavity. Where a very small
knuckle presents these characteristics, the surgeon may sometimes, with
wisdom, push the knuckle just' inside the ring, where it will probably
become adherent to the belly wall. If sloughing then occurs and gives
rise to perforation, the feces will have an opportunity to escape into the
sac, which has been left open, without invading the general peritoneal
cavity.
If by accident the intestine has become opened during the division of
the coverings, the wound should be brought together by Lembert's sutures,
as described in Wounds of the Intestines. Subsequently it, should be
returned to the abdomen as if no such accident had occurred. If the
protruded omentum is small in amount, and not gangrenous, it should be
Teturned. If, however, a large omental mass is present, or if an omental
hernia of any size is thickened or inflamed, a ligature should be cast
around it near the neck of the sac, the part outside of the ligature
gut off, and the stump pushed back into the abdomen. A silk ligature
is best and should include the entire mass in a single stump. The effort
to tie individual omental vessels is injudicious.
. The last step in herniotomy is the treatment of the sac. If the patient
is Weak, or if complications arise from the condition of the gut, or from
Peritoneal inflammation, the sac should be let alone and the external
624 D IS E A SES OF TEI E A B D O M E N A N D PEL WIS .
wound closed with sutures or left open as previously described. If, how.
ever, these complications do not exist, the sac should be dissected away
from the surrounding coverings, its neck ligated, and the body of the
sac excised. This procedure is an attempt to produce a radical cure
of the hernia, as by obliteration of the sac a recurrence of the protrusion
may be prevented. In inguinal hernia the columns of the ring may
then be sewed together with silk. In femoral hernia such drawing
together of the margins of the ring is probably impossible. In umbilical
hernia the sac should be cut away and the edges of the ring freshened
and drawn together with sutures.
The after-treatment of cases of hernia is identical with that of other
abdominal operations. Some pressure, however, should be made upon
the wound by the dressing in order to prevent recurrence of the hermial
protrusion.
The symptoms of strangulation usually disappear immediately after
the reduction of the gut, whether it has been accomplished with or with-
out operation.
A persistence of vomiting due to the anaesthetic may seem to indicate
that the hernia has not been relieved. This vomiting, however, soon
stops; it has not the gushing character of vomiting from strangulation,
and is more apt to be accompanied with retching. Temporary paralysis
of the muscular coat of the gut by interfering with peristalsis may simu-
late a condition of strangulation, while the presence of another unsus-
pected hernia which is strangulated may, of course, give rise to a continu-
ation of the dangerous symptoms. Sometimes a hernia which is believed
to have been reduced has simply been pushed backward in mass and lies
between the transversalis fascia and peritoneum. In such instances the
strangulation persists, although the tumor has disappeared from the origi-
nal site, and of course the symptoms continue. Gangrene of the gut
occurring after reduction may cause perforation and peritomitis. In rare
instances the intestine may become strangulated within the abdomen as a
result of inflammation in the neighborhood of the hernia. Acute enter-
itis and peritonitis, moreover, may give rise to alarming symptoms. In
all such cases, if within a reasonable time, the cause of the complication
is not evident, laparotomy in the median line should be performed.
It is impossible to insist too strongly upon the necessity for early inter-
ference in cases of strangulated hernia. Nearly all cases will promptly
recover if strangulation is quickly relieved, while nearly all will terminate
fatally if this is not effected. It is the continuation of efforts at taxis
and the postponement of operation that causes the fatality in patients the
subjects of this dangerous surgical disorder.
SPECIAL HERNIAs.
The most common sites of hernia are the inguinal canal, the femoral
canal, and the umbilicus; hence, inguinal, femoral, and umbilical hernias
must receive special consideration.
Inguinal Hernia.
ANATOMY.—In inguinal hernia the intestine or omentum is protruded
from the abdomen through the inguinal or spermatic canal. In some
S P E CIA. L H E R N IA S. 625
cases the hermia traverses the entire length of the canal, whereas in other
cases it comes through the abdominal wall directly behind the external
opening; which is called, anatomically, the external inguinal or spermatic
ring. In the former case the hernia is called an oblique inguinal hernia, in
the latter case a direct inguinal hernia. In the first variety the neck of
the hermial protrusion lies external to the deep epigastric artery, but in the
second variety it is internal to that vessel. In oblique hernia, then, the
intestine leaves the abdominal cavity at the internal inguinal, or sper-
matic, or abdominal ring, follows the canal through the abdominal wall
and escapes at its lower opening, called the external inguinal, or spermatic,
or abdominal, ring. Here it appears as a tumor lying outside of the
aponeurosis of the external oblique muscle, just above the body of the
pubic bone. If the protrusion is not large enough to follow the course
of the entire canal and make its exit at the external ring, the hernia
is called “incomplete,” because the viscera have not completely followed
the canal, but lie within it. If the hernia escapes from the external
ring it is a “complete ’’ one. As the complete hernia increases in size
the intestine descends into the scrotum or vulva, and it is then denomi-
nated a “scrotal " or “labial” hernia. An incomplete hernia is often
termed a bubonocele. s
The coverings of a complete oblique inguinal hernia are skin, superficial
fascia, inter-columnar fascia, cremasteric fascia, funnel-shaped process of
the transversalis fascia (infundibuliform fascia), subperitoneal fat, and
peritoneum (sac). In the female there is no cremaster fascia, and hence
this covering is wanting. In incomplete oblique inguinal hernia, instead
of the inter-columnar fascia, there is a covering formed by the aponeu-
rosis of the external oblique muscle, and instead of the cremasteric fascia
the lower fibres of the internal oblique and transversalis muscles make a
covering. In this instance there is no difference between the male and
the female. The pupil must remember that the words “abdominal,”
“inguinal,” and “spermatic” are indiscriminately used to describe the
canal and its inner and outer orifices. The different adjectives mean the
Same thing.
The stricture in strangulated oblique inguinal hernia occurs at either
the internal or external ring, or in the canal.
FIG. 390. FIG. 391. FIG. 392.
Diagram of “ congenital Diagram of “acquired Diagram of “acquired com-
hernia.” (BRY ANT.) hernia.” (BRY ANt.) genital hernia,” or the “em-
cysted hernia of Cooper.”
(BRYANT.)
There are several varieties of oblique inguinal hernia. In the acquired
form the peritoneal sac is pushed down through the inguinal canal and
"to the scrotum, so that the hernia usually lies above, or in front of and
above, the testicle or cord.

40
626 DIS E A SES OF T H E A BID O M E N A N D P E L VIS .
In congenital inguinal hernia the intestine descends into the scrotum
along the unobliterated funicular process of the peritoneum which
makes the foetal canal between the vaginal tunic of the testicle and the
abdomen. In these instances the protruded gut lies within the vaginal
tunic and comes in direct contact with the testicle. There is no true
hernial sac.
In another form the hernial sac may be pushed down behind the
unobliterated funicular process, and give rise to what has been termed
infantile inguinal hernia. Varieties of inguinal hernia occur in which
the relations of the sac and the funicular process vary from the most fre-
quent varieties just given.
Direct inguinal hermia is a protrusion through the abdominal wall be-
hind the external inguinal ring. In this variety the gut does not enter
the canal at all, but after piercing the wall escapes through the external
ring. Sometimes, however, it bursts through the belly wall a little out-
side of the external ring, and then does enter the lower part of the canal
before emerging at the ring. The neck of the Sac in both varieties of
direct hernia is internal to the deep epigastric artery.
FIG. 393. t FIG. 394.
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Oblique inguinal hernia. (BRYANT.) Direct inguinal hermia. (BRYANT.)
The protruding intestine in direct hernia may push the conjoined tendon
in front of it, may go through an opening in the tendon, or may pass
under its lower border. The coverings of direct inguinal hernia are skin,
superficial fascia, inter-columnar fascia, conjoined tendon, transversalis
fascia, subperitoneal fat, and peritoneum (sac). It is evident that a
covering from the conjoined tendon will not be present if the hernia, in-
stead of stretching and pushing forward this tendon, perforates it or goes
under its lower border. The strangulation of a direct inguinal hernia
occurs at the external ring, or at the opening in the conjoined tendon.
DIAGNOSIS.–The differential diagnosis between oblique and direct
hemia is often difficult, because when oblique hernia attains considerable
size, or has existed for a long time, the internal ring is by the weight of
the tumor dragged down until it is directly behind the external open.
ing. The neck of the sac, therefore, lies immediately over the body of
the pubes, and seems to be at the externalinguinal ring. It is under.
stood, of course, that a direct hernia may descend into the scrotum 9"
labium exactly as does an oblique hernia.


















S P E CIA L H E R N IA S. 627
Inguinal hernias present the general signs and symptoms of all hermial
tumors. The neck of the sac in old oblique hernias, and in recent direct
ones, as has just been stated, is over the body of the pubes and internal to
the spine of the pubes. In recent oblique hernias the inguinal canal is
filled up with a protrusion which can be seen and felt, occupying an
oblique position, above Poupart's ligament. The tumor is reducible at
first, if subjected to moderate pressure applied upward and outward.
An incomplete oblique hernia might be mistaken for a femoral hernia
which has curled up over Poupart's ligameut, but is differentiated by the
fact that a femoral hernia has its neck below Poupart's ligament. More-
over, a femoral hernia to turn up so as to overlie Poupart's ligament must
be large, and is reduced by pressure applied at first downward and back-
ward, and then a little upward. The inguinal canal in femoral hernia
is unoccupied by a mass, while in oblique inguinal hernia, even when in-
complete, the mass seems to fill up or to occupy at least part of the
canal.
Chronically enlarged lymphatic glands may resemble inguinal hernia,
but here the tumor is apt to show the characteristic signs of enlarged
or inflamed glands, and the inguinal canal is unoccupied by any swelling.
The characteristic impulse of hernia is also absent.
An encysted hydrocele of the spermatic cord occupies a position similar
to inguinal hernia. It is, however, tense, oval, and well-defined in out-
line, and without impulse. A cyst of the canal of Nuck in the female
presents similar characteristics An encysted hydrocele of the spermatic
cord can usually be pushed up into the belly.
An undescended testicle may be discriminated from an inguinal hernia
by absence of impulse on coughing, and by the facts that the tumor is
not reducible, that pressure produces the peculiar sickening testicular
pain, and that the testicle on the corresponding side is absent from the
scrotum. An inflamed, undescended testicle may give rise to vomiting
which will suggest strangulated hernia. The vomiting, however, is not
gushing, as is that which occurs as a symptom of strangulated hernia. In
doubtful cases an exploratory incision is justifiable.
A scrotal hernia may be confounded with hydrocele, orchitis, solid
tumor of the testicle, and varicocele. Hydrocele of the vaginal tunic is
often translucent, and is a tense, semifluctuating tumor without impulse.
Its rounded upper margin is generally very distinctly felt when the sur-
geon's fingers are placed upon the upper part of the cord and the tumor
is pushed up against these fingers by pressure exerted with the other
hand. This well-defined upper limit is very different from the gradual
extinction of the upper portion of a hernia as it blends with or is lost in
the belly wall,
It must not be forgotten, however, that in hydrocele of infants the
fluid can sometimes be pushed back into the abdomen so as to simulate
hºrnia. There is, fortunately, no such croaking sound accompanying the
disappearance of the tumor as is frequently heard in reducible hernia.
Unfortunately for diagnostic purposes the hernia of children is sometimes
translucent, and thus resembles hydrocele.
In orchitis the tumor is heavy, showing signs of inflammation, and is
more or less ovoidal and hard. The swelling does not extend up into
the inguinal canal.
Varicocele disappears when the patient lies down, is increased by pres-
*ē made upon the external inguinal ring, gives the sensation of a
628 D IS E A SES OF T H E A BID O M E N AN ID P E L VIS .
bag of worms under the skin, and coughing conveys to the finger a thrill
rather than an impulse. Reducible hermia is, after reduction, prevented
from recurring by pressure at the ex-
FIG. 395. ternal abdominal ring, and therein
differs from varicocele.
TREATMENT.-The treatment of in-
guinal hernia is identical with the
treatment described for hernia in gen-
eral. The incision should be made
directly upward in order to avoid the
epigastric artery, which will be upon
the inner or outer side of the neck
according as the hernia is oblique or
direct. As it is often difficult to decide
which variety of inguinal hernia exists,
the position of the epigastric artery is
uncertain, hence incision directly up-
ward is safest. If an undescended tes-
ticle lies in the groin and is a compli-
Irreducible inguimal hernia showing cation of strangulated hernia, it may
concave moulded pad, which is already be necessary to excise the testicle at
applied on right side. (BRYANT.) the time herniotomy is done. Indeed,
such excision may be demanded in the
treatment of reducible hernia accompanied by undescended testicle, in
order to make it possible for the patient to endure the pressure of a
truss in this region.
P'emoral Hermia.
ANATOMY AND PATHOLOGY.—Femoral hernia is never congenital, and
occurs in women more often than in men. The protruding viscera escape
from the abdomen into the sheath of the femoral vessels. Usually the
exit is made internally to the femoral vein through what is called the
internal femoral ring. The descending intestine then follows the femoral
canal and comes out upon the thigh at the saphenous opening, also called
external femoral ring. If the tumor increases it turns up over the falci-
form process of the fascia lata and lies just below or may even overlap Pou-
part's ligament. In the latter case the tumor lies beneath the integument
upon the aponeurosis of the external oblique muscle of the abdomen, but
the neck of the sac is at the internal femoral ring. This ring or opening
is situated below Poupart's ligament above the horizontal ramus of the
pubic bone, where this bone is covered by the pectineus muscle. Toward
the middle line the ring is bounded by the sharp edge of Gimbernat's
ligament, while on the outer side it is separated from the common femoral
vein by a thin, fibrous partition within the sheath of the femoral vessels.
Sometimes the hernia lies in the femoral canal and does not escape at the
external femoral ring or saphenous opening. It is then an incomplete
femoral hernia.
There are no structures of importance on the inner and upper sides of
the neck of the hermial sac.
When the obturator artery, as an anomaly, takes its origin from the
deep epigastric artery, it occasionally curves around the inner side of the
neck of the sac. It is then in danger of being wounded in the operation.
of herniotomy, when the stricture at the neck of the sac is divided.

S P E CIA. L H E R N IA S. 629
The coverings of a complete femoral hernia are skin, superficial fascia,
cribriform fascia, anterior layer of the sheath of the femoral vessels, femoral
septum, subparietal fat, and peritoneum
(sac). These coverings are often thinned FIG. 396.
so that the hernia seems to be almost *
directly under the skin. In other cases,
however, the coverings are thickened. If
the hernia is incomplete the fascia lata
becomes a covering in place of the cribri-
form fascia. When strangulation occurs
in femoral hernia the stricture is either
at the Saphenous opening, at Gimber-
nat's ligament, or at the neck of the sac.
. §, ...#
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º § % º ſº ſº % ź
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DIAGNOSIS.—Femoral hernia presents \ ºn |
the ordinary symptoms of hernia. The e
tumor is usually small, tense, globular Femoral hernia. (BRY ANT.)
or ovoidal in shape, and situated below
Poupart's ligament, with its long diameter transverse or oblique. The
neck of the sac is felt to be external to the pubic spine, which distin-
guishes it from inguinal hernia, in which the neck of the sac is internal
to the pubic spine. Occasionally a femoral hernia may be as large as
a fist, and in such cases, as has been described, it turns upward and
overlaps Poupart's ligament in a way which causes it to resemble an
inguinal hernia. The essential point in the diagnosis of these large
femoral hernias from inguinal hernias is the position of the neck of the
hernia relative to the spine of the pubes. The neck is outside of the
spine in femoral hernia. A femoral hernia never attains the immense
size that is possible in inguinal hernia.
A group of enlarged lymphatic glands about the saphenous opening
may resemble a femoral hernia. If a small femoral hernia is overlaid
by enlarged glands the hernia may escape notice even when symptoms
of strangulation are present. Suspicious symptoms occurring in such a
Case should cause an exploratory operation to be instituted.
A psoas abscess pointing in the groin gives rise to a swelling near to
the site of femoral hernia. In such cases the tumefaction is usually out-
side of the femoral vessel instead of inside, as in hernia. There is some
fulness in the iliac fossa, the tumor shows some fluctuation, and there is
often evidence of tubercular disease in the spinal column.
Varicosity of the saphenous vein may give rise to a small tumor in the
neighborhood of the saphenous opening. It presents the characteristic
tortuosity of varicose veins, and will probably be associated with a vari-
Cose condition down the inner side of the thigh.
TREATMENT-Reducible femoral hernias should be reduced and the
recurrence of protrusion prevented by wearing a truss.
Operations for a radical cure are not likely to be successful, because the
internal femoral ring has rigid borders not readily sutured with satisfac-
toy results. In strangulated femoral hernia taxis should be undertaken
With the thigh slightly flexed upon the pelvis, adducted, and rotated
ºward, in order to relax the falciform edge of the saphenous opening.
If the tumor is large pressure should be directed downward before the
hernia is pushed upward and backward. As in all hernias, lifting up the
"mor so as to draw a little more intestine out through the ring is often a
8000 preliminary manipulation. In reducing the hernia it must be recol-







630 D IS E A S E S OF T H E A B D O MEN A N D P E L V [.S.
lected that the portion of the gut which has protruded last must be
pushed into the abdomen first.
Etherization, opium, and hot baths are not very efficacious in aiding
the reduction of strangutated femoral hernia; hence, early operation is
demanded in cases that do not yield to moderate taxis. The incision
should be a vertical one. The skin over the hernia is usually pinched
up in a fold and laid open by transfixion, because the thinness of the
coverings renders an incision made by puncture from the exterior a little
dangerous. The point of strangulation is discovered by the tip of the
finger after opening the sac. It is usually necessary to open the sac in
operations for strangulated femoral hernia, since relief of the strangula-
tion without opening the sac is not often possible in femoral herniotomy.
The strangulating band should be divided by incision inward and upward.
Several shallow notches are better than one deep one, since there is less
possibility of injuring an abnormal obturator artery, which might be
present, curving round the neck of the sac or along the edge of Gimber-
mat's ligament. The occasional abnormal course of this artery renders
the use of a quite dull hernia knife judicious at this stage of the opera-
tion, since the arterial wall is less liable to be injured with a dull knife
than with a sharp one. The dense fibrous tissue causing the stricture is
readily sawed through with a dull edge. Sometimes the surgeon can
feel the artery beating as he pushes the tip of his finger against the edge of
Gimbernat's ligament. Under such circumstances incision of or notching
Gimbernat's ligament close to the pubic bone is less liable to do damage
than the ordinary cut upward and inward. It is said that incision
directly inward is not so satisfactory as one directly inward and upward,
since it is apt to make a larger wound, and causes difficulty in restraining
the hernia afterward by means of a truss.
Umbilical Hernia.
A hernia occurring at the navel is termed an umbilical hernia. It
occurs in infants through the umbilical ring, and in adults either close to
or at the opening. This form of hernia is most frequent in infants and
in old, corpulent women. The hernial sac is thin and often full of holes.
The contents of the sac are omentum with perhaps some coils of intestines
wrapped up in it. The coverings of an umbilical hernia are skin, super-
ficial fascia, transversalis fascia, and peritoneum (sac). Very often these
coverings are so thin that there is scarcely anything outside of the hernia
but the skin and the peritoneum. In adults this hernia may become very
large and it is frequently more or less irreducible. Obstruction is not
uncommon; strangulation is comparatively rare. In infants the condi-
tion is often cured spontaneously. Nevertheless it is wise to keep the
hernia reduced by placing over the umbilicus a pad held in place by
means of adhesive plaster or bandage. A large coin or a piece of coºk
wrapped up in an adhesive plaster with the adhesive side out may be
applied with great satisfaction. The adhesive surface of the plaster keeps
the coin from slipping, and a broad strip of adhesive plaster carried over
the whole with the ends fixed at the back makes a convenient dressing:
The plano-convex disk of yellow wax used by seamstresses for Waxing
thread makes a good pad and the wax adheres well to the child's skin.
In adults an umbilical truss or an elastic bandage should be applied. .
If strangulation occurs an incision for the relief of the stricture is
SPEC I A L H E R N IA S. 631
demanded. The external wound may be made over the top of the tumor,
or at one side close to the neck of the sac. From the latter position the
surgeon can often work under the growth and relieve the stricture with
very little disturbance. It does not make very much difference in what
direction the constricting band is divided, as there are no structures of
importance, around the umbilical aperture. An upward incision, how-
ever, is probably the most desirable. Division of the band may be made
in some cases without opening the Sac.
If it is necessary to open the sac great care should be taken, because
the coverings are so thin that the intestine may be suddenly and unex-
pectedly wounded. The protruding omentum should be ligated and
excised, after which the stump should be returned. Any portion of intes-
time hidden from view by thickened omentum should be carefully searched
for, since the strangulation of gut may be unrelieved unless the intestine
is fully inspected. After the strangulation has been overcome and the
sac excised, the edges of the ring should be freshened and sutured with
silk sutures.
In large umbilical hernias and in those giving trouble because of their
irreducibility or tendency to become obstructed, radical operation is jus-
tifiable. This is scarcely judicious in small umbilical hernias, which are
easily controlled by trusses.
C H A P T E R X. XII.
DISEASES OF THE RECTUM.
PATHOLOGY..—Certain congenital malformations of the anus and rectum
require operative treatment. These congenital deformities are ordinarily
discovered soon after the birth of the child, by the absence of intestinal
discharge and by the occurrence of vomiting. The anus may be entirely
occluded, or it may be represented by a minute orifice through which the
meconium and feces are not effectually expelled. In other cases the amus
may be entirely absent, and the skin between the buttocks not even
dimpled in the anal region. The partition between the surface and the
end of the rectal pouch varies in such cases from a quarter of an inch to
an inch in thickness. If the occluding tissue is thin it may bulge down
when the child cries, and transmit to the eye the dark color of the meco-
nium on the other side; thereby indicating that it is of no considerable
thickness.
In some cases the anus is perfectly formed, and it is only by the intro-
duction of a probe, or the finger, that the nurse or the surgeon discovers
that the exterior orifice has no connection with the rectum above. In
still other instances, the whole rectum may be absent, and the large bowel
terminate in a blind pouch at the top of the sacrum, or at a still higher
point. In these cases the anus is usually imperforate, that is, absent.
Clinically, it may be impossible to tell a case of simple imperforate, or
absent, anus from a case of imperforate anus complicated or associated
with imperforate rectum. It is readily seen that if the anus is absent the
surgeon has no means of discovering whether the rectum is present or
absent, unless examination of the external surface of the abdomen gives
indications of a swelling due to retention of the intestinal contents in a
colon which has no lower outlet.
TREATMENT.-The operative treatment in these cases consists in dis-
secting from the perineum toward the rectum, with a view of establishing
an outlet for the meconium and feces. If only a thin diaphragm causes
the obstruction, a crucial incision liberates the retained contents and con-
verts the deformity into a normal condition. Operation under such cir-
cumstances is unattended with shock, and the functions are soon normally
performed. If a comparatively deep dissection is required to find the
lower end of the bowel, the operation is a serious one and may terminate
fatally from shock. Under such circumstances, a straight incision is
made from behind the scrotum to the point of the coccyx, and gradually
deepened backward and upward, following the line of the coccygeal curve.
Caution is required to avoid injuring the bladder. Excision of the coccyx
has been advocated in order to gain room for such operative manipular
tion when the lower end of the rectum is situated at a high point.
Some authorities advise that when the bowel is found, an attempt should
be made to draw it down and to stitch its wall to the skin. This can
seldom be accomplished if the distance is great; and as it is a somewhat
dangerous operative procedure under such circumstances, it is probably
IN F L A M M ATION OF T H E R E CTU M. 633
best not to attempt it. If a dissection extending from an inch to an inch
and one-half upward does not enable the operator to find the rectum, iliac
colotomy on the left side of the abdomen is the proper operation. If it is
uncertain whether the descending colon is properly developed, colotomy
above the right groin is to be done.
The rectum or colon occasionally opens into the bladder, urethra, or the
vagina, or upon the surface of the body, at some distance from the anal
region. In such congenital deformities an attempt should be made to
open the normal route to the intestines from the anal region; when this
has been done successfully the abnormal opening will close spontaneously,
or may be occluded by plastic operation. If it is impossible to construct
a canal from the anus to the bowel when the rectum opens into the bladder,
it is proper to make a perineal incision into the posterior urethra, in
order to permit free escape of the intestinal contents. If the rectum
opens into the vagina by a large orifice, operation may be deferred until
the child is two or three years old.
After constructing new openings for the escape of feces, in cases of con-
genital malformation of the anus and rectum, the surgeon must use rectal
bougies, or have the mother insert her finger, daily, in order to prevent
cicatricial stricture.
PRURITUS OF THE ANUs.
PATHOLOGY AND SYMPTOMS.–Pruritus, or itching, of the anus is usu-
ally most troublesome at night. It may be due to lice, to the vegetable
parasite causing eczema marginatum, to thread-worms, to a papular erup-
tion about the anus, or it may be secondary to uterine disease. In some
cases the gouty diathesis is probably a predisposing cause. The symp-
toms are violent itching, making it often impossible for the patient to
abstain from scratching, while locally there is little or no cause for the
troublesome affection, except perhaps a little redness of the skin. In old
gases there may be enlargement of the cutaneous folds at the anal open-
ing, and the skin is thickened and discolored by prolonged inflammation,
due to scratching. Hemorrhoidal tumors may be associated with anal
pruritus. -
TREATMENT.-Anal pruritus is to be treated by removing the cause,
and by keeping the bowels open, and the parts well washed. It is impor-
tant that after washing, the skin should be thoroughly dried by a soft
towel or absorbent cotton without rubbing the skin, since the least rubbing
may start an attack of itching, which will be followed by scratching.
Carbolic acid is probably the best application to relieve the intense itch-
ing. It may be used in a lotion containing from 10 to 20 grains of car-
bºlic acid to the ounce of water, with which a little glycerin is mixed.
About 5 grains of fused potassa may at times be added to the ounce of
liquid with advantage. Tar ointment and sulphur ointment are also
Valuable. Arsenic given internally seems at times serviceable. If the
disease is manifestly due to a gouty tendency, colchicum, a properly regu-
lated diet, and exercise are important adjuvants. Relief has sometimes
been obtained by introducing a conical bougie into the rectum.
INFLAMMATION OF THE RECTUM.
b The normal pouches of the mucous membrane of the rectum sometimes
°ome enlarged and distended, owing to protracted retention of the feces.
634 D IS E A S E S OF T H E R E C T U M .
This condition causes pain and itching in the rectal region. There is in
this disease, however, no spasm of the sphincter, such as occurs in anal
fissure. *
The treatment consists in drawing down the enlarged pouches with a
blunt hook and clipping off the folds of mucous membrane, so that the
fecal matter cannot be retained.
Inflammation of the mucous membrane of the rectum is called proc-
titis, and is a medical rather than a surgical condition, unless ulceration
occurs. It may be due to gonorrhoea, to the use of the leaves of the
poison ivy for cleansing the amus after defecation, and to foreign bodies
inserted into the rectum. The symptoms are somewhat similar to dysen-
tery. Tenesmus, rectal pain, and the discharge of bloody mucus, or of
pus, are indicative of proctitis.
The treatment consists in removing the cause, and in the use of mild
astringent injections, such as nitrate of silver (2 or 3 grs. to the ounce of
water), or sulphate of zinc (5 grs. to the ounce), or in the introduction
of suppositories of an anodyne and astringent composition.
FOREIGN BODIES IN THE RECTUM.
Indigestible articles which have been swallowed may become impacted
in the rectum, because their exit is prevented by the sphincter muscle.
On the other hand, foreign bodies may be pushed into the rectum through
the sphincter by the individual himself, as a curious sort of masturbation,
or by others during the patient's unconsciousness from alcohol. Articles
of extraordinary size, such as turnips, bottles, and earthen jars have thus
been put in the rectum. Chronic inflammation of the rectum may be
set up by foreign bodies, and, at times, simulate malignant disease of the
part. Such foreign materials are to be removed by means of forceps, or
the fingers, after etherization of the patient and dilatation of the sphinc-
ter muscle. In some cases, where the foreign body is large, it has been
necessary to deliver it with obstetric forceps. Incision of the sphincter
muscle is justifiable if sufficient dilatation to permit extraction is impos-
sible. -
IMPACTED FECEs.
Dilatation of the rectum is not unusual in old persons; and in this
pouch-like dilatation fecal masses may remain and become compressed
into a large, hard mass, which it is impossible for the muscular wall of
the stretched rectum to expel through the anus. The irritation from the
retained fecal masses may give rise to a mucous discharge which, becom-
ing stained with fecal matter, causes the patient to think that he is suffer-
ing from diarrhoea.
The diagnosis of impacted feces can only be made with certainty by
examination with the finger introduced through the anus. $
The symptoms are pain, tenesmus, and chronic constipation; this last
symptom, however, is concealed in cases where the diarrhoea-like discharge,
spoken of above, occurs. Laxatives and cathartics can be of no Serylº
in cases of impacted feces, because the condition is mechanical and it is
impossible for the large mass to be extruded through the normal orifice:
therefore, it must be broken up by means of instruments introduced
through the anus. The handle of a spoon, or a pair of forceps, by which
the mass may be perforated and disintegrated, is an efficient aid to the
P R O L A P S E O F T H E R ECT U M . 635
surgeon's fingers. Repeated and copious injections of warm water and
oil into the bowel will aid in softening and removing the mass thus broken
into pieces.
PROLAPSE OF THE RECTUM.
PATHOLOGY AND SYMPTOMS.–By prolapse of the rectum is meant pro-
trusion of more or less of that portion of the intestine in a healthy condi-
tion, and not the mere pushing out of the mucous membrane, which
occasionally occurs in connection with hemorrhoids. The mucous mem-
brane of the rectum is loosely attached to the muscular coat, and there-
fore an inch or two of the mucous membrane may project through the
amus without any change of location of the rest of the bowel. This pro-
lapse of the mucous membrane alone is called partial prolapse of the
rectum; whereas the term complete prolapse is applied when the rectum
is turned inside out, as it were, by a process of invagination, and all the
coats form the external tumor.
Partial prolapse is, of necessity, limited in extent, because the amount
of sliding between the coats is not indefinite. In complete prolapse, how-
ever, almost any length of the intestinal tube may be found external to
the anus. The disease is most common in children and in aged persons,
and is due to a weakened condition of all the tissues, although the ex-
citing cause is straining. Stone in the bladder, urethral stricture, phi-
mosis, dysentery, chronic constipation, and polypus in the rectum may
be causes, because of the abdominal straining and bearing-down which
they induce. '
The diagnosis is very clear when complete prolapse of the rectum
occurs. The smooth folds of the mucous membrane on the outside of
the sausage-like tumor are characteristic. There is a groove around the
mass at the site of the sphincter muscle.
Partial prolapse presents some resemblance to a mass of internal hem-
orrhoids, but has not the bunched appearance that is exhibited by the
purplish piles and the prolapsed mucous membrane accompanying them.
Rectal polypus, when protruding from the anus, is harder than prolapsed
intestine, and has a distinct pedicle.
The prolapsed tissues at first appear outside the anus only after stool,
but repetition of the protrusion occurs, and finally the disease may be-
Come so aggravated that the intestine is protruded outside of the body
Whenever the patient walks or assumes the upright position. The anus by
this time has become so dilated that retention in the rectum is almost im-
possible. Sometimes the protruded gut becomes strangulated by the
Sphincter, but this is more apt to occur in the earlier than in the later
Stages.
TREATMENT.-The prolapsed rectum must be reduced when it first
99eurs by gentle, though firm, pressure with the fingers after anointing
the protruded gut with some oleaginous preparation. During the reduc.
tion the patient should assume the knee-elbow position, or be placed in a
"ecumbent position upon one side. In the case of infants it answers well
to place the child upon its abdomen across the lap of the nurse. Steady
Pressure may be required for several minutes. It is evident that the por-
on of the intestine which has been protruded last must be pushed up
first. If these manipulations fail, reposition may often be obtained by
introducing the finger, covered with a piece of lint, into the orifice of the
Potruded bowel and pushing it slowly upward into the intestine. During
636 D IS E A SES OF T H E R E C T U M .
this manipulation the lint, adheres to the mucous membrane, carrying it
upward so that the invaginated bowel is drawn back into the normal
position. The finger is then withdrawn, and, subsequently, the lint is
pulled out.
Support to the perineum and to the rectum should be given after
reduction by applying a T-bandage, which is a piece of muslin carried
around the perineum and attached to a belt in front and behind. After
having reduced a prolapsed rectum in an infant, I have gained sup-
port by passing a deep suture through the tissues at the verge of the
anus, thus narrowing the orifice. If the prolapsed rectum is strangu-
lated by the sphincter, it may be necessary to dilate or cut that msuche,
in order to prevent the occurrence of gangrene and permit the replace-
ment of the gut.
To prevent the recurrence of prolapse after reduction requires a great
deal of careful treatment. The patient should never be allowed to
assume the sitting position when evacuating the contents of the bowels.
He should be compelled to defecate when lying down upon the side, or
in a standing position. If the anus is drawn a little to one side with
the fingers as the fecal material is being evacuated, the tendency to
prolapse is greatly diminished. The bowels should be kept in such a
condition that constipation and the evacuation of hard masses may be
avoided, since all straining is dangerous. Broad strips of adhesive
plaster carried across the buttocks, so as to hold the two nates close
together, is quite an efficient means of giving support to the rectum in
small children. Astringent ointments or suppositories, such as tannic
acid (30 grains to the ounce), may be found effective; or astringent
enemas containing zinc sulphate, alum, or similar preparations, or rectal
injections of cold water, may be substituted for the ointments or Sup-
positories. Glycerin suppositories will probably be found valuable in
keeping the bowels open without producing straining. Under such a
line of treatment cases occurring in infancy, and cases of moderate
severity in adults, will probably be cured in a few months. The more
inveterate cases require surgical treatment.
If there is a small mass of mucous membrane protruding from the
anus, and no prolapse of the other coats of the bowel, a pair of Scissors
may be used to trim away the redundant tissue, in the hope that the
resultant cicatricial contraction will produce cure. In more severe cases
fuming nitric acid may be applied to the mucous membrane of the
intestines, so as to produce sloughing and cicatricial contraction. The
agent should be thoroughly applied to the entire surface of the pro:
truded part of the intestine, excepting a circular strip extending about
half an inch above the anus. Another method is clamping, with a
hemorrhoid clamp, a longitudinal portion of the mucous membrane,
which is subsequently cut off and the stump seared with the red-hot
cautery iron. Three or four such longitudinal folds may be removed.
The operation will result in cicatricial contraction of the dilated gut;
and by the adhesions produced between the rectal wall and surrounding
tissues the tendency to prolapse is prevented. &
The orifice of the anus, which has become dilated in all chronic gasº
may be reduced by cutting out a V-shaped portion of the Sphinº
at the posterior part or at the sides, and thus cause retention ºf the
relaxed rectal structures. I have recently operated with satisfactiºn.”
a bad case of this affection by cutting out V-shaped portions of the
sphincter and of the entire posterior wall of the rectum; the two "
H E MO R. R. H. O II) S. 637
angles having a common base at the back of the anal opening. Catgut
sutures were then applied within the gut so as to bring its divided walls
together and through the sphincter muscle and skin externally. This
somewhat resembles the method of Dieffenbach.
FIG. 397.
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Author's method of operating for prolapse of rectum.
Where no operation will be permitted by the patient a certain amount
of comfort may be obtained by wearing an anal truss. This consists of
a belt, to which is attached a spring going between the buttocks and
holding a pad against the anus.
HEMORRHOIDs.
PATHOLOGY..—The term hemorrhoid or pile is applied to several varie-
ties of tumors about the verge of the anus. Unfortunately, this want
of accuracy in the use of the term creates confusion in the pathology
and treatment of anal conditions. It would be better if the tumors
called internal hemorrhoids were the only ones to which the name hemor-
rhoid was applied; while to the various affections called external hemor-
rhoids better descriptive names might be given.
An internal hemorrhoid is a vascular tumor or angeioma, situated
beneath the mucous membrane of the
lower portion of the rectum, and usu-
ally not higher than one or two inches
from the anus; ordinarily, these
tumors lie just within the anal open-
Ing.
The dilated veins, capillaries, and
small arteries constituting the essential
structure of the pile may be held to-
gether by so much thickened connect-
ive tissue as to give the tumor quite
a hardened consistence. Repeated sº
attacks of inflammation have a ten- ~. w sº
dency to increase the cellular connect- Internal hemorrhoids with prolapse of
ive tissue and to obliterate some of mucous membrane. (TREVEs.)
the vascular channels, and thereby
increase the bulk and hardness of the tumor. Prolapse of the mucous
membrane in the region of the hemorrhoidal tumor may also occur through
sº
§§










638 I) IS E A SIES OF T H E R E CT' U M .
the anus and increase the bulk of the mass. The essential components
of an internal pile, however, are the dilated vascular channels and the
accompanying cavernous structure, which perhaps may be in part a
new formation.
Anything tending to increase the blood pressure about the lower end
of the rectum may cause internal hemorrhoids. Obstruction to circula.
tion arising from disease of the heart, lungs, or liver, or from an over.
loaded colon, may all give rise to hemorrhoids. Downward pressure upon
the pelvic contents by contraction of the diaphragm and abdominal
muscles increases the congestion in the inferior hemorrhoidal vessels. It
is this mechanism which gives rise to hemorrhoids in cases of enlarged
prostate gland, stricture of the urethra, stone in the bladder, phimosis,
carcinoma or stricture of the rectum, and in prolonged and frequent
straining at stool.
SYMPTOMS.—The presence of hemorrhoidal tumors in the rectum gives
rise to pain, itching, a feeling of weight, tenesmus, and other symptoms
of discomfort. Pain, in fact, may radiate to the genital organs and in
other directions. At first these symptoms are not very marked, but after
a time they increase, and there is a tendency for the tumors to protrude
through the anus when the patient is at stool. This will require him to
use his fingers to replace the growths within the rectum. Later the ten-
dency to prolapse becomes more marked and is more constant. Finally,
it is not unusual for a portion of the mucous membrane of the bowel to
be prolapsed with the hemorrhoids. Such a protruding mass may, by
contraction of the sphincter muscle, become strangulated, whereupon it
becomes much swollen and painful, and the seat of inflammation. Occa-
sionally gangrene of the protruding portion occurs; and if it is too large
to be replaced by the patient, and he does not seek competent assistance,
inflammation of the piles without strangulation may occur and cause
increased rectal symptoms.
When the congestion of the growths becomes very great during strain-
ing at stool, rupture of the thinned mucous membrane covering the dilated
vessels of which hemorrhoids consist may cause hemorrhage. Sometimes
the bleeding is only a slight staining, at other times the fecal masses are
coated with blood; while on still other occasions there may be a spurting
hemorrhage of several ounces, when the patient endeavors to evacuate
the contents of the bowels. This may also happen when there is no fecal
mass extruded, because the desire to go to stool is felt from the swollen
condition of the mucous membrane of the rectum. The blood which
flows from hemorrhoids is redder than blood which has escaped, for any
cause, from the bowels higher up than the rectum, since the latter is
altered in character and made darker by intestinal secretions.
In long-standing disease the sphincter becomes relaxed and does not
resist the pressure from above, and allows the protrusion of the piles to
exist almost constantly. The bleeding often relieves the pain and other
local symptoms, but if occurring frequently, as it does in extreme cases, it
will lead to dangerous anaemia of the patient. g
DIAGNOSIS.—The diagnosis of hemorrhoids where they are protruding
is simple enough. The difference between this disease and prolapse of the
rectum has already been mentioned. When, however, the hemorrhoidal
tumors are collapsed and not distended with blood, the surgeon's fingers
may scarcely recognize them. A diagnosis must then be made by careful
examination after the rectum has been emptied of its contents by enemas.
The patient, while lying upon his side, should be ordered to bear down
H E M O R. R. H. O II) S. 639
as if at stool, while the surgeon draws the anus open with his fingers. If
hemorrhoids exist a red or purplish shining tumor, with a more or less
irregular surface, will protrude. There may be one or several such vas-
cular masses. Between the sphincter and the tumors there is usually a
deep groove. The inner surface of the protruding growth usually appears
somewhat bluer than the surface near the anus. Such tumors may sur-
round the anal opening like a rosette and at some portions show ulcera-
tion from which bloody serum escapes.
The presence of a tumor protruding from the anus and associated with
great pain, because it cannot be pushed back by the patient, should cause
a suspicion of hemorrhoids. Even if this pain is not accompanied with
hemorrhage an ocular examination should at once be instituted.
TREATMENT.—I have purposely omitted the consideration of external
hemorrhoids because the condition is so different from internal hemor-
rhoids, and I shall, therefore, at this point speak of the treatment of
internal hemorrhoids alone.
Palliative treatment consists in carefully regulating the bowels, so as
to keep them open, and so prevent the rectum from becoming blocked
with hardened feces. Alcoholic stimulation in excess and other errors in
regard to food and drink may often lead to increased discomfort to those
subject to piles. Compound licorice powder, confection of Senna, saline
cathartics, and other laxatives answer very well for regulating the condi-
tion of the bowels. Locally the patient should use mild astringent oint-
ments, which should be applied to the anus and pushed up into the rectum
so as to come in contact with the mucous membrane. Tannic acid oint-
ment (1 drachm to the ounce of ointment) is beneficial, and the ointment
of galls combined with equal amount of the ointment of stramonium will
often be found effectual. The ointment of the nitrate of mercury mixed
with seven parts of simple ointment is another good application. Enemas
of the tincture of the chloride of iron (ten minims to the ounce of water),
and a somewhat similar enema made of the subsulphate of iron are also
Valuable. Suppositories of glycerin may perhaps be found convenient in
keeping the bowels open; and at the same time prove a good application
for the affected structures.
When the tumors are in a state of inflammation, at which time, of course,
the symptoms are aggravated, an enema of five minims of the tincture of
opium and half an ounce of starch-water will give great comfort, as will also
the insertion of a one-grain suppository of opium. Hot water formenta-
tions should be applied to the amus, and the patient kept in bed, with the
bowels made slightly loose with laxatives. If the piles are protruded and
Strangulated they must, of course, be pushed back into the rectum, even
if etherization and stretching of the sphincter are necessary for the accom-
plishment of the object.
When palliative means fail to give relief, when repeated attacks have
lendered the tumor so large that more or less discomfort is constantly
felt, and when repeated hemorrhage shows a tendency to break down the
Patient's health, a radical operation is demanded. Such an operation, if
Properly done, causes a permanent cure. It should not be undertaken,
ºf course, when the hemorrhoids are due to pregnancy, and perhaps not
when they are secondary symptoms resulting from stricture or malignant
disease of the rectum. In the last two cases the primary disease should
be treated as an initial step in the management of the case.
º Moderately severe cases of hemorrhoids may at times be cured by
*Ple dilatation of the sphincter by means of the surgeon's two thumbs
640 DIS E A SES OF T H E R E C T U M .
inserted into the anus and then separated with as much force as he can
bring to bear upon them. This operation requires the administration of
ether and should be thoroughly done. It often results in such change in
the circulation of the hemorrhoidal vessels as to cure the patient's dis-
ease. When the patient is not able to remain in bed for a few days for
such an operation, cure may be obtained by a protracted course of treat-
ment by means of injections of carbolic acid into the tumor. This
treatment requires a long time for its accomplishment, because each indi-
vidual pile must be treated separately. The length of treatment, there-
fore, depends upon the number of hemorrhoidal tumors, each one requiring
from a week to ten days for a cure by this means. A solution of carbolic
acid of the strength of about thirty grains to a fluidrachm of water, and
a fluidrachm of glycerin should be used. The hemorrhoidal tumor to
be operated upon is drawn down and about four minims of this carbolic
solution injected into the centre of the pile by means of a hypodermic
syringe. It is essential that the fluid be placed in the centre of the hem-
orrhoid, and not close to the surface, since in such an event it is liable to
cause sloughing, with subsequent ulceration.
Of all the operations proposed for the radical cure of the more severe
cases of hemorrhidal disease, the best probably is excision and cauter-
ization. The patient's bowels should be well emptied by a laxative given
the night before, and a large enema of soapsuds given a few hours before
the operation. He is then placed in the lithotomy position; that is, upon
his back, with his knees and hips flexed. The surgeon, as a preliminary
step, should widely dilate the anus by stretching it with all his force by
means of his two thumbs, which are inserted into the bowel. A portion
of the large mass of hemorrhoidal tissue and prolapsed mucous mem-
brane is then drawn down with a volsella forceps. A clamp, consisting
of two blades of ivory protected by steel strips on the outer surface and
FIG. 399.
Clamp for hemorrhoids.
which can be screwed firmly together, is then placed upon the base of the
pile and screwed tightly, so as to prevent hemorrhage when the tumor is
out off with a pair of scissors. The surgeon then cuts away the mass
protruding from the blades of the clamp, leaving about a quarter of an
inch near the clamp. This stump is left in order that there may be some
tissue left to sear with the hot iron, which is now applied to prevent hem-
orrhage from the vascular tissues when the clamp is removed. The cautery
iron should be heated to a red heat, so as to sear the tissues and occlude
the open mouths of the vessels. So soon as the probability of hemo".
rhage is thus prevented the clamp is removed and the shortened stun P.
allowed to recede into the rectum. The other tumors are successively
treated in the same manner until all have been excised and seared. Thº
operation removes the hemorrhoidal tissue, prevents hemorrhage, and gives


EI E M O R. R. H. O I DS, 641
an aseptic surface which cannot readily become infected by micro-organ-
isms in the bowels or upon the outer surface of the anus. It is thorough,
efficient, and a less troublesome operation than the other usual methods.
The patient should have his bowels moved about the fourth day by
means of a mild laxative, such as castor oil. Even in severe cases the
patient need seldom remain in bed for more than five days, or in the house
for more than ten days. Retention of urine requiring catheterization does
not often occur after this operation.
Some surgeons make an incision around the internal margin of the
amus and dissect out the hemorrhoidal tissue, after which the mucous
membrane is stitched to the integument covering the sphincter. This
operation is probably a little more difficult to perform neatly than is the
operation just given, and is scarcely so sure, it seems to me, to be aseptic.
If the operator has not the hemorrhoidal clamp figured in the diagram,
the operation can be satisfactorily performed by the use of an ordinary
pair of pincers for the clamp and a red-hot poker in place of the cautery
iron or Paquelin thermo-cautery.
Evternal Hemorrhoids.
PATHOLOGY..—The term external hemorrhoids has, unfortunately, been
applied to three different conditions occurring at the verge of the anus
external to the sphincter. The three forms have been called thrombotic
hemorrhoids, oedematous hemorrhoids, and cutaneous hemorrhoids.
A thrombotic hemorrhoid is a blood-clot beneath the muco-cutaneous
covering at the verge of the anus, due to rupture of one of the small
veins, or to inflammation and thrombosis occurring in a subcutaneous
vein. While straining at stool a small tumor the size of a pea may
appear from rupture of a small vessel, and on examination show a pur-
plish color through the thin skin. On the other hand, the clot may be
due to inflammation of one of the veins in this locality, the inflammation
being due to irritation arising secondarily from a small crack or laceration
in the cutaneous tissue at the verge of the anus.
The first form, due to rupture of a small vein, may cause some little
pain and soon disappear. If inflammation occurs around the blood-clot
painful symptoms arise and even suppuration may occur. The symptoms
then are similar to those arising from the second form of thrombotic pile,
which begins as an inflammation.
The so-called oedematous pile is simply an inflammation, which may be
quite severe, of the muco-cutaneous crevices and elevations which are
normally present about the anus, due to the normal puckering of the skin
in that region. Such inflammation gives rise to pain, a bearing-down
sensation, and swelling, and is the condition usually present when one of
the laity speaks of an attack of piles. The condition, of course, is simply
one of inflammation of the tissue about the anus, and is in no sense
Related to either form of pile mentioned, except that it occupies the same
lºcality. The term “piles,” as used by the laity, is often also the condi-
tion called pruritus of the anus, either alone or associated with one of the
forms of internal or external hemorrhoids.
The third condition to which the name external pile has been
applied is a hypertrophy of the muco-cutaneous folds without the anus,
§Wing rise to pedunculated tumors or tabs of muco-cutaneous and cellu-
lar tissue. The hypertrophy results from previous attacks of inflamma-
41
642 I) IS E A SES OF T H E R ECT U M.
tion of these folds, such as described under the heading oedematous hem-
orrhoids. These enlarged cutaneous elevations give no trouble under
ordinary circumstances, but when they become inflamed they cause great
discomfort and symptoms similar to those produced by the thrombotic
and Oedematous tumors just mentioned.
TREATMENT.-It will be seen that the pathology of external hemor.
rhoidal tumors is quite different from the vascular condition called internal
hemorrhoids, and therefore it will not surprise the reader to find that they
are treated in a different manner. The thrombotic form is best managed
by incising the pea-shaped tumor and scraping out the small clot, after
which the anus should be bathed with an antiseptic solution and anointed
with a slightly astringent ointment. The ointment of the oxide of zinc,
with which 20 grains of carbolic acid to the ounce have been mixed,
answers exceedingly well.
CEdematous piles are to be treated by bathing the anus with warm
water, and applying a similar ointment of the oxide of zinc and carbolic
acid, or one consisting of about ten grains of the yellow oxide of mercury
ointment to an ounce of simple ointment. In both cases the evacuations
from the bowels should be kept soft, so as to prevent pain at defecation.
The cutaneous piles should be let alone if they cause no trouble. Under
other circumstances they should be cut off with a pair of scissors. They
should never be ligated with a string; for while ligation is applicable to
internal hemorrhoids, although inferior to excision and cauterization, it
is not adapted to these cutaneous tumors. If the cutaneous hemorrhoid
has a very large base, it should be trimmed off in such a manner as to
leave a sort of stump, in order that the resulting cicatricial contraction
about the anus may be less marked.
Cutaneous hemorrhoids frequently co-exist with internal hemorrhoids.
When such a combination exists, internal hemorrhoids may be treated,
and the cutaneous ones clipped away at the same operation. It must be
understood that a danger after operations on internal hemorrhoids is con-
cealed hemorrhage into the rectum, which is the reason for using the clamp
and the cautery iron. In the external tumors, however, there is no special
danger from hemorrhage, because they are not angeiomas; and if any
occurs after excision, the external position of the bleeding point renders
it amenable to treatment by means of ligation or some form of pressure.
When clipping away cutaneous hemorrhoids the operation should be con-
ducted and the wounds treated antiseptically.
RECTAL ABSCESS.
PATHoLogy.—Abscesses may occur in the cutaneous tissue about the
anus (marginal); in the ischio-rectal space, which is the fossa between
the ischium and the rectal tube (ischio-rectal); in the tissue between the
mucous membrane and the muscular coat of the bowel (inter-murt l);
and in the pelvis surrounding the rectal wall (peri-rectal). There may
occur also a gangrenous cellulitis about the rectum, giving symptoms not
unlike those of peri-rectal abscess.
The predisposing causes of abscess in these special locations are exter”
injury, irritation or puncture of the rectal wall by foreign substances tº
troduced into the rectum through the anus, inflammation due to small
portions of hardened feces, or indigestible substances swallowed becomº
impacted in the folds of the mucous membrane; and breaking down 9
al
A N A L FIST U L E . . 643
tissue from want of resistance to pyogenic infection. In all cases of acute
abscess the presence of pyogenic bacteria is a necessary causative factor.
Tubercular infection may cause a chronic, or so-called “cold abscess.”
SYMPTOMS.–Marginal abscesses are similar to other superficial abscesses,
both in symptoms and treatment. Such abscesses may be mistaken for
piles unless the surgeon makes an ocular examination. The ischio-rectal
abscess, which is the most common form in this region, appears as a hard
mass between the anus and the tuberosity of the ischium. Aching and
throbbing, with pricking sensations, are felt ; the skin becomes hard, red,
and brawny, and finally these symptoms are succeeded by fluctuation and
evidences of pointing.
Inter-mural abscesses are usually overlooked until they burst and dis-
charge pus into the bowel, whence it is evacuated. Peri-rectal abscesses
are often similarly overlooked. The sensation of weight and fulness, and
the pelvic discomfort associated with this condition, are in such cases fre-
quently attributed to other lesions. Rigor occurring in the course of such
symptoms should put the surgeon on his guard as to the possibility of Sup-
puration taking place in this region. The finger introduced in the rectum
may detect swelling, or a fluctuating tumor in cases of inter-mural or
peri-rectal abscess. The latter, of course, is much more dangerous than
the former, and may be secondary to malignant disease or rectal stricture.
Such abscesses bursting into the peritoneum would probably lead to a
fatal issue, unless the surgeon immediately opened the abdomen and
washed out the pelvis.
TREATMENT.--All rectal abscesses should be opened as early as possi-
ble, and if it is thought that suppuration is about to take place, an inci-
sion, even before the formation of pus, is justifiable. In the event of pus
not being given an opportunity to discharge through an opening made by
operation, a great deal of burrowing usually takes place before spontane-
Ous evacuation occurs, and, in the ischio-rectal form, an anal fistule is very
apt to remain. *
Inter-mural abscesses may be evacuated by tearing through the mucous
membrane with the finger-nail, or by puncturing it with a knife intro-
duced through a speculum. The ischio-rectal and the peri-rectal forms
should be opened by free incision made through the skin, after which the
abscess cavity should be curetted. If the curetting can be done
thoroughly, the cavity may then be sewed up by deep sutures, with the
hope of obtaining immediate union. If there is any doubt as to the aseptic
$ondition of the curetted cavity, a drainage-tube had better be introduced
before the wound is closed. Rectal abscess thus treated will usually re-
Cover without the formation of an anal fistule.
ANAL FISTULE.
PATHoLogy.—An anal fistule is a communication between the surface
of the buttock and the interior of the rectum by means of a narrow pus-
*ting track. It results from an ischio-rectal or a peri-rectal abscess
which has not been opened early enough to prevent the formation of an
9rifice into the bowel as well as upon the surface of the skin. After such
*ºnal orifice has been established there is difficulty in spontaneous
healing of the pus-secreting tract, because small particles of feces get into
the fistule from the calibre of the bowel, and because frequent movements
* the sphincter muscle interfere with cicarization.
644 DIS E A SES OF T H E R ECT U M .
The usual form of fistule has, as before stated, an opening upon the
skin and an internal opening within the bowel. This is called complete
fistule. Occasionally the fistulous track runs from the surface into
the cellular tissue surrounding the rectum, but has no opening into the
bowel (incomplete or blind external fistule). At other times there is an
opening from the bowel leading into the abscess cavity, or suppurating
tract in the tissues surrounding the rectum, but with no opening upon
the skin (incomplete or blind internal fistule). These last two forms re-
quire similar treatment to the complete anal fistule, though they vary
somewhat in symptoms. Incomplete external anal fistule may be due to
a wound received from without. The incomplete internal fistule is hard
Diagram of three forms of amal fistule.
A. Complete fistule. B. Internal blind fistule. C. External blind fistule.
to recognize, because there is no external indication of the tumor, except
when the cavity in the tissues around the rectum fills up with pus and
makes a slight bulging of the skin. This can be made to disappear by
pressing upon the cutaneous surface and forcing the accumulated pus
through the internal opening into the rectum. The diagnosis in such
cases may sometimes be confirmed by feeling with the finger in the rectum
the ragged orifice through which the communication between the cavity
and the bowel is kept up. In complete anal fistules the rectal opening is
usually within an inch of the anus, but the pus-secreting pouch or pocket
situated in the ischio-rectal space may extend to a higher point than this
on the outside of the rectum. This is readily understood, because at the
time of the formation of the abscess the pus may have burrowed upward
along the rectum before the abscess pointed and finally evacuated itself
into the rectum. In searching for the internal orifice of an anal fistule,
the surgeon should feel with the finger, or look through the speculum on
all sides of the bowel just within the internal sphincter. A probe passed
into the external opening may, unless carefully manipulated, find its Wºy
into the top of the pouch alongside of the rectum, or it may readily be
forced into the meshes of the normal connective tissue, instead of fol.
lowing the fistulous track and entering the bowel by the orifice just
within the anus. The internal opening is usually single, even when the
buttock is riddled by sinuses running in all directions. The internal
orifice will usually be found to be the same for all these sinuses Whº"
a probe is successively passed into the various cutaneous openings. The
rectal opening may be upon the side of the rectum furthest from the
external or cutaneous orifice, because the pus has burrowed around the
gut. It must be remembered that a sinus opening far down the thigh
may, when opened up, be found to lead to the rectum. On the other
hand, the surgeon should not forget that a sinus in the neighborhood
of the anus may be due to caries or necrosis of the tuberosity of tº
ischium or of the coccyx, and have no connection whatever with the

A N A L FIST U L E . 645
rectum. Usually, however, sinuses in the neighborhood of the anus will
be found, on careful exploration, to be anal fistules.
SYMPTOMs.-Anal fistules, when complete, are recognized by the dis-
charge of gas and feces through the abnormal track, and by the existence
of a slight purulent or sero-purulent discharge. The external orifice will
occasionally become closed and remain so for several days, perhaps for a
week or two, when a slight increase of pain and some swelling will be
followed by a reopening of the closed orifice, the discharge of a small
amount of pus, and subsidence of the active symptoms. Quite a large
abscess will sometimes form as a result of these temporary closures of
the external orifice, through which drainage ordinarily takes place. A
similar closure may occur in incomplete external fistules, though in
these there will at no time be escape of gas or feces. Incomplete in-
ternal fistulas exhibit at times an intermittent discharge of pus into
the rectum and from the anus, especially when pressure is made upon
the skin, as described above.
TREATMENT.-Injecting the anal fistule with stimulating solutions is
usually unavailing. An operation is almost always necessary for a cure.
Even in cases of phthisis an operation should be performed as on a
fistule in a healthy person, unless the phthisical condition is actively
progressing. There is no more risk to the patient than in non-phthisical
subjects. Amal fistule occurring in a patient with tuberculosis of the
lungs should be treated on the same principles that would guide the
surgeon in operáting upon any other surgical condition in a tubercular
subject. Fistule resulting from stricture or malignant disease of the
rectum should not be subjected to operation, unless it is evident that
the primary disease can be dealt with, or that the fistulous complica-
tion adds markedly to the patient’s discomfort.
During the operation for anal fistule the patient is put in the lith-
otomy position, or in the elbow-knee position. The surgeon then intro-
duces the forefinger of his left hand into the rectum, and feels for the
dimple or slight elevation which indicates the internal orifice of the
fistulous track. This, in most cases, is just inside the internal sphincter.
A grooved director, slightly bent at the point, is then introduced into
the external orifice and along the pus-secreting track until it emerges
through the orifice in the rectum, Ordinarily, it is possible for the
surgeon to bend the director with the finger which is in the rectum
until the point of the instrument comes out at the anus. A bistoury
is then carried along the groove of the director so as to divide the
sphincter muscle and all other structures between the two openings.
Any other communicating fistules or sinuses should then be laid open
by incisions through the skin, but no second opening into the rectum
should be made. After all the tracks have been thus laid open and
exposed to view, it will be seen that all communicate through the
Various ramifications with one rectal opening. The membrane lining
all these sinuses must be scraped out with a curette until healthy tissue
has been reached. They should then be washed out with corrosive sub-
limate solution (about 1:2000), and the walls brought together by cat-
šut sutures. This method converts a chronic suppurating surface into a
healthy one, makes the wound aseptic, and, by division of the sphincter
*uscle, prevents muscular movements of the divided structures, thus
§Vº great assistance to the healing process. An antiseptic dressing
º then be applied, and movement of the bowels prevented for about
&l Week.
646 D IS E A SES OF T H E R E C T U M .
The patient's intestinal canal should, however, be thoroughly emptied
by laxatives and enemas before the operation.
If it happens that no internal orifice can be found when the surgeon
has his finger in the rectum, and the point of the director has failed to
find one, the end of that instrument may be pushed through the mucous
membrane at any convenient point and the sphincter and other structures
divided and treated as above. If the orifice, when found, is very high up
in the intestines it may be well to cut through the sphincter and other
structures with a probe-pointed bistoury or scissors, since the point of the
director cannot be bent so as to protrude at the anus. Let the operator
be careful not to tear up the healthy cellular tissue, with a small probe
point in his search for an internal orifice, but remember that in the vast
majority of cases the rectal opening is not further than one inch from
the amus. In internal incomplete fistule the internal orifice should be
found and the tissues, including the sphincter, divided, after making an
opening by forcing a grooved director or probe against the skin from
within. In no case should the sphincter muscle be divided in more than
one place, since such multiple division may lead to fecal incontinence.
In women the division should not be made through the anterior portion
of the muscle. When it is impossible to scrape out the fistulous tracts
thoroughly and approximate them with sutures, it becomes necessary to
plug the wound with antiseptic gauze in order to make it granulate from
the bottom and prevent a recurrence of the fistule.
Recto-vesical, Recto-wrethral, and Recto-vaginal Fistules.
A communication between the rectum and the bladder, the urethra, or
the vagina may occur as a congenital malformation.
Such fistules, at times, result from ulceration, malignant disease, or
injury. Whether congenital or acquired, the abnormal communication is
recognized by the unnatural course which the feces or urine take during
discharge. If the orifice is small a small portion only of these excretions
will pass through the abnormal channel. If the condition is not due to
malignant disease, attempts at closure should be made by cauterization
with nitrate of silver, the actual cautery, or by plastic operation. Judic-
ious cauterization and retention of the patient in such recumbent position
as will prevent the urine and feces from getting into the abnormal channel
will greatly aid the surgeon's efforts at occluding the abnormal fistulous
aperture. e
Sometimes it is well to make temporarily another abnormal opening in
order to divert the urine and feces during the closure of the original
defect. This opening is usually placed in such a position that it can sub-
sequently be easily treated by the surgeon. g
A speculum somewhat similar to Sims's vaginal speculum, if used in
the rectum, will permit the surgeon's manipulations to be carried on with
considerable ease. The plastic devices used for this condition are similar
to those employed in gynecological practice, when abnormal vaginal open-
ings are to be closed.
ANAL FISSURE.
PATHOLOGY.—Among the various forms of ulceration of the anus * d
rectum is a peculiar ulcer to which the name anal fissure is applied. It
A N A. L. FI SS U. R. E. 647
is so different in its symptoms and treatment from the other forms of
anal and rectal ulcers that it is better to discuss it separately.
Anal fissure is a local disease occurring in patients who are otherwise
in good health. It is in reality either a small linear ulcer just within the
verge of the anus involving the mucous membrane covering the sphincter,
or a small ulcer not larger than the little finger-nail involving the mucous
membrane of the rectum just above the sphincter. Such ulcers usually
occur at the posterior or coccygeal portion of the anus.
A peculiarity of the condition is the intense pain that occurs immedi-
ately after defecation, and which is due to spasm of the sphincter muscle.
An anal fissure frequently begins as a small crack in the mucous mem-
brane, due to the evacuation of hardened feces causing a tear in the
tissue named. This fails to heal because of the constant motion of the
sphincter muscle; or possibly because a tab of hypertrophied mucous
membrane or a small rectal polypus coming in contact with it prevents
cicatrization. At times small and superficial eczematous ulcers may
occur upon the outer aspect of the amus. These are due to a want of
cleanliness, or to contact with leucorrhoeal discharges. This slight condi-
tion is quite different from anal fissure, is unaccompanied by the intense
pain of the latter, and is easily cured by cleanliness and the use of oxide
of zinc ointment or by some similar astringent application.
SYMPTOMS.–The symptoms of anal fissure are remarkable, because of
their severity, notwithstanding the insignificant appearance of the lesion.
The pain, which is the chief symptom, is intense and smarting, and occurs
immediately after defecation. This pain may last for a few minutes or it
may continue for many hours. It may radiate toward the coccyx and
Sacrum, and finally becomes a dull ache before disappearing. There is
then no return of the pain until defecation is repeated; after each stool,
however, the agonizing pain occurs. Sometimes a slight discharge of a
muco-purulent character or a slight bleeding may be a coincident symp-
tom. The manner in which the pain is reflected occasionally causes the
patient to attribute the suffering to disease of the bladder or the urethra.
The bearing-down sensation, or tenesmus, accompanying anal fissure is
Sometimes remarkable. The dread of intense pain after defecation causes
the patient to refrain from emptying the rectum, and chronic constipation
therefore occurs as a secondary symptom. As a sequence of the difficulty
in finally avoiding the hardened fecal masses so produced, greater pain
and tenesmus supervene.
Spasm of the sphincter muscle is the occasion of the agonizing distress,
and always exists in true anal fissure. The elevator muscles of the amus
may also be involved in the spasmodic condition. In all instances of
Severe pain after stool anal fissure should be suspected and a thorough
examination at once instituted. The irritable condition of the sphincter
may result in such contraction of the anus when an examination is
attempted that it will be impossible to pass the surgeon's finger into the
Tectum without etherization. If the presence of a fissure or linear ulcer
is not discovered by examination of the external border of the anus, the
patient should be etherized and the lower portion of the rectum and the
interior aspect of the anus thoroughly explored by the finger and specu-
lum. (Fig. 402.) The ulcer may be very superficial or it may be deep
°nough to expose the muscular fibres. As stated above it is sometimes
*linear, but a small irregular ulcerated surface.
TREATMENT—When the disease is of recent date cure may occasion-
ally be effected by maintaining a softened condition of the feces by the
648 DISE A SES OF T H E R ECT U M .
use of laxatives; by washing the parts after each act of defecation ; and
by smearing the anus and lower portion of the rectum with the ointment
of oxide of zinc, or an ointment containing the red oxide of mercury (gr.
15 to the ounce). When this treatment fails, and it always will failin
the more chronic cases, operative procedures are required. The operation
is so unimportant, and the relief So great and immediate, that it should
not be postponed. It is ordinarily sufficient to etherize the patient and
thoroughly paralyze the sphincter muscle by stretching it with the two
thumbs. This dilatation should be done thoroughly and with all the
power which the surgeon can exert by introducing his two thumbs and
FIG. 401.
Rectal speculum.
forcibly separating them, usually in a lateral direction. Some of the
fibres of the sphincter muscle are probably ruptured by this manoeuvre.
Another method, which is said to be more effectual than dilatation, is to
incise about one-third the thickness of the sphincter with a bistoury.
The incision is always made through the base of the ulcer, beginning a
little above its upper border and terminating at the muco-cutaneous
junction at the exterior of the anus. A speculum is usually needed to
enable the surgeon to perform this operation dextrously. One of the
forms of ointment mentioned for mild cases may then be applied.
When simple dilatation of the anus has been selected as a means of
cure, it is well to scrape away with the finger-mail, or with a curette, the
granulations and indurated tissue forming the base of the ulcer. Any
small tab of mucous membrane, polypoid growth, or small fissure compli-
cating the condition should be excised or incised at the same time that
the other operation selected is performed.
ULCERATION OF THE ANUs AND RECTUM.
PATHology.—Ulceration about the anus and rectum may be syphilitic,
malignant, tuberculous, or dysenteric; or it may be due to injury from
hardened feces or a syringe improperly used, or to foreign bodies. In
old people there occurs an ulceration which appears to be due to chroniº
venous congestion, and is similar, therefore, in pathology to the senile

STRICT U R E O F T H E H ECT U M. 649
ulceration which occasionally shows itself in the legs. It must not be
forgotten, however, that chancre may be found at the anus. The ordi:
nary form of syphilitic ulcer belongs to the tertiary or to the congenital
stage of syphilis,
SYMPTOMs.-Irregular diarrhoea, purulent discharge, pain, tenesmus,
and other symptoms resembling dysentery are the clinical features of
rectal ulceration. The discharges often consist of material resembling
yeast, or at times coffee-grounds, mixed with more or less mucus and pus.
Ulceration in the upper part of the rectum is far less painful than a
small ulcer at the lower part, as has been described in another paragraph;
nor does great pain accompany the latter affection when the ulceration
at the lower part of the rectum is extensive. Examination with the
speculum reveals the condition of the mucous membrane of the rectum ;
and digital examination conveys to the surgeon's fingers the sensation of
rough irregularities and stiffened rectal walls quite different from health.
There may be irregular distortion of the tube, and even stricture may
OCCUll’.
TREATMENT.-It is essential in managing such a condition to keep the
intestinal excreta soft and to use astringent and anodyne enemas and
suppositories. The recumbent position may be valuable in severe cases,
as it prevents abnormal congestion of the pelvic viscera. Washing out
the rectum with large enemas of warm water containing boro-glyceride
(1 to 30) and other non-poisonous antiseptics is a valuable means of get-
ting rid of irritating secretions in the rectum ; drying the ulcer and pow-
dering it with a mixture of oxide of zinc (3 grs.), mild chloride of mer-
cury (20 grs.), and powdered starch (2 drachms) is good treatment. An
enema containing 10 drops of the tincture of opium to the ounce of
starch-water will often relieve the distressing pain. In tuberculous ulcers
iodoform in powder or suppository is indicated ; 10 grains would proba-
bly be a sufficient, as well as a safe, amount in most circumstances to
introduce into the rectum.
Syphilitic cases will always demand antisyphilitic remedies in addition
to or instead of the tonics generally needed in ulcerations here. When
great pain exists it may be necessary to stretch or divide the sphincter
muscle to relieve the spasm present. In some extensive ulcerations the
pain from the passage of feces over the diseased surface is so great that
lumbar colotomy or excision of the lower portion of the rectum is
demanded. These important operations, however, are not often required
by the symptoms. Scraping away the ulcerated tissue with a curette, or
Cauterizing the ulcer with a red-hot iron or fuming nitric acid, is often
sufficient.
STRICTURE OF THE RECTUM.
PATHOLOGY..—Malignant disease is often the cause of stricture of the
rectum, but contractions of the rectum due to fibrous formations will here
be alone considered. These contractions are due to chronic inflamma-
tion, or to such prolonged irritation of the muscular fibres in the rectal
Wall as to cause them to undergo a sort of fibroid degeneration. The
°oats of the rectum at the seat of coarctation are thickened or welded
ºgether either by a new fibrous tissue or an increase of the normal
fibrous tissue. Ulceration of the mucous membrane is not uncommon in
the vicinity of the stricture, and dilatation of the tube naturally takes
Place above the stricture from retention of fecal masses at that point.
650 D IS E A SES OF T H E R ECT U M .
The stricture when involving less than an inch of the tube is denomi-
mated an annular or ringed stricture; when a greater length of the intes-
time is contracted the term tubular stricture is applied. The former may
be increased by further pathological changes and thereby be converted
into the latter.
Inflammation and ulceration of the rectum due to operations upon this
organ or other causes, as well as pelvic inflammations subsequent to labor
may be the exciting cause of fibrous degeneration which results in contrac-
tion of the gut.
SYMPTOMs.-The first symptom of stricture of the rectum is difficulty
in defecation, which is usually considered by the patient to be simply
functional constipation. Finally the fecal masses discharged become
smaller in diameter, resembling, perhaps, the size and shape of a lead
pencil. At other times, however, the extruded material consists of small
irregular masses, without definite shape. Occasionally they may even be
ribbon-shaped. Flattened or tape-like feces, however, occur also from
irritability of the sphincter without there being any stricture of the
rectum. The small nodules of feces, called scybala, so usual in constipa-
tion, must not be mistaken for evidence of stricture. A bearing down
sensation and a feeling of defecation being incomplete are marked feat-
ures. Diarrhoea, alternating with constipation and painful defecation,
will, perhaps, supervene. When ulceration occurs as a complication of
fibrous stricture, mucus and blood will probably be mingled with the
feces, and the solid material passed will be small in amount and accom-
panied with the yeasty or coffee-ground discharges mentioned as a symp-
tom of ulceration of the rectum. The desire to go to stool is apt to
occur soon after the ingestion of food or liquid. The effort at stool is
followed by little result, and is soon succeeded by a repetition of the
tenesmic sensation, showing that the rectum has not been fully emptied.
Dyspeptic symptoms, such as the accumulation of flatus, become more
or less prominent. Abscess or fistule in the vicinity of the stricture may
cause the patient to undergo an operation for its cure without the sur-
geon, if he be careless, discovering that the true cause of this condition is
a stricture. Retention of feces, great emaciation, excoriation of the anus
due to discharges, and intestinaſ obstruction leading to peritonitis, and
finally death, may result from long-continued fibrous stricture of the
rectum.
A definite diagnosis can only be made by exploring the rectum care-
fully with an oiled finger. If the stricture is within three or four inches
of the anus it can be felt. There is usually less than the normal contrac:
tility of the sphincter and rectum, and below the point of obstruction
the rectum has a tendency to be dilated like a distended balloon. This
is not due to retained feces in this part of the gut, for none are retained
there. The tip of the finger may discover a sort of diaphragm in which
there is a small opening, or it may feel a funnel-shaped thickening of the
rectum leading up to a small orifice. The introduction of a sound with
an acorn-shaped head will enable the surgeon to determine whether the
contraction is annular or tubular.
If the disease is situated beyond the reach of the finger it is exceed-
ingly difficult to make an accurate diagnosis, because the rectal boug”
used for examination may become entangled in the mucous folds which
line the rectum or be arrested by the promontory of the sacrum. It is
possible that an examination made when the patient is standing, or makes
a bearing-down effort, will bring the strictured portion within reach of
STRIC TU RE OF T H E R ECT U M . 651
the finger. When a diagnosis of high stricture is rigidly demanded a
very small hand, well oiled, may be pushed into the rectum and thrust up
to the sigmoid flexure. Acute obstruction of the intestine may supervene,
when the stricture of the rectum does not entirely occlude the calibre of
the organ, by undigested food becoming impacted in the narrow opening. It
must be remembered also that there is a phantom stricture of the rectum,
as there exists a similar condition of the oesophagus, and that an enlarged
prostate gland or a displaced uterus may push its wall inward and create
a condition resembling stricture. A diagnosis is then made by the nor-
mal condition of the mucous membrane and by the symptoms indicative
of the other pathological conditions.
TREATMENT.-The feces in all forms of rectal strictures should be kept
in a soft condition by the use of laxatives and enemas, and an attempt be
made to restore the calibre of the gut by gradual dilatation. This is
undertaken by passing a well-oiled bougie through the contracted portion
every other day and allowing the instrument to remain in position for a
few minutes, or perhaps an hour, if pain does not contra-indicate the
longer period. The bougie should be small, for no bougie that requires
force should ever be passed through a stricture of the rectum. Any
attempt to force a large bougie through the diseased area, or to dilate
the stricture rapidly with the finger or bougie, is liable to cause inflam-
mation or rupture of the intestine. If no pain of moment is produced
by the small bougie, larger sizes may be successively substituted for the
smaller instruments every four or five days. At the end of six or eight
weeks a much larger bougie than that originally used will probably be
comfortably received, and much relief will be given to the patient from
the dilatation thus effected. It is essential that no active inflammatory
conditions be induced by the dilatations. After the surgeon has given up
attendance upon the case the patient should introduce the bougie for him-
self about twice a week. This should be continued for many months in
order to prevent recurrence of the contraction. In annular stricture this
method of treatment often produces cure, but it is usually of little avail
in the more serious tubular strictures.
In the event of failure of gradual dilatation in the treatment of annular
stricture, internal incision of the annular band may be practised, provided
that the stricture is quite limited in its extent. If the stricture is exten-
SIVe in area, internal incision is not free from risk, because the contact of
the large wound with pus and feces, in a position where free drainage is
hot obtainable, is liable to give rise to serious inflammation and burrow-
ing of pus. When, however, a small and shallow incision is made in the
lesser degrees of stricture, such untoward complications are not to be ex-
Peºted. It therefore becomes necessary in the more extended annular
*ictures, and in tubular strictures, to perform linear proctotomy, which
* * Complete division of the rectal wall and the tissues behind it. After
this Operation granulation slowly closes the wound, while the calibre of
the gut is maintained by the use of bougies. Linear proctotomy is per-
formed by introducing a long curved bistoury through the anus until its
Pºnt is above the stricture. The posterior rectal wall is then punctured,
*nd the point of the knife carried backward and downward toward the
end of the coccyx, until its extremity makes its appearance through the
skin near the Coccyx. An incision is then made which divides the stric-
* the rectal wall below, and all structures between the anus and the
*neous opening made near the coccyx. The wound is packed with
652 D IS E A SES OF T H E R E C T U M .
antiseptic gauze, and frequently washed out with antiseptic Solutions,
Bougieing should begin at the end of the first week.
Bad tubular strictures are not amenable to treatment by any of these
measures, though the simple form of tubular stricture may sometimes be
so treated. Temporary relief from pain and distress during defecation
through the diseased gut is, however, obtainable by lumbar colotomy,
which establishes an artificial anus in the left loin, and permits the extru-
sion of the feces at that point. This operation gives great relief, and is
not as serious a procedure as would at first be supposed. It should not
be delayed until the patient is exhausted by suffering.
MALIGNANT DISEASE OF THE ANUS AND RECTUM.
PATHOLOGY..—Cylindrical epithelioma is the form of malignant dis-
ease which nearly always occurs in the rectum and at the amus, although
sarcoma and scirrhus occasionally attack this locality. The malignant
affection usually assumes an infiltrated form, though occasionally the
growth is a distinct tumor, projecting into the calibre of the rectum, with
the mucous membrane over it remaining for a long time normal. Finally,
however, the malignant tissue breaks through the mucous covering and
fungation occurs. The infiltrated form begins between the mucous mem-
brane and the muscular coat, and ulceration occurs quite early.
SYMPTOMS.–Malignant disease of the rectum may be present for a con-
siderable time before the symptoms are conspicuous; then pain, bleeding,
muco-purulent discharge, diarrhoea, and symptoms of stricture supervene.
The clinical history of malignant disease of the rectal tube is, in fact,
very like that of fibrous stricture or ulceration in the same locality.
When the anus alone is attacked, the symptoms are similar to rectal dis.
ease, but are more patent. A diagnosis between malignant disease and
fibrous stricture of the rectum is sometimes difficult. In the former Con-
dition, however, the mucous membrane between the seat of disease and
the anus is usually less ulcerated than in stricture. The course of malig-
nant disease also is more rapid than that of stricture of a non-malignant
kind.
A finger introduced into the rectum can feel the diseased area if it be
not more than four inches from the anus. Ordinarily the nodular char-
acter of the rectal wall is marked, although it happens sometimes that a
soft fungous mass is felt. This is the case when the disease occurs as a
tumor rather than as an infiltration.
Villous tumor of the rectum, which is an innocent growth, is soft. and
velvety to the touch, though thoroughly resistant. In this respect it diffe's
from the fungous form of epithelioma, which is not resistant, has a harsh
feel, and is surrounded by indurated tissue. This subjacent induration is
not found in villous tumor. The discharge from villous tumor is a sticky
rather clear mucoid fluid; but it is not purulent, and does not have a dark
appearance like coffee-grounds. These are characteristics of the dischargº
in cases of rectal epithelioma.
Fistulous tracks connecting the rectum with the bladder, urethra, 9.
vagina are not uncommon in advanced malignant disease. Pressurº 9
the malignant growth upon the iliac veins may cause odema of the legs.
Death occurs from exhaustion or from intestinal obstruction similar "
that which takes place in fibrous strictures. I have in one case know"
the lower portion of the rectum and the surrounding structures to be S0
M ALIGN ANT DISE ASE OF THE AN U S A N D RECT U M. 653
thoroughly destroyed by malignant disease that the space between the
buttocks was converted into an immense funnel shaped opening with the
apex directed upward.
TREATMENT.-The treatment of malignant disease of the rectum should
be directed to keeping the amount of fecal matter small, and the bowels
sufficiently loose to avoid impaction of fecal masses above the stricture
or ulcerated surface. To this end food leaving small undigested residue
and mild laxatives are to be employed. A small amount of opium is at
times necessary as an anodyne. The anus should be kept free from irri-
tation due to contact with the acrid discharges by frequent bathing and
the use of oxide of zinc powder mixed with starch (twenty grains to the
ounce), or by some other soothing application applied externally. Warm
water enemas thrown over the seat of the disease by means of a small
rectal tube, or a catheter passed beyond the malignant mass will be of
service by cleansing the rectum and facilitating evacuation of fecal matter
lodged above the diseased area.
These palliative measures should not be relied upon, however, when it
is possible to remove the diseased tissue by excision of the rectum. This
operation is easy of accomplishment in suitable cases, and gives great
relief to the patient as well as prolongation of life. Excision of the rectum
should not be done unless the finger introduced at the anus can reach
above the malignant growth; this means that the growth must be within
four inches of the amus.
Malignant disease of the posterior wall is more amenable to operation
than that of the anterior or lateral walls, because of the important struc-
tures adjacent to and liable to be involved in the disease when the front
of the tube is the seat of infiltration. It is possible in women, however,
to separate the rectum from the vaginal mucous membrane, even when
the anterior portion of the rectal tube is diseased. Operation, therefore,
is more justifiable in women than in men when the morbid growth occu-
pies an anterior situation. In a case otherwise suitable for operation it
is essential that the rectum be not tied down to the surrounding
structures through malignant infiltration outside the rectal wall. The
general health of the patient should be in fair condition before he is sub-
jected to the risks of operative complications. Numerous cases are upon
record in which there has been no return of the disease for a number of
years after excision of the lower part of the rectum,
At the time of the operation the patient, whose bowels have been pre-
viously thoroughly emptied, is put in the lithotomy position. The sphinc-
ter and skin behind it are divided by a straight incision extending back-
Ward to the coccyx. A semilunar cutaneous incision is made around
each side of the anal sphincter beginning at the front of the posterior
Wound just made, and terminating in the perineum in front of the anus.
The finger is then inserted behind the rectum and used to tear up the
attachments of the rectum posteriorly and laterally. The intestine is
separated from the vagina or urethra and bladder in front by careful
dissection with a knife, because the finger would be liable to do damage
if used for that purpose. In men it is well to place a bougie in the
urethra and bladder in order that the location of these structures may
be clearly perceived. After the rectum has been thus detached from the
Surrounding tissues to a point above the seat of disease, it is drawn down
and cut across with scissors at some distance above the disease. In this
manner the rectal tube and sphincter muscle are completely removed.
After hemorrhage has been stopped the wound is packed with antiseptic
654 DISE A SES OF T H E R ECT U M .
gauze. No attempt should be made to draw down the intestine and stitch
it to the skin. Such a procedure interferes with drainage and is liable
to do damage to the peritoneum above. The cavity slowly fills up with
granulation tissue and a sort of pseudo mucous membrane is developed
between the lower end of the intestine and the cutaneous surface. The
patient regains control of the contents of the intestine in about two
months. After the first two or three weeks it is well to use the bougie
to prevent cicatricical contraction causing stricture.
In those cases in which excision is not justifiable, left lumbar colotomy
should be done, and not delayed too long, since it adds greatly to the
comfort of the patient and prolongs life even in cases of great severity.
In malignant disease of the rectum without stricture, but where there
is great pain caused by passage of the feces over the ulcerated surface,
left lumbar colotomy is the proper treatment.
The operation of colotomy has been discussed under Diseases of the
Abdomen.
NoN-MALIGNANT RECTAL TUMIORs.
PATHOLOGY..—Fibrous and adenoid tumors having a pedicle are at
times found in the rectum, and are then called rectal polypi. Fibroid
rectal polypus is developed beneath the mucous membrane; while adenoid
polypus originates in the mucous membrane itself, and may have a very
long pedicle. Rectal polypus is a comparatively rare disease, but is
more common in children than in adults. The tumor is apt to be pro-
truded at stool, when it may be mistaken for prolapse of the rectum or
for piles. The fact that hemorrhage is one of the symptoms of rectal
polypus adds to the liability of the disease being mistaken for hemor-
rhoids. Anal fissure is occasionally complicated with small rectal
polypus.
TREATMENT.—The sphincter muscle of the rectum should be dilated,
and the polypoid tumor drawn down and twisted off with strong forceps.
Twisting of the pedicle is judicious in order to avoid the possible occur-
rence of hemorrhage. If the tumor is sessile such removal by torsion
may be impossible, in which case clamping and cauterization, as employed
in removing piles, may be used. If the surgeon prefers, the tumor may
be removed with scissors after transfixion of its base with needles carrying
catgut or silk ligatures. The ligatures may be tied so as to cut off the
blood supply before excision is attempted. Care must be observed not
to divide them when cutting away the growth.
Villous tumor of the rectum is an innocent growth, adenoid in char:
acter, but has a less marked pedicle than a polypus. It does not spread
and infiltrate the tissues as does malignant disease. The growth secretes
a stringy mucoid discharge, and from it small fragments frequently break
off and pass out at the anus. When felt with the finger it gives the im:
pression of a soft but resistant velvety tumor, not surrounded by a hard-
ened base as is malignant disease. It may be present for many years
without causing much disturbance, except a sensation of fulness in the
rectum, and occasional hemorrhage.
The proper treatment of villous disease is dilatation of the sphingter
and removal of the growth by clamp and cautery, or by ligation:
Curetting may be attempted, if precautions are taken to avoid subsequent
hemorrhage by packing the rectum thoroughly with iodoform gauze after
the operation.
C H A P T E R X. XIII.
DISEASES AND INJURIES OF THE URINARY ORGANS.
DISEASES AND INJURIES OF THE KIDNEY.
METHODS OF EXAMINATION.—Diagnosis of affections of the kidney
is made by palpation, general symptomatology, and by examination of
the renal secretion.
The general outine of an enlarged kidney can often be ascertained by
pressure upon the loin by the extended hand, while the abdominal walls
are relaxed and the patient lies upon the abdomen or side. Palpation
may also be made through the vagina, rectum, or an exploratory incision
in the loin or anterior abdominal wall.
That the product of each kidney may be separately examined, catheter-
ization as well as compression of the ureters has been employed, but with
questionable success. Where compression is made use of the bladder is
well washed out, while both ureters are compressed against the pelvis.
Then one is let go, and after twenty to thirty minutes the urine which has
come through it is drawn from the viscus. The bladder is now again
washed, and the other ureter allowed to flow whilst its fellow is compressed.
CONGENITAL MALFORMATIONs.
Congenital malformations of the kidney, so far as surgery is concerned,
consist of: Anomalies of size, blood supply, implantation of ureter, and
situation in the abdomen. There may be but one kidney present, or both
may be fused together (horseshoe kidney, etc.). Lobulated and multiple
kidneys are unusual. Cystic disease is frequently congenital.
MISPLACEMENTs.
Misplacements of the kidney may be congenital or acquired. They
are of unusual occurrence, and most common in women. One or both
may be displaced; the left more frequently than the right. The amount
of displacement may be inconsiderable, or such as to make diagnosis
almost impossible.
e The organ may be misplaced and fixed, or misplaced and yet movable;
it is generally hypertrophied, but normal in structure.
Simple Misplacement.
In this variety the gland is misplaced and fixed at some anomalous
Point almost anywhere in the abdomen, but usually between bladder and
*ctum or uterus, or over the sacral promontory.
656 DISE AS ES AND IN J U RIES OF THE U RIN A RY O R G A NS,
MOVABLE AND FLOATING KIDNEY.
Here the organ may be normally or abnormally situated, but is capable
of making regular or more or less erratic excursive movements. Movable
kidney differs from floating kidney in that the former remains behind the
peritoneum, and has a more or less limited up-and-down, lateral, or rotary
movement between that membrane and the spinal muscles; while the latter
has pushed through the peritoneum, thereby securing a meso-nephron and
an almost unlimited range of motion. In either case the renal vessels
become elongated. It is frequently impossible to differentiate the two
War 16tleS.
CAUSES.—The causes are loose connections of capsule, injuries, traction
or pressure from growths, hypertrophy or pregnancy, distention of renal
pelvis, and congenital. Most cases, particularly of floating kidney, arise
from the latter cause. During motion of the organ its vessels or ureter
(pedicle) may become twisted, and result either in atrophy of the renal
tissues or distention of the renal pelvis by urine. Floating kidney may
become prolapsed into herniae.
SYMPTOMS.—Evidence of movement or displacement by palpation;
dragging or acute pain in loin or in the displaced organ; sense of a mov-
ing body along spine or in abdomen; pain caused by certain attitudes or
motions, as upon lying upon one side; increased frequency of micturition ;
disturbances of bladder, bowels, stomach, or mini—even hypochondriasis
or insanity.
TREATMENT.-Corsets and imprudent exercise must be avoided. This,
with perhaps the wearing of some supporting mechanical appliance or an
abdominal belt, will suffice for most cases. If the inconvenience or suf.
fering justify operation, nephrorrhaphy should next be performed. Should
this fail, or, in any case, if the organ be also diseased, nephrectomy may
be done after it has been ascertained that a second kidney exists. There-
fore, abdominal nephrectomy will generally be more preferable than
lumbar nephrectomy.
HYDRO-NEPHROSIS.
Distention of the pelvis and calices of the kidney, resulting from back
pressure of urine due to partial or complete mechanical obstruction at a
lower point.
The obstruction may be situated anywhere between the renal pelvis and
meatus urinarius, but is usually found in the ureter, and caused by pres:
sure from without, as by uterine fibroids, etc., also by impacted calculi
and stenosis, chronically over-distended bladder, stricture of urethra, or
phimosis. º
One or both kidneys may be involved, depending upon the site and
nature of obstruction.
The affection may be (1) congenital or (2) acquired.
1. Obstruction is likewise congenital. There is great distention-per-
haps sufficient to interfere with or prevent parturition, and both sides are
nearly always involved. * g
2. Here distention follows injuries and other acquired obstructions to
the renal outlet. w
PATHOLOGY..—The pelvis primarily, and calices secondarily, become diº,
tended and stretched by pressure of the retained urine. Finally, partial
HY D R O - N E P H R O S IS . 657
or total atrophy of the renal substance ensues, the capsule becomes dis-
tended, and the whole organ becomes replaced by one large cyst. Hydro-
nephrotic cysts vary in size from that of the normal kidney to huge pro:
portions. The sac is very prone to form adhesions to the peritoneum and
other surrounding structures. Suppuration may take place within the
cyst, and give rise to pyo-nephrosis. Occasionally they rupture, discharg:
ing their contents into periºrenal tissues or peritoneum. The fluid of
hydro-nephrotic cysts is urine of very low specific gravity, but may in
part be made up of colloid or grumous material.
SYMPTOMS.–The symptoms depend much upon the mode of origin.
Thus, a very gradually acting cause gives rise to no symptoms until a
tumor forms and signs of pressure or ulceration follow. There is always
percussion dulness over an increased area in the loin ; the amount of
urine passed is decreased. When the disease arises from acute cause, as
injury to, or torsion of ureter, impacted calculus, etc., there at once de-
velops great local and radiating pain and speedy formation of tumor.
The swelling will be irregularly lobulated, fluctuating, flat on percussion,
at first occupying the loin, later, perhaps, filling the entire abdomen. The
colon is usually in front. The tumor may disappear from time to time,
concomitantly with a large passage of urine of very low specific gravity,
and perhaps tinged with blood, owing to temporary giving way or re-
moval of the obstruction. This condition is termed intermittent hydro-
nephrosis.
In either form, as a rule, there is little or no local or systemic disturb-
ance, discovery of the tumor being the first evidence of trouble. Uraemia
sometimes supervenes—especially when both kidneys are involved. The
cyst may suppurate or rupture into the peritoneal cavity. *
DIAGNOSIS.—Vaginal and rectal examination is of greatest value. The
contents of the tumor are very similar to ascitic fluid. Diagnosis from
peri-renal abscess or extravasation is frequently impossible, and fortu-
mately is of little consequence, as treatment for both is identical; careful
examination will usually differentiate hydro-nephrosis from ovarian or
parovarian cysts. Prognosis depends upon whether the disease exists
upon one or both sides, rupture or non-rupture of the cyst, and upon the
treatment employed.
TREATMENT_-Examine for and relieve obstruction, if possible. Accu-
mulations of moderate size should only be interfered with when there
is great suffering, inconvenience, or danger to life. Gentle massage of
the tumor may displace an obstructing blood-clot, etc., from the ureter,
and overcome the obstruction.
Operative treatment embraces: 1. Aspiration; 2. Incision and drain-
age; 3. Nephrectomy.
1. In most cases tapping is purely palliative, reaccumulation taking
place in a very short time. Repeated aspirations will occasionally per-
manently relieve. 2. Where such reaccumulation ensues, or suppuration
of the cyst takes place, the sac must be freely exposed from the loin
or through the abdominal wall, incised, washed out, the edges of the cyst
Yound sutured to the external incision, and a large drain-tube left in.
Usually, but not invariably, a permanent urinary fistula persists. Rup-
* of the cyst into the abdominal cavity demands immediate abdomi-
nal section, flushing out of the belly and cyst, and suture of the rent in
the latter to the parietal incision. 3. Nephrectomy may be necessary
When foul discharges continue for a long time to come from the sinus
42
658 DISE A SES AND IN J U RIES OF THE U R IN ARY ORGANs.
remaining after incision; also for annoyances attending the presence of
a persistent fistula, and in certain cases of cyst rupture.
PYo-NEPHROSIs.
Pyo-nephrosis is usually but a late stage of hydro-nephrosis, where
Suppuration within the cyst has taken place. It may also arise from
cases of simple pyelitis, complicated by obstruction. Acute hydro-
nephrosis is especially liable to evolve into pyo-nephrosis. Repeated
tappings, by infecting the cyst, frequently produce the same change; or
infecting material may gain entrance through the ureter from below.
Obstructive calculous disease of kidney or ureter is the almost invariable
primary cause.
SYMPTOMS.–In pyo-nephrosis there is more rapid destruction of kid-
ney substance than in hydro-nephrosis, as well as great constitutional dis.
turbance and severe pain, which is increased by pressure. There are
fluctuations of temperature, chills, and, when chronic, hectic. Tumor
usually cannot be felt. The Sac is apt to form extensive adhesions, and
to rupture into perinephritic tissues, peritoneum, bowels, stomach, peri-
cardium, pleura, or upon the surface; having one or more fistulous open-
ings. Pus may be present in the urine continuously or intermittently,
if the obstruction is not absolute. Should complete destruction of the
kidney take place the sac may shrink, its contents may be absorbed or
caseate, and a natural, though very rare, cure result.
TREATMENT.-The treatment is much the same as for hydro-nephrosis.
Massage should be omitted if painful, and aspiration must not be repeated
if it fails once. The peripheral disease—as stone or stricture—must be
removed if possible. Nephrotomy should be resorted to early, and espe-
cially if peri-nephritis exists; nephrectomy is indicated for long-continued
purulent discharge or where the obstruction is irremediable and per-
manent,
SUPPURATIVE NEPHRITIS.
Inflammation of the kidney which has advanced to a suppurative
Stage.
One or both organs may be affected, but, when both, one to a greater
extent than the other. Foci or pus may develop in many portions of
the kidney (miliary abscess), which later may coalesce into one or more
large abscesses; or, from other causes, one or more large abscesses may
originate in any part of the organ. A common cause will often orig-
imate either or both varieties. The kidney may become a mere pus Sãº,
all renal tissue being destroyed. *
CAUSES.-Miliary abscesses result from pyelitis, the presence of para,
sites, calculi, foreign bodies, decomposed clots, cancer, bladder or urethral
disease, any urinary obstruction, ingestion of irritating drugs, as tupentinº
carbolic acid, cantharides, etc., and as result of pyaemia and septic feyes.
Larger renal abscesses result from coalescence of smaller ones, In,"
ries, septic emboli, metastasis from blood or lower urinary apparatus,
calculi and other foreign bodies, and from continuity or contiguity 9
suppurative or other disease. Such abscesses may (rarely) caseate; or be
absorbed or discharged into the ureter, peri-renal tissues, or elsewhº
SYMPTOMS.–The symptoms are generally indefinite until late. There
P E R I-N EP H R ITIS. 659
is sometimes great constitutional disturbance (“typhoid state”), but just
as often no sign of a suppurative process. Chills, fever, and local pain
or swelling, as well as the history of the case, may furnish valuable clues.
Usually, no pus appears in the urine unless the abscess should rupture
into the ureter.
TREATMENT.—The treatment must be directed to remove disease of
the lower urinary tract, and to prevent continued putrefaction therein.
Vigorous stimulation and supporting constitutional measures are early
indicated. Quinine and laxatives should be freely exhibited. Local
depletion should be reserved for acute cases. If the accumulation be-
come diagnosable or self-evident, it should be promptly laid open, and the
sac washed out, freed of foreign bodies, as calculi, if present, drained and
sutured to the surface.
In doubtful cases exploratory incision down to the kidney may be
employed, and an exploring needle then used to locate the pus if present.
PERI-NEPHRITIS.
Inflammation of the peri-renal cellulo-adipose tissues. Abscess is the
usual result. It may occur at any age from injury, but when otherwise
caused is mostly confined to adults.
CAUSES.–The causes may be (1) intra-, or (2) extra-renal.
1. Laceration or abscess of kidney, ulceration, pyo-nephrosis, pyelitis,
tuberculosis, or calculi.
2. Here the kidney may or may not be involved. The usual extra-
renal causes are: metastasis to peri-renal tissues, or involvement of them
by continuity or contiguity of irritative, inflammatory or purulent pro-
cesses, as from the pelvis, peritoneum, testicle, along retro-peritoneal tissues,
and from the thorax; injuries, urinary infiltration, and infection after
renal operations.
PATHOLOGY..—A limited portion or all of the peri-renal tissues may
be involved. Or the inflammatory process may spread indefinitely to
contiguous structures, or pus burrow along the fasciae to a great extent.
The kidney may remain entirely uninvolved, even after the formation of
Very large abscesses around it, but usually the kidney is primarily in-
volved, and the surrounding tissues secondarily take on inflammatory
action by ulcerative extension or through urinary extravasation.
SYMPTOMs are often disguised and entirely overridden by those of the
causative disease. They vary according to the acuteness or chronicity of
the process. When arising from injury, haematuria is a frequent symptom.
The “typhoid state” often supervenes in chronic or subacute cases. Pain,
deeply-seated, dull, and increased by pressure or motion, exists, perhaps
intermittently, in the loin. A sense of resistance and hardness is detected
deep in this region. The corresponding testicle may be retracted, and
bladder irritation, with increased frequency of micturition, may be
present. Or all symptoms may be referred to the hip. Indeed, the con-
tiguity of the psoas muscle to the seat of disease may readily confuse the
Wo diseases, especially when, as occasionally happens, a peri-nephritic
abscess ruptures into the sheath of that muscle and points in the groin
or upon the thigh.
When abscess has formed, fluctuation may be developed in the loin, but
usually not unless the collection is quite large, when a marked tumor
With superficial cedema appears in the flank. If not interfered with, the
660 D IS E A SES AND IN J U R IES OF T H E U R IN A R Y O R G A N s.
abscess will open upon the abdominal wall, through the pelvis upon the
buttock, into intestines, peritoneum, vagina, bladder, rectum, lung, or
psoas sheath. The contained pus is often violently offensive, but may be
odorless. &
DIAGNOSIS.—Peri-nephritis must be distinguished, by the above and
elsewhere noted symptoms, from rheumatism, hip, spine, or kidney dis.
ease; when upon the right side, from appendicitis and perityphlitis; from
typhoid fever, impaction of feces, empyema, and pulmonary abscess.
TREATMENT.-Under local counter-irritation and depletion, hotfonenta-
tions and laxatives, some cases of peri-nephritis will resolve. But so soon
as there is reason to suspect the presence of pus, a lumbar incision, as for
nephrotomy, should be made. If pus be found, make the incision quite
free, explore the cavity and surface of kidney, or its interior if opened up,
with the finger, to find a stone or other foreign body if present. If a sinus
only connects the kidney with the abscess, it should be thoroughly ex-
plored by a probe or finger. All sloughs are now curetted away, the cavity
well washed out with antiseptic solution, and the wound sutured, leaving
in a very large drain-tube. Urinary fistula does not usually form or
persist.
Incision will be followed by great relief, even if made before actual
pus formation. It should be free and subsequently well drained. If the
source of trouble is found to be a suppurating or tuberculous kidney, the
question of immediate or subsequent nephrectomy should be considered.
TUBERCULOSIS OF KIDNEY.
Tuberculosis of the kidney exists in two distinct varieties: 1, As part
of a general miliary tuberculosis, having no surgical importance, and, 2,
where the disease is localized in the kidney, or therein exists in conjunc-
tion with tuberculosis of other portions of the urinary tract.
2. In adults, but one kidney will be found involved in one-half of all
cases; in children, both are affected more frequently. Persons of all ages
seem equally liable to the disease. . Usually, cheesy masses form in the
renal papillae, and extend deeply into the kidney substance, involving
new areas in all directions. These foci may coalesce, degenerate into puri.
form material, and form a cold (tubercular) abscess. The kidney sub-
stance is more or less, perhaps entirely, destroyed. The ureter may become
plugged with pultaceous tubercular material. A large tumor may form,
but more usually enlargement cannot be made evident. When renal
tissue is entirely destroyed the contents of its capsule may shrink and
calcify, or in any case where the pus remains fluid or increases in amount
the capsule may ulcerate and let it pass into adjacent tissues or organs,
whence it subsequently makes its way to the surface. Tubercular nephritis
may be complicated by the presence of renal calculi, when the disease
becomes much more acute, rapid, and destructive. g
SYMPTOMs.-At first there is often unaccountable physical depression,
then pain and tenderness in the loin, but the urine as yet remains tº
changed. At a later period blood, but in trivial amount, pus, tubercle
bacilli, and cheesy masses may appear in it, but never tube-casts. With
these phenomena great irritability of the bladder with increased frequency
of micturition develops, and constitutes a very significant symptº:
Later still, rigors, sweats, hectic, and perhaps fluctuating tumor in the loin
appear, or, in lieu of the latter, the quantity of pus in the urine may
R E N A L C A LC U L I. 661
greatly increase. On the other hand, any, or almost all, symptoms may
be absent in not a few cases.
This disorder is most liable to be confounded with renal calculus, but
may usually be differentiated therefrom by the degree of constitutional
involvement in tuberculosis, and by the absence of bacilli and much
greater amount of blood in calculus. Inflammation of the lower urinary
tract is common in the former disease, rare in the latter.
If tuberculosis attacks both kidneys or affects a wide expanse of the
urinary tract, death usually ensues in from a few months to several years.
If one gland alone be affected, cure may result spontaneously or through
surgical aid. General miliary tuberculosis may occur.
TREATMENT.—The general condition of the patient should receive
treatment appropriate to tuberculosis elsewhere. Locally, nephrotomy
and drainage or antiseptic packing should be employed. When early
undertaken, this method is satisfactory in result, but when operation is
performed after general destruction of the organ or formation of peri-
nephritic abscess, nephrectomy is more advisable if the other kidney and
the lower urinary organs are not similarly affected.
RENAL CALCULI.
Renal calculi may form at any age, but are not frequent before the fif-
teenth and after the fiftieth year. They may be congenital, present in one
or both kidneys, single or multiple. They vary in size from a few grains
to several ounces in weight, and in shape from round, or round with
facets where they touch one another, to an exact cast of the pelvis and
calices of the organ.
CAUSES.—The causes are generally constitutional: those predisposing
to deposit of uric acid or to decomposition of the urine. But inflamma-
tory disorders of any portion of the urinary apparatus with decomposition
of urine may, by extension to, or irritation of, the kidney, give origin
to them. Foreign substances, as blood-clots, tumors, etc., in the gland may
likewise cause deposition of urine salts and the formation of a calculus.
When arising from constitutional cause, both kidneys are commonly in-
Volved, but when from local causes the disease is usually unilateral.
Stones located in the tubular substance give rise to severe symptoms
even when of minute size, while those situated in the renal pelvis or
calices may be large, and exist for a long time without causing definite
Symptoms or being suspected.
Usually the nuclei of renal calculi are formed by salts precipitated
from the urine in retention cysts, or by decomposition transmitted to the
pelvis of the gland through the ureter. These become plastered together
by mucus, blood, etc., and upon the nidus thus formed are deposited layer
after layer of uric acid or salts, until a calculus of varying size is pro-
duced. Stones may arise in any portion of the kidney, but always pro-
duce more or less nephritis or pyelitis, according to their situation. Ab-
SČess may originate around them. Those which develop in the renal sub-
stance form a bed for themselves by pressure absorption, and are apt to
ulcerate into the pelvis or a calyx. Rarely they make their way through
the capsule, escape into the surrounding tissues, and cause perinephritic
*bscess. By dropping into the ureter they may pass into the bladder or
become lodged in that canal, and give rise to urinary obstruction with
*ute hydro-nephrosis and “renal colic.” Should both ureters become
662 DISE As ES AND IN J U R IES OF THE URIN ARY O R G A N S.
obstructed, death may ensue from uraemia. From the bladder they may
pass per urethram, or remain and give rise to vesical calculus. Finally,
a stone may become completely encysted in the kidney and give rise to
no further annoyance.
s."; no symptoms are present the case has not yet become
surgical. But if signs are present they usually comprise continuous or
intermittent dull or agonizing pain in the loin, with retraction of the
corresponding testicle, and perhaps referred pains in the penile head or
shooting down the thighs. Or pain may be dull with acute exacerba-
tions.
There is vesical irritation, increased frequency of micturition, and per-
haps spasm; continuous or intermittent haematuria, even pus in the urine
in acute cases or where renal suppuration or pyelitis has been set up.
Albumin may likewise be present intermittingly or continuously either
from kidney irritation or consecutive—perhaps chronic—nephritis. The
posture of the patient is such as to relax and ease the affected side and
to prevent jarring or motion, Exercise, carriage or horseback riding
cannot be tolerated, or may precipitate an attack of renal colic, Pain
is increased also by pressure. Rarely very large stones can be palpated,
or, where there are several, may be felt to grate upon each other. Sym-
pathetic pain in the opposite kidney may simulate the presence of stone
there also, but other symptoms will be absent.
Constitutional symptoms of grave character may develop from kidney
changes incident to the presence of calculi. A history of former attacks
or of having passed uric acid or minute concretions is of great diagnostic
value.
TREATMENT.--When it is known or strongly suspected that renal
calculus is present, and the symptoms are distressing or urgent and
demand more than tentative treatment, the operation of nephro-lithotomy
should be performed. Even should operation be undertaken and no
calculus discovered, symptoms are invariably more or less relieved thereby,
and there are few risks involved. Moreover, diagnosis is thus established.
Where calculus is complicated with hydro- or pyo-nephrosis, etc., the
indications are, if possible, even more strongly in favor of operation.
Nephrectomy may be found necessary to permanently relieve certain
complicated cases.
Renal Colic.
Renal colic occurs when a calculus enters the ureter. Its onset is gen:
erally very sudden and unexpected, and apt to set in after exertion,
coughing, straining, etc., have displaced a calculus from its renal bed.
Pain is most intense, often causing nausea, vomiting, fainting, or collaps;
It darts down the lumbar plexus into the testicle, penis, and thigh, Chill
or convulsions may follow. There is great vesical irritability, tenešmº,
and desire to micturate frequently. The urine is blood-tinged, dimi".
ished in quantity, and loaded with urates. Copious perspirations take
place. These symptoms continue unabated or intermittently, while mus-
cular action and urine pressure force the stone along the ureter and
finally into the bladder, when they cease like magic. From a few nº
ments to as many days may be consumed in the making of this transit.
Successive stones may follow the first at varying intervals.
TREATMENT.—Anodynes to control or palliate pain, and even an *.
thetic for the more severe paroxysms, should be freely administered.
T U M O R S OF T H E KID N E Y. 663
Local or general application of moist heat is very grateful. If symptoms
persist unduly the ureter must be cut down upon and the stone extracted.
The latter is especially indicated where uraemic symptoms ensue from
obstruction of one or both ureters.
RENAL FISTULAE.
Renal fistulae are passages other than its normal outlet connecting the
kidney with the skin surface or other organs. These usually are caused
by ulcerative, suppurative, or obstructive disease, and as a result of acci-
dental or surgical wounds of the organ. .
The sinuses may communicate with the rectum, small intestine, stomach,
vagina, or open upon the groin, thigh, etc., and may themselves become
blocked by concretions and originate obstructive symptoms. Pus usually
accompanies the urinary discharge. The entire secretion of a kidney, or
but a very small proportion, may thus escape.
TREATMENT.-The cause which has given rise to the fistula should be
removed if possible, communication with the kidney made evident, and
a long time allowed for the tract to close spontaneously, if it will, before
other treatment is undertaken. If no success results from these methods,
stimulating injections, applications of the cautery, or laying open the
sinus may be tried. These also failing, and the patient's condition de-
manding, nephrectomy should be done.
TUMoRS OF THE KIDNEY.
These may be (1) solid or (2) cystic.
1. The solid tumors which affect the kidney are: sarcoma, carcinoma,
papilloma, lipoma, and rhabdo-myoma. Carcinoma is most usually meta-
static. All are prone to degenerations. They occur with equal frequency
in either sex and at all ages. Both kidneys are not uncommonly con-
jointly or consecutively involved. Renal tumors mostly originate in the
peripheral cortex and spread inwardly. There is little tendency to involve
neighboring structures, or to spread along lymphatics, unless it be during
advanced stages, but great size is frequently attained.
SYMPTOMS.–The symptoms are generally obscure until enlargement
of the organ can be made out. Cachexia and great loss of weight indi-
cate a malignant tumor. Pain—perhaps referred to distant points—may
or may not be present. In sarcoma, carcinoma, or papilloma the urine
may contain blood or bits of the growth which may be recognized micro-
scopically. Fever is generally absent. Varicocele and other pressure
Symptoms are often very marked.
...DIAGNOSIS.—The diagnosis at any stage of development is often impos-
sible without exploratory operation. Growths are diagnosed from inflam-
natory enlargements, by absence of fever, also of severe pain, as a rule.
Renal tumors do not project backward, the colon is always in front; there
is no line of percussion resonance between the growth and spinal column,
and it is usually of symmetrical rounded proportions.
TREATMENT—Benign growths, when recognizable, require no treat-
*ent except for pressure symptoms or inconvenience occasioned by
their size, when nephrectomy may be considered. When malignant
"mors are diagnosed and there is fair reason to believe that they are of
664 DISE ASES AND IN J U RIES OF THE U RIN A R Y O R GANs,
primary origin, limited to one kidney, and other structures have no
become likewise diseased, nephrectomy should be attempted.
2. Cystic tumors of the kidney other than have already been consid.
ered, embrace: simple obstruction or conglomerate cysts—usually limited
to one kidney; congenital cystic disease, which is always bilateral, may
develop to enormous size before birth, in infancy, or even late in life, and
in which condition one renal gland is unable to supplement or assume
the work of its fellow ; and echinococci, or hydatid cysts. The latter
are rare, usually involve the left kidney, behave in a manner almost pre-
cisely similar to hydro-nephrosis; may attain huge size, entirely destroy
the kidney and rupture or suppurate into contiguous tissues or organs.
TREATMENT.-All cysts, when large or inconvenient, should be treated
by incision and drainage (nephrotomy) through the loin or any prominent
fluctuating point. This measure failing, nephrectomy may be employed
in all except those arising from congenital cystic disease, as in the latter
the affection is invariably bilateral, and nephrectomy will certainly cause
death from uremia.
INJURIES OF THE KIDNEY.
Slight contusions, with or without haematuria and swelling in loin, may
give rise to nephritis (traumatic nephritis). More severe contusions may
give rise to laceration of kidney substance or rupture of the organ.
Such injuries areattended by great shock, haematuria, or even severe or
fatal hemorrhage through the ureter, and perhaps effusion of blood and
urine into the peri-renal tissues or peritoneum. Peri-nephritic abscess,
pyaemia, suppression of urine, and uraemia, also bladder trouble from
putrefaction of clots remaining in it, may subsequently ensue. Or the
ureter may become choked with clots, cause obstruction, and thus facili-
tate even greater extravasation of urine; or it may become obstructed
permanently by contraction of cicatrices or adhesions.
TREATMENT.-Ordinarily rest, anodynes, and an ice-bag to the affected
loin are all that will be required primarily. Symptoms of inflammation
call for local depletion or counter-irritation and warm poultices or formen-
tations. Hemorrhage may in addition be treated by pressure, as with a
tight abdominal binder. Peri-renal abscess or extravasation should be
treated by incision. Rupture into the peritoneal cavity must be treated
by immediate abdominal section and perhaps nephrectomy.
OPEN WOUNDS OF THE KIDNEY.
Open wounds of the kidney are usually inflicted by knives, bullets, or
splinters. When entering from behind, the peritoneum may escape injury,
but when the direction of the vulnerating force is from the front, almost
invariably that membrane is injured. The kidney may prolapse through
an extensive wound. º
SYMPTOMs.--The symptoms of this class of injuries are mainly thºse
described under Contusions. Urine and hemorrhage may come from the
wound. Shock is severe. Peritonitis soon arises if the abdominal cavity
is involved. Suppurative processes in the kidney are apt to follow.
TREATMENT.—The wound should be enlarged, explored and cleansed.
Hemorrhage is best controlled by packing-in gauze strips. If bleeding
does not persist, suture the wound, leaving in a large drain-tube and
dress antiseptically. If the kidney is hopelessly crushed or hemorrhage
O P E R A TI O N S UP O N T H E KII) N E Y. 665
cannot be controlled, nephrectomy must be resorted to at once. If the
peritoneum is involved, abdominal section, followed by thorough cleansing
of the abdomen and the leaving in of a drain-tube to the seat of injury
should be performed without delay. When the kidney is prolapsed
through a wound, but not badly injured, it may be cleansed, returned to
proper position and there retained by sutures or packing; but if much
injured it should be cut from its pedicle after thorough deligation and
removed.
OPERATIONS UPON THE KIDNEY.
Aspiration.
Aspiration or tapping of the kidney should be performed under rigorous
antiseptic precautions. The aspirating needle should be inserted into
any prominent fluctuating portion of the tumor, but if such does not exist
the kidney may be entered by introducing the instrument in a forward
and inward direction at a point two and a half inches posterior to the
center of a vertical line drawn from the last rib to the anterior superior
iliac spine.
Nephrorrhaphy.
Nephrorrhaphy is the operation of suturing a movable kidney to the
posterior abdominal wall. The bowels having been well emptied by
laxatives and enemata, the patient is placed upon his unaffected side
with a pillow or padded block beneath the loin, that the opposite flank
may be made prominent and the space between the ribs and ilium
made as great as possible. The affected kidney must also be steadied
by pressure upon the anterior abdominal wall. The twelfth rib is now
located by counting from above downwards, and a four and a half inch
incision is made parallel with it, but three-quarters of an inch lower,
and carefully deepened until the fatty renal capsule is well exposed. If
the anterior border of the quadratus lumborum muscle is in the way it
should be freely divided. Excessive hemorrhage can be controlled by
temporary firm packing with hot sponges or gauze. The capsule is now
well drawn out and sutured by from eight to twelve strong chromicized
catgut sutures to the deepest portion of the wound. The wound is now
closed by deep sutures, several of which should also pass through the
fibrous capsule or even tubular substance of the kidney. A large drain-
tube should be left in, or if there is continued hemorrhage the wound
should be packed and allowed to heal by cicatrization, thereby securing
an even stronger anchorage. Recumbent posture must be maintained
for five or six weeks, until all adhesions have become firm and strong,
and a well-fitting abdominal belt worn for a year or two following.
Nephrotomy.
Incision into any portion of a kidney. Incision is made as in nephror-
rhaphy until peri-renal fat, tumor, cyst, or abscess is met with. The
fatty capsule is torn through between forceps, or the cyst or abscess cut
into at once. Bleeding must be controlled by temporary packing or
ligatures as the operation proceeds. After the kidney has been well
$xposed, and palpated or explored by needle, it is cut into, if necessary,
in a longitudinal direction in the plane of the uriniferous tubules
666 DISE ASES AND IN J U RIES OF THE U R IN A RY O R. G. A. N. S.
with a narrow-bladed scalpel. If the disease is found to be limited to
the renal pelvis that portion only should be divided. A finger is then
introduced into the renal substance or pelvis and exploration made.
Even if no disease be found, simple incision into the kidney is usually
followed by disappearance of all pain and former symptoms. Wounds of
the renal tissue often bleed fiercely, but bleeding is easily controllable and
Soon ceases when packing is resorted to. When large cysts are incised
º
FIG. 402.
U Dungkºuni. Dâsı
Horizontal section of body between second and third lumbar vertebrae looking upward.
Right side of subject is at the reader's left hand. Relation of kidneys to peritoneum
and muscles is shown. Peritoneum indicated by dotted line. (LANGE.)
their walls should be sutured to the parietal wound, which should in turn
be drained and deeply sutured or packed and allowed to granulate. The
tube should go to or even into the renal incision. Secondary hemorrhage
must be treated by packing, ligature or cautery. After kidney incision
urine may discharge from the external wound for several weeks, or a
permanent fistula may form, but is unusual in absence of urinary
obstruction. -
Nephro-lithotomy.
Incision into and removal of a calculus from the kidney. The pro-
cedure is almost identical with nephrotomy. When the kidney has been
well exposed, as above, it is carefully palpated by carrying the index-
finger over it systematically in all directions. This failing to locate the
stone, an exploring needle may be inserted in various directions. A
calcareous vessel may impart the sensation of having struck a calculus.
When the stone is located, incision is made directly down upon it as
nearly as possible' in the plane of the tubules, and it is removed by the
finger or forceps. But if no stone can by the above means be located,
the kidney may be incised, and an exploring finger introduced. When
one calculus has been removed search should be made for others which
may be present.
Nephrectomy.
Removal of a kidney. The kidney may be excised without interfering
with the peritoneum, by the (1) lumbar or posterior method, or by the
(2) abdominal or anterior method through the peritoneum. Both pro-
cedures have marked advantages and distinct fields in certain cases. .
1. This method affords the advantage of non-interference with perito"
neum and excellent drainage, but is attended by the great disadvantagº

O P E R AT I O N S U P O N T H E KID N E Y. 667
of having often to ligate the pedicle at great depth, and not being able to
ascertain the condition of the opposite kidney. The principal accidents
to be feared are: tearing of the peritoneum, colon, or vessels of the
pedicle, or opening up the pleural cavity by a too extensive or too high
In ClS1Oll.
It is particularly adapted for small solid or cystic tumors, inflammatory
disease, or where operation is undertaken to relieve urinary fistulae, or by
those unfamiliar with abdominal surgery.
2. This method permits examination of the opposite kidney, gives room
to deal with and permits easy extraction of large growths, for which, and
floating kidney, it is chiefly indicated. In the hands of those skilled in
abdominal work this procedure may the more frequently, and for other
conditions, be employed.
LUMBAR NEPHRECTOMY.—Incision is made and the kidney exposed as
in nephrotomy. If then more room is required, a second incision may be
carried vertically downward as far as may be necessary from a point about
one inch anterior to the posterior extremity of the primary wound. The
organ is then rapidly shelled from its fatty bed, and the pedicle, consist-
ing of vessels and ureter, isolated. This is most easy where adhesions do
not exist. Otherwise they must be carefully separated by the fingers.
If adhesions are very strong, the kidney capsule must be incised from end
to i. and the renal substance shelled out in the form of tumor and
pedicle. &
The organ is next brought into the wound, or out of it, but using only
the slightest traction upon the pedicle. The latter is now isolated by
transfixion with an aneurism needle armed with a double extra strong silk
ligature into two portions—one consisting of the bloodvessels, the other
of the ureter—and each is separately ligated. A third ligature is now
ºwn around the entire stump at a more peripheral point and firmly
tied. -
The pedicle is then grasped by forceps and the kidney cut away con-
siderably above the ligatures. If the ureter is healthy, it may be dropped
into the wound with the pedicle; otherwise it should be isolated and
sutured to the skin margin. If the growth be very large, it may some-
times be found preferable to place a snood or rope écraseur about the
pedicle and cut away the tumor before ligation is done. No consider-
able traction must ever be placed upon the pedicle, as it is apt to be very
friable, and when torn gives rise to terrific hemorrhage, The wound
should be closed and dressed as in nephrotomy.
ABDOMINAL NEPHRECTOMY.—Abdominal section is made, as a rule,
through the linea semi-lunaris of the affected side. Its situation and extent
will depend upon the size and location of the kidney, but usually its centre
Will be upon a level with the umbilicus. In certain unusual cases median
incision will prove more advantageous. The presence and condition of
the opposite kidney is then ascertained by a finger introduced through the
Wound. If that organ is absent or also palpably diseased, nephrectomy
should be abandoned and the wound closed. Otherwise the colon, which
usually presents in the wound, is pushed outward and back toward the
Špine, and the posterior layer of the meso-colon is exposed covering the
kidney. While intestines are kept away with large retractors or flat
Sponges, the meso-colon is incised vertically four inches.
If the tumor be cystic, it is now tapped with a large trocar and its con-
tents withdrawn. Otherwise the meso-colon incision is extended suffi-
ciently to permit delivery of the growth. Two fingers or the hand are
668 DIS E A SES AND IN J U RIES OF THE U R IN A R Y O R G A NS,
now introduced, the kidney shelled from its bed, and a pedicle isolated.
The tumor is now raised up or delivered without traction upon the
pedicle, and the latter is ligated as in the lumbar method. If the ureter
is extensively diseased, it should be isolated and sutured in the abdominal
wound or brought out through a counter-opening in the loin made by
thrusting the knife from within outward. Drainage may be secured by
the usual glass abdominal drain, or by a tube through the counter-opening.
Whº the latter is employed, the meso-colon wound should be sutured, if
possible.
THE URETER.
This canal is liable to obstruction, and to become affected by extension
of disease from the kidney above or bladder below. It is but very rarely
primarily involved by disease. Obstruction of the ureter, as by a de-
scending calculus, usually gives rise to obstructive symptoms, renal colic,
or kidney disease. Injuries may give rise to extravasation of urine or
result in cicatricial obstruction. Obstruction from impacted calculus may
occasionally demand abdominal section and removal of the stone. Ne-
phrectomy of the corresponding kidney may be called for by the same, or
when the ureter has been ruptured or divided, as by a stab or gunshot
wound.
Catheterization of the ureters has for its object to ascertain whether the
canal is pervious or to find out the condition of the urinary secretion
coming from each kidney. The operation is only possible of application
in the female. The urethra is dilated, a finger inserted, and a ureteral
orifice located. A special catheter is then passed along the inserted finger
as a guide and into the ureter. When a sufficient amount of urine has
been secured the instrument is withdrawn, cleansed, and then introduced
likewise into the other ureter. Attempts to locate the ureteral outlets,
and into them insert the catheter by the guidance of a finger in the
vagina, usually fail.
THE BLADDER.
METHODS OF ExAMINATION.—The usual method of exploring the
bladder is by means of solid metal sounds, through which are conveyed
to the educated hand a more or less accurate idea of the condition and
solid contents of the viscus. To the instrument can be attached a sound-
ing board which will amplify sounds elicited from contact with foreign
bodies or calculi for class demonstration.
Digital examination through the vagina, rectum, or bimanual explora;
tion—a finger in the rectum or vagina, and a hand upon the abdominal
wall—are all useful methods, but must be gently performed, especially in
the presence of calculi or foreign bodies.
But best and most accurate of all methods is the electric cystoscope
of Nitze and Leiter, which affords a visual examination of the entire
bladder wall and its contents. The male bladder may also be explored
by means of perineal or supra-pubic cystotomy; the female bladder by
dilatation of the urethra and digital examination.
CONGENITAL MALFORMATIONS.
Congenital malformations are unusual. There are several varieties,
such as entire absence, multiple, or two-lobed bladder with a septu"
E X ST R O PHY. 669
between and a ureter emptying into each division, exstrophy, and per-
vious or patent urachus,
Evstrophy.
A congenital condition wherein proper development of the alantois is
interfered with during intra-uterine life, and results in failure of the
anterior walls of the abdomen and bladder to unite in the median line.
Possibly, portions of the abdominal or bladder wall may be absent. The
defect is invariably associated with absence of the symphysis pubis, and
in the male with complete epispadius. Males are more frequently affected
than females, in the proportion of ten to one. This condition, with its
associated deformities, is the one which most commonly gives rise to
instances of mistaken sex and to cases of so-called hermaphrodism.
SYMPTOMS.–At the site of non-union of the lower abdominal wall
a glossy red vascular prominence presents, terminating below in the
groove of a deformed or split penis, or, in the female, in a divided clitoris
and labium minor on each side. Above, the prominence usually termi-
mates at the site of the umbilicus, which is absent. The recti muscles are
greatly separated clear to their ensiform insertion. The symphysis pubis
is absent, but the ends of the pubic bones project or can be felt about two
to four inches separated on each side, and are connected beneath the urethra
by a tough ligament made up of the hypertrophied sub-urethral fibres of
the triangular ligament. The penis is flattened or split, complete epispa-
dius exists, and the scrotum may likewise
be divided or absent. FIG. 403.
The testicles are usually in the scrotum, |
but may remain in the abdomen or inguinal
canal. Hermiae frequently co-exist.
There is spreading of the pelvis, conse-
quent separation of the thighs, and a char-
acteristic waddling gait from this cause,
and from bending forward to prevent fric-
tion upon the exposed posterior bladder
wall. This latter is usually covered with |
sensitive granulations, which bleed upon

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slightest contact. The ureteric orifices are | º ſº
plainly visible, and perhaps surrounded 4” *#
by masses of granulations. From them 4; \\
urine flows in intermittent jets. Intra- \\ a
abdominal pressure, as from standing, * .
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tinual contact of urine. §
TREATMENT at very best can be but pal-
liative, and is often futile. India-rubber
urinals of special design may be worn by adults to protect the surfaces
and collect the urine, but cannot be applied to children, and are never
fully satisfactory. An attempt should be made in certain cases to partially
or Wholly cover-in the exposed surfaces by a plastic operation. The male
genital organs when involved cannot be rendered potent.
There is usually present everything to make an operation difficult and
unsuccessful: the abdominal walls are very thin, hermiae may exist on
Urimal for exstrophy.
670 DISE AS ES AND IN J U RIES OF THE U R IN A R Y OR GANs,
each side, the health is run down, great eczema is present, and asepsis
cannot be maintained.
OPERATION.—All hair upon the proposed flaps having been pre-
viously destroyed by depilation or nitric acid, the parts and surroundings
are made surgically clean. Three flaps are now outlined. A large one
is dissected from above the exposed mucous membrane, and a smaller
one from each groin. The upper flap is now turned, skin surface down,
over the bladder, and its upper angles sutured with wire to the lower
FIG. 404. FIG. 405.
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Operation for exstrophy of bladder. (AsHHURST.)
corresponding angles of the groin flaps at the base of the penis. The
inner apposed edges of the groin flaps are now sutured together in the
median line over the raw surface of the turned-down abdominal flap,
from a point close to the penile root upward as far as they will extend.
The distal extremities of the denudation wounds are coapted with hare-
lip pins, while the raw surfaces remaining are allowed to granulate
and cicatrize. Great care is necessary in dissecting the flaps not to
injure the peritoneum, also to handle them carefully without traction or
forceps, for fear of subsequent sloughing. Nor must any great tension be
put upon them in suturing; during which latter, and until healing is com-
plete, the shoulders should be kept elevated and the thighs flexed, to
secure utmost relaxation. By this operation, if successful, irritation is
relieved, and all urine is delivered at a single dependent point, to which
a urinal may be readily fitted and worn. The operation is attended with
considerable danger.
In the female, an extra large abdominal flap should be cut, and the
inguinal flaps should run down well into the labiae, so that when all are
coapted the vagina is also covered in. A large tube should be placed
therein and frequently cleansed.
Pervious Urachus.
Pervious urachus may be partial or complete—the latter when it opens
externally at the umbilicus. It is often associated with congenital absence
or obstruction of the urethra. The canal may be much dilated.













CY STITIS. 671
The entire urinary secretion may pass from the umbilicus, a constant
dribbling going on, or this may take place, in varying quantity, only when
micturition is performed or attempted. The umbilicus and its surround-
ings become eczematous, and a granular red vascular prominence sur-
rounds the urachal orifice, through which a probe may be passed, or
perhaps a catheter or finger carried into the bladder. Calculi may arise
in or be delivered from the bladder into the urachus and be discharged
from the umbilicus. Any eczema about the umbilicus should excite sus-
picion and search for a patent urachus.
TREATMENT.—The treatment must first be directed to removal of ob-
struction causes; then the edges of the opening may be cleansed, pared,
and deeply sutured.
Congenital vesico-rectal fistula, due to absence or defect of the posterior
bladder wall, is irremediable, the patient usually soon dying from intense
rectal irritation and diarrhoea. Other congenital vesical fistulae are
described elsewhere.
DISPLACEMENTS.
Displacements of the bladder are almost limited to females, except
where the viscus has been drawn into the inguinal canal or scrotum as a
constituent part of a hernia. Other displacements are: prolapse into the
vagina (vaginal cystocle) or through the urethra. The latter, which is
almost wholly confined to young children, may be complete (inversion)
or incomplete. Complete prolapse presents a dark-red mass constricted
about the base with the ureter orifices in sight. It may be reduced by
continued gentle pressure and manipulation. To cut off or ligate the
mass would be a fatal error.
Vaginal Cystocele.
Vaginal cystocele, of varying degree, is quite common in women who
have become relaxed or torn hereabouts in childbirth. It protrudes, when
distended, into the vagina or from the vulva as a globular, fluctuating
tumor and may contain calculi. It may give rise to serious diagnostic
error during, or to interference with, parturition. However, its nature
can always be determined by passing a sound.
TREATMENT.—Excise one or more large oval areas of vaginal mucous
membrane from the surface of the cystocele and suture the edges together
from side to side. Any perineal tear should be repaired at the same time.
CYSTITIS.
. Cystitis, or inflammation of the bladder, may be acute or chronic and
involve one or all of the vesical walls. In a large majority of cases, how-
ever, the mucous membrane is alone affected. Any degree of inflamma-
tion from the mildest catarrh to that resulting in gangrene may prevail.
Cystitis is almost always symptomatic of other troubles.
Acute Cystitis.
Acute cystitis is less common than chronic, which it may supervene
upon or give rise to, and is most frequent in men. Usually it is caused
y exposure, injuries, extension of septic or inflammatory affections from
672 DISE AS ES AND IN J U R IES OF THE U R IN A R Y OR GANs,
the urethra (in gonorrhoea) or kidney, low fevers, the presence of foreign
bodies or tumors, acute retention of urine, chemical and bacterial changes
in the urine, ingestion of irritating drugs, by operations upon the organ,
and by rough or unclean instrumentation.
PATHOLOGY of lesser degrees of acute cystitis corresponds with that of
mucous membrane inflammation elsewhere. Where the process is more
violent the lining membrane presents a dark crimson hue throughout,
deepening to purple or even black about the neck, is ecchymosed, and in
places may be necrotic and the muscular layer exposed. Hemorrhages
may occur from bursting veins or separating sloughs; or perforation into
the surrounding tissues or peritoneal cavity take place. Peritonitis may
arise without actual perforation.
SYMPTOMs.--Rigors or marked chill succeeded by burning pain in the
bladder and glans penis, dull pain in the perineum, increased frequency
of and spasmodic pain during micturition, and more or less fever, constitute
the ordinary symptoms of acute cystitis. Pressure upon the bladder is
intolerable. The urine may be blood-tinged throughout the attack, but
more usually is replaced soon by pus and becomes ammoniacal. Acute
retention is common.
If the exciting cause be promptly removed resolution usually at once
takes place. Otherwise it may terminate fatally, or gradually subside
into the chronic variety. The more violent forms are exceedingly dan-
gerous.
TREATMENT.-The patient should be given a hot bath and be put to
bed. Leeches should be applied to the perineum or hypogastrium and
succeeded by poultices. The cause must be sought out and removed, if
possible. Laxatives and mucilaginous or alkaline diluent drinks, perhaps
aconite by mouth and anodynes by rectum, must be exhibited. If symp-
toms continue the bladder should be washed out once or twice daily, and,
all these failing, perineal or supra-pubic cystotomy must early be resorted
to. Retention is relieved by the catheter as often as necessary.
Chronic Cystitis.
Chronic cystitis usually results from long-continued vesical irritation
or follows an acute attack. It is an inseparable accompaniment to many
disorders of the urinary tract, and is usually symptomatic of other dis-
orders. Causes are: changes in the urine, presence of tumors or foreign
bodies, retention of or residual urine, disease of the kidney, prostate or
urethra, instrumentation, injuries, venereal excesses. Stricture is the most
prolific cause.
PATHOLOGY..—The vesical mucous membrane becomes swollen, rugous,
softened, and presents patches of capillary engorgement or ulceration.
The epithelium desquamates rapidly; mucus at first and then pus is poured
out in large quantity. The urine may be acid at first, but soon becomes
alkaline and putrescent. Pus and mucus, also frequently blood, are
prominent features. Decomposition precipitates the urinary salts, and
calculi or calcareous deposits upon the bladder walls are of frequent
occurrence. When the disease has been of long duration the muscular
wall becomes either hypertrophied and contracted, or its fasciculi become
irregularly stretched apart while the mucous membrane sinks into the
intervals, giving rise to the condition known as sacculated or ribbed
bladder. These depressions or sacs may become large and retain decom"
CY ST IT I S. 673
posed urine, act as receptacles for calculi, or perforate and give rise to
peritonitis or peri-vesical abscess. . The ureters and kidneys sooner or
jater also become involved, and add greatly
to the seriousness of the disease. FIG. 407.
SyMPTOMS.–The symptoms are mainly 23;
those of the acute variety, but in milder de-
gree. Only slight fever is ever present, but
the combination of pain and other distress
rapidly undermines the general health. Renal
implication makes a general breakdown even
more rapid. The urine is turbid, alkaline,
and contains much mucus and pus, which
forms a tenacious clot at the bottom of the
retaining vessel. The bladder wall in late
stages will be found ribbed and sacculated
by the exploring sound.
FIG. 406.
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Enlarged prostate with ribbed and saeculated Double or “two-way ” catheter for
bladder. (DRUITT.) washing out the bladder.
* TREATMENT—The cause must be found and removed. Rest in bed
is essential; no exposure of any kind must be allowed. Milk is the best
diet. Drugs, such as quinine, capaiba, buchu, oil of sandalwood, salol,
and laxatives are useful for their general or local effects. Depletion by
leeches to the epigastrium or perineum and hot local applications are
both curative and comforting. If, with the above, symptoms do not rap-
idly subside, the bladder should be washed out once daily, at first with
simple hot water, but later with antiseptic solutions of gradually increas-
ºng strength as the organ becomes more tolerant: such as nitrate of
silver (gr. 1 to oz. 1 of water), borax (gr. 5 to oz. 1 of mucilage-water),
ºtric acid (m. 1 to half-pint of water), and, especially where urinary
decomposition is excessive, quinine bisulphate (gr. 2 to oz. 1). An injec-
tion of a grain of morphia in two ounces of water and allowed to remain
in the bladder will give ease or a good night's rest in many cases.












43
674 DISE As ES AND IN J U R IES OF THE U R IN ARY O R G A NS
These methods having failed, nothing remains but to perform perineal
cystotomy, which gives permanent drainage and rest to the bladder. In
women this latter can be accomplished by dilatation of the urethra, or by
making an artificial vesico-vaginal fistula.
TUBERCULOSIS OF THE BLADDER.
Tuberculosis of the bladder is not so rare an affection as formerly was
thought. It occurs most frequently in males, and between the twentieth
and fiftieth year. Generally it is secondary to disease elsewhere; when
primary the prospect is more favorable. There are two favorite situations
for this disease—namely, near the trigone and upon the posterior wall
the former being almost invariably secondary to prostatic tuberculosis.
SYMPTOMs.-The symptoms resemble closely those of calculus. There
is usually great pain, tenesmus, and contraction of the bladder; blood,
pus, and tubercle bacilli in the urine. The cystoscope shows the mucous
membrane at first thickened in patches and infiltrated with gray miliary
tubercles. These patches later break down, leaving deep, irregularly-
round ulcers with infiltrated edges and perhaps surrounding oedema.
Rarely these perforate; should they heal, a distinct scar remains. When
the disease is primary and can be reached by appropriate treatment, the
outlook is fair; but when otherwise, is most unfavorable.
TREATMENT.--When primary (never otherwise) and favorably situated,
the disease may be reached and thoroughly curetted out after supra-
pubic cystotomy has been performed.
y
VESICAL NEUROSEs.
Neuralgia, irritability, and spasm of the bladder, while they may very
rarely be pure neuroses, yet usually can be traced to causes just beginning
to originate cystitis; of which, indeed, they are frequent precursive symp-
toms. On the other hand, reflex nervous phenomena arising from the
prepuce, urethra, kidney, or spine, and appearing as vesical affections, are
by no means uncommon.
Paralysis.
Lack of contractile power more or less marked and prolonged may fol:
low retention of urine, be reflex or hysterical, or due to serious brain or
spinal lesions. Treatment should include: prevention of urinary reten-
tion or decomposition, and attempts to remove the cause and restore the
lost power.
Atomy.
Atomy is the term applied to slight degrees of lack of contractile forgº
in the bladder wall. It is usually senile in origin, but may be brought
about by disease at any age. Treatment is practically the same as for
paralysis.
VESICAL FISTULAE.
Fistulae are rare, except in women. In men they result from nonºlº
of accidental or surgical wounds, and from ulceration through the bladder
wall. They may terminate in intestine or upon the perineum, abdominal
TU M O RS OF THE BLA DD E R . 675
wall, or thigh. In women parturition furnishes the most fruitful cause:
here they are most apt to open into the vagina or uterus. Diagnosis is
usually palpable. Treatment is considered elsewhere.
TUMoRS OF THE BLADDER.
The primary tumors which occur in the bladder are, in order of rela:
tive frequency: papilloma, carcinoma, myxoma, sarcoma, fibroma, and
myoma. All have a marked tendency to become pediculated. Secondary
tumors are exceptional, unless by extension from contiguous parts.
Dermoid cysts of the bladder have been described, but they invariably
find their way into the viscus by ulceration from without.
Papillomata.
Papillomata are met with, as a rule, in men after puberty, but any age
or either sex may give them origin. While usually single and sessile,
yet the entire bladder wall may become involved. Urinary salts may
become deposited upon the growths and give rise to a false diagnosis of
calculus. The vesical floor about the ureteral openings is their usual
situation. In structure they conform to the usual type of papilloid
growth, and are covered with luxuriantly proliferating bladder epithe-
lium. Those developing in the aged are very prone to carcinomatous
changes.
Carcinomata.
Carcinomata are frequent in those of advanced years, and in situation
correspond with papilloma. They generally have a broad base but may
likewise become pediculated; the surroundings are always more or less
infiltrated.
Mya!omata,
Myxomata or polypoid tumors are almost limited to childhood. They
correspond pathologically with nasal polypi; are often multiple, form
with rapidity, and may prolapse from the female urethra or obstruct
that of the male.
Sarcoma, fibroma, and myoma are exceptionally rare in this situation.
SYMPTOMS.—The symptoms of bladder tumor correspond mainly with
those of foreign bodies. The first sign of papilloma and myxoma is hemor-
rhage. Blood may be suffused through the urine, appear in clots, or be
passed almost pure; it may be continuously present or internittent, but
instrumentation always brings on or aggravates the hemorrhage. Later,
pain, tenesmus, and perhaps cystitis set in. When the tumor is malignant,
however, symptoms of vesical irritation or inflammation precede haemat-
uria. Portions of the growth may pass with the urine, or be removed
by instruments and perfect the diagnosis. In benign tumors pain is a late,
usually not prominent, symptom, while in malignant disease it occurs
early and is very distressing. Cachexia and advanced age also point to
the more serious affection.
Rectal, abdominal, vaginal, and direct digital examination through a
Perineal wound made for the purpose (external urethrotomy) are valu-
676 DISE A SES AND IN J U RIES OF THE U RIN A R Y O RG ANs.
able aids to diagnosis, but nothing can equal the visual assistance afforded
by the cystoscope. Digital examination of the female bladder may be
made through the dilated urethra.
PROGNOSIS.–The outlook for cases of malignant disease is invariably
fatal, but a partial removal of the growth may give comparative comfort
and much delay the fatal issue. Happily, benign tumors are now avail-
able for successful operations, and, while always serious, are no longer
commonly fatal.
Vesical hemorrhage is rarely fatal, per se, but weakens the constitution
and may give rise to putrefaction in the organ. Cystitis is a troublesome
and dangerous complication, as it reduces the patient by increasing his
discomfort.
TREATMENT.-Papillomata and other benign growths should be
promptly removed by supra-pubic or perineal section, and gently tearing
them away with the finger-nail, fingers, forceps, curette, or knife. Or, if
a large pedicle is present, by an écraseur. Occasionally, one may be
delivered from the wound and ligated off. Still again, the cautery, which
is always useful to check hemorrhage after removal, may be employed for
their destruction. Vinegar here is a most excellent haemostatic. From
the female bladder certain tumors may, in like manner, be extracted
through the dilated urethra; others by incision through the anterior
vaginal wall or by the supra-pubic operation.
Secondary or metastatic tumors of the bladder are invariably malig-
nant, hopeless, and require but palliative treatment.
VESICAL CALCULI. (STONE IN THE BLADDER.)
Vesical calculi are found at all ages, but principally after the fiftieth
and between the second and thirteenth years. Stone may be congenital.
It is much more common in males than in females, because of the difficulty
of escape for small concretions and the much greater prevalence of
genito-urinary disorders, dissipation, and exposure amongst the former.
Negroes, and the people of certain districts, are almost exempt from calculi,
while in other localities, especially where the water is “hard,” stone is most
COIO IOOIl.
CAUSEs are: (1) predisposing, and (2) exciting.
1. Heredity, drinking-water, gouty or uric acid diathesis, indigestion,
dissipation.
2. Disease of any portion of the urinary tract, presence of foreign
bodies, or any cause producing irritation of the bladder, such, particularly,
as retention or decomposition of urine.
CoNSTRUCTION.—Most vesical calculi are composed of a nucleus upon
which have been deposited successive layers of urinary salts, all of which
may be made evident by sawing the stone in half. The nucleus may con,
sist of inspissated blood, pus, epithelium, mucus, an aggregation of
crystals, or a true foreign body, such as a piece of catheter, splinter of
bone, bullet, etc. Upon it may be deposited layer upon layer of the same
salt, or deposits of varying precipitates may, from time to time, according
to changing conditions, add to its bulk and give rise to what is called the
alternating calculus.
NUMBER.—Stones are most commonly solitary, but two or more, alº
frequently met with, and, rarely, great numbers are encountered. Soft
stones may partially disintegrate and become fractured by bladder 90"
W E SI C. A. L. C. A. LC U L I. 677
traction or by concussion against one another when multiple, thus increas-
ing the number present. The more quickly formed and softer stones are
more apt to be multiple; oxalic and uric acid calculi are almost always
solitary.
PROPORTIONS.—The usual weight of bladder-stones is from three to six
drachms; but they may be found ranging from that of a grain or two up
to many ounces. A stone weighing over four pounds has been removed
from the human bladder post-mortem. Form depends upon the position
of origin and detention; the stone may correspond in shape with the pelvis
of the kidney, with that of a saccule or other portion of the bladder, but
more especially with that of the nucleus. The average calculus is flat-
tened, oval, or round, and may be smooth, granular, or roughly tubercu-
lated. Multiple stones are apt to be flat, irregular, and to be faceted at
points of mutual contact.
CONSISTENCE depends upon the composition. Those composed of
oxalate of calcium or uric acid are excessively hard, while phosphatic
stones vary from the firmness of soft brick to that of dried clay.
VARIETIES.—The usual types of vesical calculi, in order of relative
frequency, are: (1) uric acid, (2) oxalate of calcium, and (3) phosphatic.
These ingredients may be almost pure, or intermingled in various propor-
tions or in alternating layers.
1. This variety is chiefly limited to youth and middle age ; almost
always descends from the kidney, and constitutes the nucleus of most
other varieties. They are of slow growth, moderate proportions, smooth,
regular surface, dark-brown color, and develop in acid urine.
2. (Mulberry calculus.) Are more slow in development, and harder,
also rough and irritating. They chiefly appear during middle age.
3. Of this type there are three varieties: (a) phosphate of calcium
(earthy phosphates); (b) ammonio-magnesium phosphate (triple phos-
phates), and (c) phosphates of calcium, ammonium and magnesium
in varying combination or mixture (mixed or fusible phosphates).
Varieties a and b are unusual; c is the common representative of the
phosphatic group. They are large, irregular, soft, white, generally have
a nucleus of harder calculus or foreign body, and originate in alkaline
urine, usually during later life.
Other possible but very rare varieties of stone are composed of cystic
9xide (cystine), xanthic oxide, and carbonate of calcium or magnesium.
Certain organic substances by inspissation and concretion sometimes form
foreign bodies in the bladder which, to all intents and purposes, resemble
true calculi. These may be fibrous, sanguinous, or urostealithic.
PROGRESS.–If stones are not promptly removed—perhaps in any case
-cystitis and involvement of the kidneys may result. The possibility of
such changes being present must be borne in mind when operative inter-
ference is contemplated. Stones, if neglected, may ulcerate through the
Yesical wall into the perineum, rectum, or vagina, or by their presence in
the bladder impede or prevent childbirth. Small calculi not infrequently
(especially in the female) are passed per urethram. &
SYMPTOMs of vesical calculus are chiefly those of the inflammatory and
tubercular affections of the organ which have already been described.
There is the pain of cystitis, but perhaps only present at the end of
*icturition, when the stone is forced upon the sensitive trigone or neck;
It is, In fact, referred to the end of the penis, or elsewhere, as a rule, and,
* Children, the prepuce may become very long and redundant from con-
stant pulling to relieve the pain there felt.
678 DIS E A SES AND IN J U RIES OF THE U R IN ARY O RG ANs.
Often it is more easy for the patient to pass water in certain positions,
as upon the back, side, or belly. Pain is least at night, and when the
person is quiet; jolting and exercise greatly aggravate symptoms.
Frequent irresistible desire to micturate is an early and prominent
symptom. The act may be suddenly cut short by the stone falling against
or into the vesical outlet. Blood is passed in greater or less degree, con-
tinuously or intermittently. Priapism and incontinence are common in
children. Often there is agonizing tenesmus of the bladder and rectum
at the end of micturition, when the stone is grasped by the bladder wall,
The urine corresponds to that passed during cystitis, but with the presence
of a greater proportion of blood, as a rule. Normal urine, and entire
absence of symptoms, are not absolutely incompatible with the presence
of even moderate-sized stones.
DIAGNOSIS.-A history of inheritance, gouty diathesis, previous calculus,
or of renal colic, may render diagnosis more easy, but scarcely any symptom
or group of symptoms is pathognomonic. Stone may complicate other
diseases, while almost all urinary affections present symptoms precisely
similar to those arising from calculus. Hence physical demonstration of
a stone's presence must invariably be secured before diagnosis is made or
operation attempted. This can be accomplished by means of the metallic
sound. Stones may occasionally be felt by rectal, vaginal, or bimanual
palpation.
Sounding the Bladder.
The patient should recline upon a table or bed, with hips elevated, and
the bladder moderately distended by accumulated urine or injection of
warm water. Anaesthesia is often necessary in children, or where examina-
tion causes much suffering. “Gentleness,” should be the watchword in all
FIG. 408.

--- DWil{0}_BE - S0N,
2- S-C
Type of sound.
bladder manipulations. The sound is made of steel, about 17 mm. in
diameter, with a dull, short beak curved upon the shaft to an angle of
120°. A much smaller size is requisite for children.
This instrument is inserted in the same manner as a catheter, and its
point carried in a gentle jerky manner systematically over the entire
vesical area. The point is first turned into the base and trigone, then
above the pubis, and finally over the other portions of the viscus. If no
stone is found, a finger is inserted into the rectum or vagina, and, while
ressure is made upon the abdominal wall, the organ is again gone OWeſ.
Still failing, the urine should be withdrawn and examination repeated.
These successive manoeuvres having been carried through without
loss of time, further efforts should not be made, but the patient quickly
gotten to bed, and kept warm. Several days later he may be again
sounded, when, with the familiarity which has been gained in the former
examination, the stone, if present, will generally be discovered. Diºgº
nosis of some sacculated calculi, or those rare instances of pediculation
or suspension of a stone by a lymph-band, may be impossible short of
VE SI C A L C A LCU LI. 679
operative exploration. Non-discovery of a stone by sounding may be
taken as presumptive, but never as absolute, proof of its absence.
When the instrument comes in contact with a calculus, a grating sen-
sation and click are produced. These may be greatly amplified by a
sounding-board attachment. The sensations arising when a stone is struck
FIG. 409.
Sounding-board attached to sound.
are totally different from those arising from the instrument impinging upon
the pelvic bony prominences, or from rubbing over a tumor or mucous
membrane coated with phosphatic deposit. Confusion could only arise
with those who had never experienced the former. The presence of two
or more stones can be decided by seizing one in the jaws of a lithotrite
and then striking another with the instrument.
A stone having been found, it is important to determine its approximate
size, shape, composition, and whether or not it is encysted. Size and
shape can be ascertained by an experienced operator by passing the sound
around and across it, but the better plan is to measure the distance to
which the blades of a lithotrite must be separated to grasp it. Compo-
sition is roughly determined by the size, history, condition of urine, rough-
mess of surface, and contact sensation. Encysted Stones are always found
at the exact spot where they were first encountered, and cannot be moved
or seized by the lithotrite.
After sounding put the patient to bed, keep him warm, and administer
—if it has not been done beforehand—a full dose of quinine; also, if
pain should follow, an opium (one grain) and belladonna (one-quarter
grain) suppository.
TREATMENT.-The presence of calculus having been determined, the
imperative indications are to remove it and to treat any remaining patho-
logical conditions of the bladder.
Attempts to dissolve the stone in situ are not permissible; operation
alone must be resorted to. If the patient is run down and exhausted, a
betterment of his condition by rest in bed and milk diet should be at-
tempted before undertaking removal of the stone. It is always best to
thus treat the patient for a few days prior to operation. Where grave
kidney changes exist, palliative treatment by anodynes may alone be
Sanctionable.
. There are two chief methods of removing a stone: (1) that by a crush-
ing and (2) that by a cutting operation, and it is often most difficult to
judge which is best for the case in hand.
1. Crushing (lithotrity and litholapaxy) is generally best suited to
cases where the stone is neither too large nor too hard ; where no serious
urethral, prostatic, bladder, or kidney complications exist; where the

680 DISEAS ES AND IN J U R IES OF T H E U R IN A R Y OR GANs.
organ will hold three or four ounces of fluid, and when the nucleus is also
crushable. Tumors of the viscus contra-indicate this procedure; also
stricture, unless it can first be thoroughly relieved. Conditions of para-
lyzed, atonic, or sacculated bladder, while unfavorable, do not absolutely
prohibit its employment. Sacculated stone is usually a positive contra-
indication.
For crushing, hard stones must not be larger than three-quarters of an
inch, and soft ones one and a half inches in diameter.
2. Cutting operations include (a) lateral (and bilateral) or sub-pubic
lithotomy, and (b) supra-pubic lithotomy. They should never be per-
formed save when crushing is inadvisable. a is, as a rule, best suited to
cases presenting grave complications, such as those of urethra, prostate,
and kidney, and to very aged persons; also where it is necessary to com-
plete the removal in the shortest possible time. Children stand this
operation extremely well. Calculi larger than one and a quarter inches
should not be removed by this route. b is adapted to all stones larger
than one and a half inches, to those complicated by tumors, and to per-
sons who suffer severely from “urethral fever.”
Calculi in the female bladder are removed, according to size and com-
plications, by forceps through the dilated urethra, crushing, cutting
through the vesico-vaginal septum, or by the supra-pubic operation.
Stone returns in about 4 per cent. of all cases operated upon by this
method.
FOREIGN BODIES IN THE BLADDER.
Foreign bodies are frequently met with in the bladder. Such include:
pieces of broken instruments, as lithotrite blades, catheter ends, etc.,
bodies inserted into the urethra with lascivious intent or to relieve reten-
tion ; also those coming into the organ through wounds, such as bullets,
chips of shells, bits of clothing, splinters of wood or bone; by ulcerative
processes, as foetal remains, sequestrae; or, through vesico-intestinal fis-
tulae, feces, fruit-stones, or parasites. Hydatids may descend from the
kidney.
# is when retained in the bladder usually form nuclei for calculous
deposit. Symptomatology and diagnosis correspond with that of stone.
History is usually most obscure.
TREATMENT.--Give nature a fair chance to expel the body. Then try
to extract or crush with the lithotrite, or wash out with the lithotrity
apparatus. Glass should not be crushed, and care must be taken not to
close the lithotrite strongly upon soft substances, for fear of impacting its
blades. These measures failing, supra-pubic cystotomy should be promptly
done.
INJURIES OF THE BLADDER.
Contusions are often followed by blood-tinged urine and cystitis. Treat
as if beginning acute cystitis. *
Wounds arise from direct or indirect force applied from within, as
instrumentation or rupture; or from without, as shot and stab wounds,
or puncture by a fragment of broken pelvis. Of these varieties there
are two great classes: the (1) intra- and (2) extra-peritoneal.
1. Intra-peritoneal wounds are usually accompanied by great shock,
hypogastric pain, inability to micturate, nausea, vomiting, perhaps hic-
cough, signs of fluid in the peritoneum, and later, signs of peritoniº
R. ET ENTION OF U R IN E. 681
and absorption of urinary products by the peritoneum. The catheter
(which should be perfectly aseptic) may bring away either a large amount
of blood-tinged or clear urine, none at all, or pure blood. Perhaps the
instrument can be inserted unnaturally far and be felt among the intes-
times through the abdominal wall.
Diagnosis may be made or confirmed by injection of air through a
catheter and noting absence of tympanitic bladder distention, while the
whole abdomen becomes tympanitic ; or by exploratory abdominal section
where other means fail.
TREATMENT.—Where intra-peritoneal rupture or other wounds exist,
immediate abdominal section in the median line low down must be per-
formed. Any foreign body present must be removed and the rent sutured
with Lembert stitches, six or more to the inch. The abdominal cavity is
then freely washed out and the parietal wound closed, leaving in a glass
drain to the pelvis. If it is impossible to suture the tear, the tube alone
must be relied upon. The urine should be drawn at frequent intervals
for the first week, or a soft catheter may be tied in the urethra.
2. Evtra-peritoneal wounds are often, short of abdominal section, ex-
ceedingly difficult to diagnose from those involving the peritoneum.
Usually there is shock and copious hemorrhage from the urethra, desire
to urinate and great pain. Extravasation of urine generally soon appears
in the perineum or lower abdominal wall.
TREATMENT.-Perimeal section and drainage, with free slitting up of
infiltrated areas, are the prominent indications.
RETENTION OF URINE.
This disorder may be (1) acute, or (2) chronic, complete or incomplete.
Causes may be mechanical, functional or organic. Retention must not be
confounded with suppression of urine.
CAUSES.–1. Impaction of calculi or foreign bodies in the urethra, or
changes in the urethral wall due to strictures, inflammation, tumors, out-
side pressure, enlarged prostate, blood-clots or abscesses, also nervous
influences, more especially after operations upon the genito-urinary organs
Or rectum, are the most common causes of acute retention.
2. Here the bladder itself may be at fault, being powerless, through
paralysis or atony, to discharge its contents, or a combination of causes
usually giving rise to the acute variety may establish the chronic retention.
Course.—The bladder becomes over-distended and appears as a rounded
tumor, yielding a flat percussion note in the lower abdomen above the
pubic symphysis, and may extend to, or in old cases even above, the
umbilicus, and without care give rise to false diagnosis. In long-standing
Cystitis with contracted bladder the tumor may be very small and yet
give rise to the utmost distress, while, on the other hand, a bladder holding
many pints, distending the whole abdomen, and of weeks' duration, may
not be complained of. The organ very rarely ruptures unless subjected
to traumatism. More usually, when its extreme limit of expansion has
been reached, small amounts of urine are forced by the great pressure
through the obstruction to its outflow, and constant or intermittent drib-
bling from the urethra takes place. Where incontinence is complained
of the state of the bladder should always be examined into. Rupture
of the urethra behind an obstruction—especially if the impediment be an
old stricture—is by no means an uncommon result of extreme retention.
682 DISEASES AND IN J U R IES OF THE U R IN A R Y O RG AN S.
The back pressure in the ureters and pelvis of the kidney dilates those
parts, or may develop serious disease therein. The bladder, after relief
of severe retention, usually remains paralyzed for a longer or shorter
time and is highly predisposed to putrefactive and inflammatory changes.
SYMPTOMS.–If acute, there is much pain and distress, little or no
urine is passed, and tumor, as above, appears. Pressure in the hypogas-
trium is intolerable. A finger introduced into vagina or rectum perceives
the bladder pressing down, and impulses upon the abdominal wall are
transmitted to it. Typhoid symptoms accompany some cases of long
standing. When onset is gradual the subjective symptoms are less
severe; dribbling of urine may alone be complained about.
TREATMENT.-The methods of relieving retention are: the catheter,
if it can be passed; supra-pubic aspiration repeated twice daily for days,
if necessary; perineal cystotomy, which latter will often permanently cure
such causes as enlarged prostate and stricture. When obstruction is due
to vesical calculus or tumor, retained blood-clots, etc., supra-pubic cyst-
otomy is preferable. After-treatment must be directed to removal of both
cause and results of the malady. Hemorrhage may take place from
engorged vesical veins if pressure is relieved too suddenly by rapid with-
drawal of the accumulated urine. Kidney symptoms must be treated if
they arise.
SUPPRESSION OF URINE.
This is a most dangerous and fatal condition, in which secretion of urine
by the kidneys ceases. Previous kidney disease, aggravated by the effects
of anaesthesia and operations upon the urinary organs, is the usual cause,
but it may supervene during or after retention. Symptoms are those of
acute uraemia. No urine comes into the bladder. Treatment is almost
universally futile.
INCONTINENCE OF URINE.
Of this there are three varieties: 1. True incontinence, where the
urine dribbles as fast from as it is poured into the bladder. 2. Nocturnal,
where, independent of disease, urine is passed during sleep. 3. False
incontinence, the result of retention.
1. May be due to atony or paralysis resulting from spine or cerebra!
disease, over-dilatation of the urethra; or certain tumors, or localized
hypertrophy of the prostate or bladder, interfering with the vesical
sphincter. Treat by removing the cause, if possible.
2. This is practically limited to children; is an involitional act depen-
dent upon reflex inhibition of the sphincter vesicae resulting from some
irritation of the alimentary or genito-urinary tracts, such as seat-Worms,
phimosis, polypus, stone in the bladder, or indigestion.
The cause should be removed, and tonics, laxatives, and small doses of
belladonna will be useful. The child should never be punished.
HZEMATURIA.
Haematuria, or blood in the urine, is usually indicative and the result
of disease or injury at some point in the urinary tract, but may rºl
from purpura haemorrhagica, scurvy, fevers, or to the ingestion of su"
O P E R A TI O N S U P O N T H E B L A D DE R. 683
drugs as cantharides, turpentine, carbolic acid, or to the presence of para-
sites (Bilharzia hamatobia). It may be continuous or paroxysmal, accord-
ing to the cause. Its presence in the urine is indicated by the color and
confirmed by the microscope. The amount of blood may be trivial or
enough to compromise life. If it remain long in the urine, the corpuscles
decompose and the liberated haematin imparts a dark smoky hue to the
Ull'Iſle.
The Source of the blood may be approximately determined by its propor-
tionate amount and the occasional presence of structures recognizable by
the microscope; also, by the condition of the blood; whether decom-
posed, clotted, in casts, etc. Usually, when of kidney origin, it is inti-
mately mixed with the urine; when from the ureter the same, or in long
clots or fibrinous casts; when from the bladder or prostate, it comes after
or in the last portions of urine; when from the urethra, in the intervals
of or during the early stages of urination—either pure, almost so, or in
casts corresponding to the urethra.
TREATMENT.-Control causes as elsewhere described. Clots in the
bladder soon decompose and give rise to serious effects. They should be
dissolved by digestive ferments, broken up and washed out by the lithot-
rity evacuator, or removed by supra- or infra-pubic cystotomy.
PNEUMO-URIA.
Escape of gas with the urine. The gas always originates from : intro-
duction through instruments, fermentative processes in the bladder, or
vesico-rectal fistulae.
CHYLURIA.
Chyluria, or escape of milky chylous fluid with the urine, is caused by
lodgment of the filaria or haematode worm in some portion of the urinary
lymphatic system, with consequent engorgement and rupture of lower
lymphatic channels and pouring out of lymph into the urinary canal.
OPERATIONS UPON THE BLADDER.
Aspiration.
The surroundings are made aseptic and the outline of the bladder
mapped out by percussion. The aspirator needle is then, avoiding veins,
thrust through the abdominal wall one inch above the symphysis pubis
in the median line. Anaesthesia by freezing, together with a slight skin
incision, renders the operation almost painless. A small antiseptic dressing
should be applied after withdrawal of the canula.
Lithotrity.
lithotrity, or the extraction of a stone by crushing, is here meant to
include both crushing and removal of resulting fragments. Sometimes
the name lithotrity is applied to simply crushing the calculus and allowing
(as in former times) the fragments to come away subsequently with the
urine; litholapaay to crushing and immediate evacuation of the débris.
The patient's general condition having been improved as much as
Possible, all strictures well dilated, and the meatus incised if it is nar-
684 DISE A SES AND IN J U RIES OF THE U RIN A R Y O R G ANS.
row, he is placed upon a table with his hips raised six inches and a pillow
beneath the knees. Anaesthesia is always necessary. The thighs are
separated and the urine drawn. From five to eight ounces (according to
its capacity) of warm water are injected into the bladder and the litho-
trite gently inserted. The blades after introduction should look upward
FIG. 410. FIG, 411.
d
º
*f;
*i;
§
.
º § |
#
Jaws of Bigelow's lithotrites, exact size. Jaw of fenestrated lithotrite.
and rest upon and slightly depress the floor of the organ. Now, holding
the handle of the instrument firmly with one hand, pull out the sliding or
“male’’ blade two inches. Wait a second to let the stone settle and then
push the blade home again. If the stone is caught throw on the screw
mechanism until the calculus is securely fastened between the jaws. Lower
FIG. 412. £ º
sº
* { -
º flºº
Rºſſº,
*
à
º
ºf &
=º
//////////)}|||}}}
% | §
Ordinary lithotrites.
the handle to carry the stone and blades away from the bladder-wall. . If
there is any resistance to this movement mucous membrane probably has
also been caught and the stone must be let go and again ensnared. Other.
wise the blades are at once screwed together until the calculus is crushed
between. Then each resulting fragment must be likewise caught and
crushed. If the stone does not at once fall into the instrument, as above,






O P E R A TI O N S UP O N T H E B I. A D D, E R . 685
;he blades are reopened and carried above the symphysis by depressing
she handle. This failing, they are rotated through a half circle from side
FIG. 413.
:º
:ſº
i.
:º
--H
;E-F-
:-
-º
i-
H T
iFº.
is~-- *.
..
:
|
Handles of Bigelow's lithotrites.
FIG. 414.
Position of lithotrite in crushing stone. (LISTON.)
FIG. 415.
(ERICHSEN.)
Seizing stome when behind prostate with lithotrite.
'9.side, always open to prevent pushing the stone out of reach. Again
failing, the blades are rotated until they point to the rectum, the handle is
*aised, and the bladder behind the prostate explored, always remembering




686 DISE ASES AND IN J U R IES OF THE U R IN ARY ORGANs,
to carry the jaws away from the bladder-wall before crushing. A stone
having been caught in any situation and crushed, the fragments always
FIG. 416,
ſº
º &
ſº
sº U. * :
Wº º § ''
w : , , ºº -
º º #
*Aſ Yº...
Wy º * º ſº ºr ~~.
s {} ſ
*"...Tº S.*. ºft
&āšā Qº
Removal of fragments by Bigelow's evacuator. (ERIgHSEN.)
fall vertically and can be secured by the first or last described manoeu-
vres and successively crushed. When all have been broken to small
fragments, the blades are screwed firmly home and the instrument with-
FIG. 417.
§NSW
N §§
\\
')
%
.**
** 2&
.."
**
% A }
% %,”
^2/
*
2 *. 2%
§§§ 3; 2.
S= #:2
: *-*
Bigelow's apparatus for removing fragments.
..º. §
\
|
drawn. A large and powerful crusher may be used to break large or
very hard stones and a smaller one to deal with the fragments. ©
Now introduce the largest evacuating catheter that the urethra will






O P E R A TI O N S U P O N T H E B L A D D E R . 687
accommodate, allow all fluid to escape from the bladder, and then inject
into it about three ounces of water. Connect the bulb with the catheter
and inject rather suddenly from it, by compression, about as much more.
Quickly release it, when the return current, induced by expansion of the
bulb, will draw into it a quantity of débris and fragments. Give these
time to settle into the receiver below the bulb, and then repeat the act again
and again until no more fragments are withdrawn. Great precaution must
be taken to ascertain previously the extreme capacity of the bladder and
not to inject more fluid than it can hold without tension. Otherwise
it may be ruptured. The evacuator is then taken out and the organ
explored by the sound. If any fragments remain they must at once
be crushed and removed. Dangers to be feared are: suppression of
urine, rupture of the bladder, and impaction, bending or breaking of
the lithotrite while in the bladder.
Perimeal Cystotomy (and Lithotomy).
There are two methods of performing this operation, lateral and median.
Lateral Perimeal Cystotomy (and Lithotomy).
The bowels are previously well cleared by laxatives and an enema
just before operation, and the parts well shaved and cleansed. Anaes-
thesia is essential. The hips are brought to the edge of a table and
the legs fastened in the “lithotomy position ” by bandages, shackles, or
a crutch. The urine is drawn, the bladder moderately distended by
injection of warm water, and a centrally grooved staff introduced into
it and held steadily upright in the median line against the under surface
of the pubis by a skilled assistant.
sº
º *
N. N. tº #
4 - sº -. 2
FIG. 41 S. FIG. 419.
\
Method of securing hand and Position of patient and lime of incision in lateral
foot for lithotomy. (DRUITT.) lithotomy.
. The surgeon sits facing the perineum between the patient's legs. He
inserts his left index-finger into the rectum to make certain that it is
empty, to cause it to contract and to act as a guide; and with his right

688 DIS E A SES AND IN J U RIES OF THE U R IN A R Y OR GANs,
hand makes a cutaneous incision from a point in the raphe one and a quarter
inches in advance of the anal margin, downward and outward to a point on
a level with, but one-third nearer to, the left tuber ischii than the anus.
FIG, .420.
Grooved staff for lithotomy.
This incision divides skin, superficial fascia, the external hemorrhoidal,
and, perhaps, the superficial perimeal vessels and nerves. A finger now
thrust into the wound locates the staff, and all structures are divided
FIG. 421.
Lithotomy knife. -
down thereto, and, the finger acting as guide, the point of the knife is
engaged in the groove. This cut, severs the transverse perineal muscle
and artery, the lower border of the triangular ligament, and punctures
FIG. 422.
ſ w
º
gº.3% ºf Ş.
easºn
*
ſ
Mode of cutting into the bladder and holding knife. (LISTON.)
&º.
r
Jºlſ||
º: * 1W
jº
t .*.*. *
the accelerator uringe muscle and urethra. Now, while the knife is held
in a horizontal position and deviated slightly to the right, it is pushe
along the groove into the bladder. A gush of water through the wound
announces that the viscus has been entered. This cut divides the mº"









O P E R A TI O N S U P O N T H E B L A D D, E R . 689
branous urethra and floor of the prostate. As the knife is withdrawn its
handle should be depressed so as to deepen the prostatic incision. Any
subsequent cutting that may be necessary should be done with a hernia
FIG. 423.
W
\ ,
I, eft Ureter.
\
Lateral lithotomy. Incision of the neck of the bladder as seen from within. A is a
rent in the wall made by introduction of the finger. B is an extension of the incision
involving only the mucous membrane. (STIMSoN.)
knife or blunt-pointed bistoury. The staff is next removed and the left
index-finger thrust through the wound into the bladder.
If the perineum is very deep, a blunt gorget may be introduced before
FIG. 424.
==9'."""Pº (2) &
# === ==& º
- sºº". "...: * -
Lithotomy scoops.
the staff is withdrawn. This terminates the operation of cystotomy, but if
the extraction of a stone (lithotomy), foreign body, or tumor is contem-
Plated, straight or curved forceps, guided by the inserted finger, must be


44
690 DISE ASES AND IN J U RIES OF THE U RIN ARY ORGANs.
employed for the purpose. If the stone is found to be too large for ex-
traction without severely bruising or stretching the parts (which is always
dangerous), and cannot be broken by forceps or lithotrite into more
manageable size, perineal extraction must be abandoned, and the supra-
pubic operation performed. Blood-clots, etc., should be flushed out of
the organ before the patient leaves the table. No sutures are required.
DANGERS.—Wounding of the rectum, posterior bladder wall, prostatic
capsule, or prostatic plexus of veins, the artery of the bulb, or an anoma-
lous pudic vessel, constitute the chief dangers. Tearing of the bladder wall
also may take place in removing bodies with forceps.
AFTER-TREATMENT.-No dressings need be applied. The patient should
be placed upon a bed with mackintosh and draw sheets—the latter to be
changed as often as required. If the urine does not flow out freely a
canula may be tied in the bladder. Primary or secondary hemorrhage
may be promptly checked by ligation or cauterization
FIG. 426. of the bleeding points, if they be in sight, or by insert-
ing a “shirted catheter” into the bladder, and pack-
ing the “shirt” firmly with strips of gauze. These
failing, direct digital pressure by relays must be
kept up until it ceases. During the first few days
succeeding operation all urine escapes through the
wound. Then, owing to slight obstructive swelling
therein, a portion may come through the urethra;
after a day or two more, tumefaction subsides, and all
again passes through the wound, until, as it gradually
cicatrizes, more and more, and finally all, is passed per
wrethram. Should perineal fistula remain, it should
be stimulated, or its edges pared and sutured. (See
Urinary Fistula.)
Median Perimeal Cystotomy (and Lithotomy).
Preparations, up to incision, as have been described
for the lateral operation. Incision is made exactly in
the perineal raphé from one and a half inches above
* the anal margin downward one to one and a quarter
Shirted catheter. inches. The left index-finger guarding the rectum, the
incision is carried down until the urethra is opened and
the point of the knife engaged in the groove of the staff at the upper-
most angle of the wound.
Now, holding the knife at a right angle to the perineum, it is thrust
along the groove into the bladder, slightly enlarging the prostatic wound
as it is withdrawn. If the operation has been undertaken simply for ex-
ploratory purposes, the incision should be confined to the membranous
urethra and not open up the prostate. Dilatation of the prostatic urethra
and vesical exploration are then effected by the gradual insertion of a
finger.
#. median operation is only applicable for exploration, drainage, and
removal of small tumors, foreign bodies, or stones (under one inch in
diameter). Lateral incisions into the prostate and perineum will render
the wound more capacious for removal of a calculus.

O P E R A TI O N S U P O N T H E B L A D D E R . 691
Supra-pubic Cystotomy (and Lithotomy).
The abdomen is made clean, and the patient placed in the usual posi-
tion for abdominal section. A rubber bag is inserted into the emptied
rectum and distended with ten to fourteen ounces of water. This raises
and steadies the bladder. Now the bladder itself is thoroughly washed
out with mild (1 to 5000) bichloride solution, and moderately distended
with warm water by injection. A tape or rubber band wound around
the penis and tied, will prevent its escape by the urethra. As peritoneum
does not descend in front of the bladder, it will be observed that by
these measures the largest working space between the pubis and peri-
toneum is thus secured. The organ is now mapped out by percussion,
and an incision two to three inches long in the median line is made
immediately above the pubic symphysis, and carried down to the linea
alba, which is divided to the extent of two inches and held aside with
retractors.
FIG. 427.
India-rubber bag for distending rectum.
The bladder surface is now exposed freely with the knife-handle. If
peritoneum is present it is displaced upward out of harm's way. The
Yesical wall is now picked up on either side of the median line with catch
forceps or sutures, and incised vertically between them in the median line
to the extent of three-quarters of an inch. A finger is then inserted and
the organ explored. If the incision prove to be insufficiently large through
which to deal with a stone, foreign body, or tumor, it should be sufficiently
enlarged upward and downward with a hernia knife or scissors, guided by
the finger, always, however, keeping clear of peritoneum. If the operation
is done to promote continuous drainage, a rubber tube with a crosspiece to

692 DISE ASES AND IN J U RIES OF THE URINARY OR GANs.
prevent its disappearance should be fastened into the bladder. Otherwise,
if the viscus is not septic, sutures should be inserted into the muscular coat
one-eighth of an inch apart. The superficial abdominal wound must not
be sutured, so that should the bladder Stitches give way or leak, the ex-
travasated urine will readily drain away and not be forced into the cellu-
FIG. 428.
• *
Şsº
|
t
ſº tº § | Qe
Section through a frozen body with the rectum much distended (artificially). 1, peri-
toneal fold in front of bladder; 2, the bladder; 3, internal orifice of urethra; 4, prostate
gland; 5, dorsal vein of penis; 6, bulbous urethra; 7, Cowper's glands; 8, upper end
of membranous urethra; 9, recto-vesical fold of peritoneum; 10, prostate gland; 11,
abscess in bulbous urethra. (GARSON.)
lar tissues. When the bladder is inflamed or otherwise septic no sutures
whatever should be introduced, but simply a drain-tube inserted. In either
case lightly applied antiseptic dressings should be kept over the wound,
and the patient during recovery should lie first on one side and then on
the other, to prevent excoriation from urine flowing always over the same
surfaces. A foul bladder should be washed out through the wound once
or oftener daily. The wound almost invariably—often too soon—promptly
closes. Dangers comprise: rupture of either rectum or bladder from
over-distention, and wounding the peritoneum. Should the latter accident
occur the opening in it should be sutured and fastened into the upper
angle of the wound, which should be packed with gauze and the bladder
not opened until a few days later, unless it is urgent to do so at once.

P R O STATIC TU B E R C U L OSI S. 693
THE PROSTATE.
Inflammation of the prostate gland (prostatitis) may be acute or
chronic.
Acute prostatitis is not common, and usually occurs as a complication
of gonorrhoea, but may arise from traumata or the irritation caused by
instrumentation, calculi, stricture, or cystitis.
SYMPTOMS.—There is dull bearing-down pain in the perineum and
rectum, the parts are sensitive to touch, and micturition, which is increased
in frequency, greatly aggravates the distress. Cystitis often complicates.
The urine may be blood-tinged. Rectal examination reveals the prostate
to be swollen, elastic, and turgid—perhaps to such an extent as to inter-
fere with or prevent micturition. The disease may gradually subside,
become chronic, or progress to abscess formation. . In the latter case con-
stitutional and local signs of purulent formation arise and fluctuation
may be demonstrated by rectal examination. This may open into the
urethra, perineum, or other surrounding structures, and perhaps cause
intractable fistulas.
TREATMENT.-Leeches, succeeded by hot fomentations, laxatives, and
prompt perimeal incision when signs of suppuration or abscess arise.
Chronic prostatitis may follow the acute variety or arise more insid-
iously from the same causes. Symptoms are identical but of less degree,
and much resemble those of vesical or prostatic calculus. There is more
or less inflammatory interstitial infiltration and enlargement. Abscess
may likewise develop. The patient is often much depressed both men-
tally and physically.
TREATMENT-Remove the cause and restore the impaired health.
Counter-irritation by blisters or leeching of the perineum is efficient. So
also are cold hip-baths. The prostatic urethra may be cauterized by
nitrate of silver. The disease is frequently most intractable, and certain
extreme cases may justify perineal cystotomy.
PROSTATIC CATARREI (PROSTATORRHOEA).
A very mild form of irritation or inflammation of the gland accom-
panied by hypersecretion from its gland follicles which appears as a
gleety, colorless discharge from the urethra, especially after straining at
stool or otherwise, sexual indulgence, or micturition. This escape is apt
to have a profoundly depressing effect, as the patient becomes convinced
that it is semen that he is losing. From the latter it is differentiated by
the microscope, which proves the absence of spermatozoa. Its causes of
Origin are masturbation, sexual excess, and irritations of the urethra.
Removal of causes, improvement of physical condition, laxatives, and
perineal counter-irritation by small blisters, together with convincing the
patient that his condition is not serious, generally produce a cure. Other-
Wise the occasional passage of a bougie of large calibre or cauterization
of the prostatic urethra (as above) may be required.
PROSTATIC TUBERCULOSIS.
Prostatic tuberculosis is an uncommon affection and almost always
Secondary to tuberculosis of the kidney, testicle, or elsewhere. The
Symptoms correspond with those of chronic inflammation, stone, and cyst-
694 DISE ASES AND IN J U R IES OF THE U R IN ARY ORGANs,
itis, but usually there is cachexia and unaccountable constitutional dis-
turbance. Implication of the bladder and other contiguous parts speedily
results. Generally it is not diagnosable until far advanced. Tubercular
º may occur at a late stage, when tubercle bacilli can be found in
the pus.
TREATMENT:-The treatment should be directed to general support and
early incision into and curetting out of the gland.
HYPERTROPHY OF THE PROSTATE.
Hypertrophy of the prostate is an affection of advanced life, rarely
occurring before the fiftieth year. One-third of all men are more or less
affected; one-fifth of all to a symptomatic degree. Pathologically the
affection is a non-inflammatory increase of the normal glandular and
stromal elements of the gland. Both constituents may hypertrophy in
equal degree, but more usually the former greatly preponderates. The
enlargement may affect the entire organ or only limited portions. Thus
may be hypertrophied : one or other of the lateral lobes, both lateral
lobes, the middle lobe, or the whole gland. Or even smaller areas may
undergo the peculiar change and produce Small tumors which, when near
the surface, may project into the bladder or urethra. Enlargements of
the third or middle lobe and those of the last-mentioned unusual type
are alone of surgical importance, as only in the case of these is the vesi-
cal orifice or prostatic urethra obstructed and micturition interfered with,
and consequent vesical and kidney troubles given rise to. Causes are
sometimes to be found in previous urethral, bladder, or prostatic disease,
but more often none can be assigned save that of age.
SYMPTOMs.-Unless the middle lobe is involved, or the lateral ones to
unusual degree, no symptoms will exist, as a rule. Thus, even great gen-
eral hypertrophy may remain non-symptomatic, while but slight enlarge-
ment of the middle lobe or the projection of a small localized mass into
the prostatic urethra may give rise to severe symptoms.
Slight reduction in force and increase in frequency of urination are
usually the first signs noted, or a sudden attack of retention following ex-
posure may be the primary indication. Later there develop symptoms of
gradually increasing chronic cystitis, burning pain, very frequent and
perhaps painful micturition, changes in the urine, pain and sense of ten-
sion in the perineum, loss of sleep and exhaustion, and possibly retention
continuously or at intervals. Or all of these may suddenly follow ex-
posure when no prostatic trouble had previously been suspected. True
incontinence of urine may result from the enlargement of prostate inter.
fering with the action of the vesical sphincter. A crucial symptom of
hypertrophy is the finding of more urine in the bladder after its appa.
rent complete emptying by urination. This is due to the enlargement
interfering with complete contraction and emptying of the viscus, and
soon decomposition of the residual wrime begins, increases, and develops
cystitis; as a result of which stone not uncommonly develops in the blad-
der or prostatic crypts and greatly complicates the disease. Still late.
arise symptoms of violent cystitis and kidney involvement. The enlarged
gland can often be felt per rectum, and, by pressure thereinto, may cause
flattening of the stools.
DIAgnosis—In every case of vesical irritation in men over fifty th;
catheter should be passed after the patient has urinated, and, if residual
HY P E R T R O PHY OF
T H E P R O S T A T E . 695
urine is found, a diagnosis of prostatic enlargement may be arrived at.
This may be verified by rectal examination, and often also by the difficulty
encountered in passing the catheter or
other instrument through an irregu-
larly hypertrophied gland. However,
by these methods we have only recog-
nized enlargement; its cause may yet
be due to tumor or prostatic calculus.
The history, symptoms and progress
can alone differentiate its exact nature.
TREATMENT.—For the milder de-
grees nothing more will be required
than that the patient shall be provided
with and instructed in the use of a soft
catheter, with which for the balance
of his life he must draw off the re-
sidual urine every time after he uri-
nates, in order that the bladder may
be kept empty and free of irrita-
tion. Even under the most favorable
FIG. 429.
Rubber catheter.
conditions, and particularly after exposure, cystitis or retention, or both,
may occur. Retention must be relieved by the passage of a soft or
FIG. 430.
Prostatic catheters.
-º-, -a º



696 DISE ASES AND IN J U RIES OF THE U R IN A R Y or GANs,
metallic catheter of large curve (see Fig. 430) to mount over the distorted
third lobe. The passage of the latter, when difficult, can be much facili-
tated by the guidance of a finger in the rectum. If “false passages”
have been made by the patient or others in attempting to relieve the ac-
cumulation, aspiration for a few days should be practised until the sinuses
have a chance to heal. But if acute inflammation or abscess has arisen,
it may be wise to at once perform perineal cystotomy.
In all acute complications treatment as for acute prostatitis is appro-
priate.
Long continuance of prostatic hypertrophy with bladder complications
will demand median perineal cystotomy, whereby both pathological pro-
cesses may at the same time be relieved and often entirely cured. Ex-
cision of the obstructing lobe through a supra-pubic incision has been per-
formed with success, but no greater than as above.
TUMoRS OF THE PROSTATE.
Tumors of the prostate are practically limited to carcinoma and sar-
coma. Usually they are secondary; most rarely primary. Symptoms at
first simulate those of senile hypertrophy, but the growth increases with
rapidity and soon gives rise to more or less hemorrhage, often in the in-
tervals between micturition. Treatment can only be palliative. Supra-
or infra-pubic cystotomy, with curetting and thorough drainage, or simple
lavage of the bladder, often prove of the greatest comfort.
PROSTATIC CALCULI.
Calculi not infrequently develop in the follicles of the prostate, owing
to irritation or obstruction thereof by inflammation, tuberculosis or tumors.
The stones may be solitary or in great number. Where multiple and in
contact, facets mark the points of junction. Symptoms do not differ from
those of chronic prostatic and bladder inflammation. Sometimes the
catheter may make their presence known by grating as it passes through
that portion of the urethra; or they may be discovered by rectal examina-
tion. Most frequently their presence is unsuspected until perineal cyst-
otomy is done to relieve bladder symptoms—another advantage to the
credit of that operation as compared with the supra-pubic. A fragment
which can be recognized may be passed by urethra.
TREATMENT.-Perineal cystotomy and shelling-out of the calculi by
fingers, gouge or forceps.
THE URETHRA.
Congenital Malformations.
Congenital malformations of the urethra comprise: partial or entire
absence, epispadius, hypospadius, termination in the top of the glans
penis, and imperforate, contracted or multiple meatus urinarius.
Epispadias, a defect in the roof of the canal, is generally complete, but
may be incomplete. When in conjunction with vesical exstrophy 9
either sex (and it rarely exists otherwise) the defect always extends from
bladder to meatus—the complete variety. In males impotence is a usual
result.
IP R O L A P S E OF U. R. E. T. H. B. A. 697
TREATMENT.—The treatment of the complete variety is usually unsatis-
factory, but cure may be attempted by freshening the edges of the split
urethra and suturing thereto, over a
catheter, long strips of integument FIG. 431.
partially separated from the hypo- ~
gastrium or scrotum. Similar plastic
operations succeed better with less
extensive defects.
Hypospadias, defect of the lower
portion or floor of the urethra, is
very much more common than epi-
spadius, but usually affects a smaller
extent of the canal. It is unusual
in the female. Complete and ex-
tensive posterior hypospadius in the
male is associated with cleft scrotum,
and results in impotence.
TREATMENT.--When the open-
ings are close to the meatus often
no treatment will be necessary, but
when situated further back may be Complete hypospadias. (SMITH.)
relieved by dissecting flaps from the
junction of skin and urethral mucous membrane and suturing them across
a small catheter placed in the urethral gutter. Or, these flaps may be
split, the lower portions sutured over the catheter, and the upper portions
FIG. 432.
-
y _| { § |\ #|W
º +-tº- º |T|RNR&
º º
§ Ž §W
} – 2 #####
h l %| :
/\ - \ ///
%
Urethroplasty. (SMITH.)
Stitched over all. Many other ingenious methods of closing these defects
are applicable to certain cases, but cannot be described here.
PROLAPSE OF URETHRA.
Prolapse of the urethra occurs only in females; usually in children. A
mass of congested urethral mucous membrane with perhaps a portion of
that of the bladder protrudes from and more or less obscures the meatus.



698 DIS E A SES AND IN J U RIES OF THE U RIN A R Y OR GANs,
When the prolapse is acute these tissues may be inflamed, oadematous,
and give rise to retention of urine. The urethra in all cases is much
dilated. The causes are such as give rise to relaxation, tenesmus, or
straining.
TREATMENT.-Acute varieties may be reduced by continuous gentle
pressure and manipulation. If irritative distress attend the chronic or
constantly recurring forms (urethrocele) the condition can safely, speedily
and permanently be relieved by making a half-inch longitudinal incision
from without into the lower urethral wall just behind the meatus. This
is carried down until urethral mucous membrane is exposed. A large
bougie is then carried into the canal and mucous membrane is pulled
through the wound until all prolapsed portions or redundancy disappear.
Sutures are then passed through the edges of the wound, including the
distal extremities of mucous membrane drawn through it. The mem-
brane external to the stitches is now cut off and the threads tied down
firmly.
URETHRITIS.
Urethritis, or inflammation of the urethra, exists either as a simple
(non-contagious) or specific (contagious) disease. Either variety may be
acute or chronic.
Simple (or non-specific) urethritis may arise as a consequence of acrid or
decomposed urine, menstrual or vaginal discharges, exposure, excessive
venery, drugs, alcoholism, seat-worms, instrumentation, or wounds. The
symptoms are heat and burning pain in the urethra, increased and painful
micturition, pouting of the meatus, and later, muco-purulent discharge.
Diagnosis from the contagious form is generally impossible in the early
stages, but the subsequent course and absence of gonococci in the discharge
will distinguish the two. Our opinion, for prudential reasons, should be
very guarded: always deciding in favor of the simpler disorder when
slightest doubt exists, and invariably directing discontinuance of sexual
intercourse until cure is complete.
TREATMENT.-Discover and remove the cause, if it still exists, and
treat as if the specific variety. The affection is subject to the same com-
plications as gonorrhoeal urethritis, but usually subsides spontaneously in
from six to ten days.
Specific or Gomorrhoeal Urethritis. (Gonorrhoea.)
An acute, specific, infectious inflammation of the urethra, having &
definite period of incubation, and always attended by the presence of
gonococci.
In females urethral gonorrhoea is of trivial importance, existing only
as a complication of specific vaginitis.
CAUSE-Direct or indirect contagion; usually the former in sexual
congress.
SYMPTOMs.--The symptoms depend much upon the extent of urethra
involved and are generally first noted on the fourth day-rarely as early as
the second or as late as the seventh; when uneasiness and smarting at the
meatus and along the urethra, accompanied by slight mucous discharge
and scalding urination, are observed. These signs increase in severity for
an average of two days, by which time the lips of the meatus are red and
much swollen, there is slight oadema of the prepuce, the glans penis lº
U. R. ET H RITIS. 699
turgid and glossy, painful erections, especially during sleep, occur, mictu-
rition is exceedingly painful, perhaps difficult or impossible, and the dis-
charge changes to a creamy white color and consistency, becomes copious
in amount, and may be tinged with blood. Later still the color again
changes to a greenish or yellow hue, and, microscopically, will be found
composed of pus, mucus, blood, and epithelium containing clusters of
gonococci. There is swelling and turgescence of the entire penis, vesical
irritation and irritability of all the pelvic organs. The penile lymphatics
and inguinal glands may be enlarged.
FIG. 433.
('
(Z *...*, - ? &
* S wº ** -- ~~ ... f *
*:::::s § 5 §3) & #.
* Gonococci. (BUM.M.)
a. Cocci ſrom a pure culture.
b. Secretion of gomorrhoeal conjunctivitis, showing—epithelial cell covered with cocci;
a pus cell with cocci in the protoplasm; a pus cell completely filled with cocci; a free
mass of cocci in close proximity to a pus cell.
c. Scheme of development of gonococci.
This condition, as a rule, lasts from ten days to two weeks, after which
—depending much upon extent and treatment—the disease gradually
subsides and at the end of from four to six weeks, if all goes well, the
canal has regained its normal condition, but even under these most favor-
able circumstances remains more liable to subsequent reinfection than
before the primary attack. Much more frequently, however, and espe-
cially where the subject has had previous attacks, complete recovery does
not take place for months or even years.
Here (chronic specific or gomorrhoeal urethritis, or gleet) there persists,
in spite of all treatment, for a longer or shorter period, a muco-purulent
or clear viscid discharge with slight tenderness of the urethra, which
upon any imprudence or exposure may become much aggravated or
relapse into subacute gonorrhoea, Chronic persistent urethral discharges
usually indicate the presence of granulating patches in the urethra, which
almost invariably give rise to stricture later. Long-continued purulent
discharge may cause anaemia.
TREATMENT.-Up to the period of decline—the first week or two—
treatment, other than that for acute complications, should consist of per-
fect rest in bed or upon a sofa, milk or other easily digestible diet, laxa-
tives, perhaps aconite for feverishness, and the ingestion of large amounts of
diluents. Nor will more than this be required at any stage if the discharge
rapidly diminishes and disappears within five or six weeks. Otherwise,
should discharge or other symptoms unduly persist, as is common, sandal.
Wood oil, cubebs, or copaiba should be administered by mouth, and astrin-
gent injections into the canal locally. If old strictures or other compli-
Cations are present they must be eradicated, for otherwise they may
Prolong or prevent recovery. The occasional passage of a large bougie,
or cauterization of ulcerated portions of the urethra by nitrate-of-silver

700 DISE ASES AND IN J U RIES OF THE U R IN ARY ORGANs,
stick in a urethral port-caustic, will prove of great advantage in certain
inveterate cases of chronic urethritis or gleet.
COMPLICATIONS.–Few cases of gonorrhoea escape
without one or more complications. The principal
of these are as follow : retention of urine, chordee,
acute phimosis or paraphimosis, inflammation or
abscess in the prostate or Cowperian glands, epi-
didymitis, orchitis, cystitis, nephritis, inguinal bubo,
and pyaemia. Transplantation of infective discharges
to other mucous membranes, as the conjunctiva, may
occur accidentally and produce very grave compli-
cations; also by an ill-understood process of meta-
stasis, gonorrhoeal synovitis or arthritis may be es-
tablished in one or more joints.
The passage of instruments and too early resort
to injections are fruitful causes of many of these
complications, by carrying the infective material to
the deep urethra or bladder.
FIG. 434.
i
i
CowPERITIS.
Inflammation of the glands of Cowper is indi-
cated by a sudden or gradual circumscribed swelling
on one or both sides of the urethra in the perineum.
This may be distinguished from ischio-rectal abscess
by the usually unilateral and localized position of
the former. It should be treated by poultices until
pus is formed, then by prompt and free incision.
--
a--------…se-
STRICTURE OF THE URETHRA.
Two chief varieties of urethral stricture are recog-
nized, (1) true, or organic, and (2) false, or func-
tional.
1. A permanent organic encroachment upon and
diminution of the urethral calibre by contraction of
r*- : * , inflammatory products in its walls. º
Urethral injection syr. 2. Is temporary or intermittent, and results from
inge. Natural size, spasmodic contraction of the involuntary muscles of
the urethral wall, usually caused by the presence ºf
true stricture or other irritations at other parts of the canal—hence it
is an irritative or reflex phenomenon.
Organic Stricture.
Organic stricture may develop in any portion of the urethra except the
prostatic, which is exempt. They are rare before the twenty-fifth year,
but common after that age. One or many may be present, either close
together or widely separated; more usually there is but one. The *.
of constriction in order of relative frequency, are: anterior portion of
membranous, posterior portion of penile, and anterior and middle Pº.
tions of penile urethra. Strictures may be annular, lateral, or tortu"

ST R ICT U R E O F T H E U R E.T. H. R. A. 701
in relation to the urethral axis; and permeable or impermeable to in-
struments.
CAUSES.—Almost all true strictures result from long-continued irrita-
tion and inflammation of the urethral mucous membrane and subjacent
connective tissues, as a result of specific urethritis. A few are caused by
simple urethritis, and fewer still by cicatricial healing of wounds, and
ulcerative or necrotic processes.
PATHOLOGY..—The pathology of stricture is simply that of inflamma-
tion of mucous membrane and peri-urethral tissues, sometimes embracing
the deeper tissues of the corpus spongiosum or even the corpora cavernosa.
This is succeeded by inflammatory deposit which, later, organizes, contracts
to a greater or less degree, and to a proportionate extent diminishes the
urethral calibre at that point. Obstructive symptoms and changes in the
upper urinary organs then arise.
SYMPTOMS.—With or without a preceding long-continued purulent or
gleety discharge, interference with, increased frequency of, and dribbling
of the last few drops of urine after micturition, occur. This may simply
amount to diminished strength or volume of the stream, gradually increas-
ing until great straining is required to pass the urine, or retention takes
place; or after dietetic, alcoholic or sexual excess, or from mere exposure,
complete obstruction and consequent retention may suddenly occur, and
be the first intimation of the presence of stricture. The obstruction may
permit of false incontinence when the intra-vesical tension becomes great,
or, if neglected, the urethra may rupture behind the stricture and produce
extravasation of urine. Rectal hemorrhoids and prolapse, likewise her-
niae, may result from straining incident to partial or often-recurring com-
plete retention. Severe constitutional symptoms result, in neglected cases,
from the pathological processes originated in the upper urinary tract as
the result of urinary obstruction and decomposition.
DIAGNOSIS.–Presumptive diagnosis may be made from the above
symptoms, but can only be verified by instrumental exploration of the
urethra.
Exploration of the Urethra.
The patient should urinate and recline upon a flat surface. A dose of
quinine (10 grains) should have been administered several hours previously
to guard against subsequent “urethral fever.” Diagnosis of a marked
stricture can be roughly made with an ordinary metal dilating bougie, but
FIG. 435.
G
Metal bulbous bougie.
FIG. 436.
Rubber bulbous bougie.
accurate and satisfactory exploratory diagnosis can only be conducted
With bulbous bougies of metal and rubber. If the meatus is contracted,
it should be divided. (See Meatomy.) Then, selecting an instrument of
702 DIS E A SES AND IN J U RIES OF THE U R IN A R Y O RG ANs.
about 25 mm. in diameter (25 French scale) at the bulb, the penis is put
slightly upon the stretch, and the bulb passed down the urethra until ob-
struction is encountered or the bladder entered. If the former obstruct
the instrument, smaller and smaller bulbs are successively tried until one
can be gently pushed through the obstruction and into the bladder. Upon
now slowly withdrawing the explorer, resistance will be met so soon as
the shoulder of the bulb engages in the constriction. A bend or mark is
then made upon the instrument at the meatus. Traction is then made
until resistance ceases, and another mark is made. Thus we have diag-
nosed a stricture, its calibre, situation, and, by the distance between the
marks, its extent. If multiple strictures are present, they are consecu-
tively discovered, located, and measured as the instrument is withdrawn.
If the smallest bulb will not pass the obstruction, we can only thus diag-
nosticate the presence of stricture of small calibre, beginning at a certain
distance from the meatus.
Care must be taken in exploring for stricture not to mistake a slight
resistance or hitch which is invariably imparted to the instrument as the
bulb passes from the prostatic to the membranous urethra, at which junc-
tion the bulb catches upon the posterior layer of the triangular ligament,
which at that point closely invests and fixes the urethra. Nor must a
spasmodic contraction of the compressor urethrae muscle (false stricture)
be mistaken for or confounded with organic Stenosis. The former may be
recognized by its uniformity, smoothness, and, perhaps, intermittent ten-
SłOIl.
TREATMENT.-Strictures are treated either by intermittent, continuous,
or forcible rapid dilatation; by division by the knife, from within out-
ward (internal urethrotomy), or from without inward (external ureth-
rotomy), or by combinations of any of these methods.
Dilatation of the Urethra.
Intermittent dilatation is applicable to and most successful in by far
the largest proportion of cases met with, particularly those of recent
origin and annular shape.
Preserving the usual precautions, a steel bougie of diameter equivalent
to that of the stricture is warmed, oiled, and gently passed through the
stricture. Then an instrument two sizes larger is introduced, and finally
one yet a size larger, which is kept in for five minutes before withdrawal.
If no complications follow, this should be repeated, beginning with the
second largest size last used, every three to six days until the stricture
becomes dilated to the normal calibre of the urethra. The latter can be
ascertained approximately by measuring the penile circumference, for, as
pointed out by Otis, the average measurement of the flaccid penis is three
inches, and the diameter of the urethra 32 mm., and that for every quarter
inch increase or decrease in the circumference of the penis a relative dif
ference of 2 mm. exists in the urethral calibre, which amount should be
added to or subtracted from the size of the normal urethra to ascertain
the normal calibre of any individual case.
After full dilatation has thus been secured and maintained for a few
weeks, the patient should be taught how to pass the instrument, and be
provided with a full-sized one of his own, which he must pass monthly,
or oftener if need be, for the balance of his life. {}
If upon each successive passage of the instrument great irritation or
S T R ICT U R E O F T H E U R ET H R A . 703
early and firm recontraction takes place, longer intervals between dilata-
tions must be allowed to pass, or other methods of treatment employed.
General anaesthesia is but rarely necessary. Nitrous oxide gas may be
employed. Cocaine renders the operation almost free from pain, but has
more than once caused death when thus used.
Continuous dilatation is employed where the stricture is only permeable
by very small instruments which cannot be followed up by larger ones;
in certain cases associated with acute or chronic retention of urine ; and
where a speedy full dilatation is desired.
FIG. 437. FIG. 438.
gº y
Pºžº
º
%22
gº
30)
|
wnſ:
sås. y
\ ——º f
Type of metal dilating bougie. Type of bougie for dilating strictures of
the meatus.
The method is applied by passing an instrument two sizes smaller than
the largest which the stricture will admit, and tying it in the urethra for
a number of days. If the constriction will admit even a small instru-
ment readily this can be carried out easily enough, but assuming that the
stricture is tortuous and of very small calibre, we would proceed as fol.
lows: Anaesthesia having been induced, if necessary, a fine gum catheter
is garried down to the stricture and manoeuvred through it if possible. If
this pass, well and good: it should be tied in by means of tapes running
to a piece of plaster encircling the penis behind the glans, or to a band.
age encircling the waist. But failing to thus pass the stricture, the

704 DISE ASES AND IN J U RIES OF TH E U R IN A R Y O R. G. A. N.S.
|
FIG. 439.
)
/
i
urethra should be filled with filiform whalebone bougies
having vari-shaped extremities, and most gently attempting
to pass each one in turn until finally one engages in and
passes the stricture, when it should be fastened in after its
fellows have been removed. This also failing after a reason-
able effort, the patient should be put to bed, and in from
twelve to twenty-four hours another attempt made. But if
acute retention exists, aspiration or external perineal ureth-
rotomy should be immediately resorted to.
After the instrument has remained tied-in for a day or
two—the urine meanwhile constantly trickling through or
alongside of it—it should be daily removed and cleansed
or replaced by one of larger size, but never so large that it
does not fit the constriction very loosely, for otherwise great
irritation will be set up and more harm than good accom-
plished. Under influence of the retained instrument the
most callous and obstinate strictures will completely dilate
and melt away in from a few days to two weeks, after
which event intermittent dilatation should be started and
persistently carried out.
In all probability the softening, dilatation or “melting ”
of strictures under this method is not due to the exertion of
pressure, but to some unknown influence exerted by the
presence of a non-irritating foreign substance in the urethra.
Forcible (immediate or rapid) dilatation is used to pro-
duce immediate divulsion of a narrow or tortuous stricture
to permit easy application of intermittent dilatation sub-
sequently.
For this purpose a silver catheter of very small calibre,
eighteen inches long, is introduced into the bladder, and
over it are slid, one after another, dilating tubes of increas-
ing size until full dilatation has been attained.
Internal wrethrotomy is employed in certain cases where
the stricture is extremely callous, contracts firmly after
each dilatation, or is very persistent. Cases in which this
proceeding is indicated are not common. The stricture must
previously be dilated sufficiently to admit the urethrotome.
Evternal urethrotomy is applicable to a class of cases
presenting very dense or impermeable stenosis, and especially
when complicated by fistulae or rupture of the urethra;
where all other methods have failed to give a temporary
or permanent result; or in which cystitis, prostatic disease,
or stone coexist, and both diseases can be cured by this opera-
tion. No matter where situated or how bad, all strictures
melt down, become permeable and can easily be treated

Filiform whale subsequently by intermittent dilatation after this operation
bone bougies, has been performed.
URETHRAL FEVER.
Urethral fever is the name usually applied to a condition of pyrexia
or hyperpyrexia, accompanied by more or less severe chills, which is apt
to supervene upon perhaps even the slightest instrumental interference with
C. A. L. C U L I A N D F O R. E. I. G. N. B O DIES . 705
or injuries of the urethra. It may develop immediately after the passage
of a sound or what not, but more usually after the lapse of several hours.
The causes are usually reflex nervous phenomena, but may be septic
absorption on occasion.
TREATMENT.—The treatment is: warmth after operations, quinine, ano-
dynes, removal of any instrument from the urethra or bladder, and sus-
pension of all surgical interference for the time being.
URETHRAL FISTULAE.
Urethral fistulae, as a rule, result from abscesses originating in the glands
thereof in connection with stricture which rupture externally. Also fistulae
may arise from non-closure of operation or accidental wounds of the
canal and from ulceration incident to stones or foreign bodies. One or
many may be present. They may originate from any portion of the
organ, but most usually start in the scrotal or perineal divisions, are
multiple, and burrow far before opening externally, as upon the groin,
thigh, perineum, scrotum, etc., or into the rectum.
TREATMENT.-Removal of the cause will usually be followed by prompt
closure, otherwise treat as described under Hypospadias if confined to
the penis, or by freely slitting up the sinus to its point of origin from the
urethra and packing or suturing the refreshed margins of the wound, if
opening upon the perineum or scrotum.
CALCULI AND FOREIGN BODIES.
Small calculi lodged or developed in the urethra, and foreign bodies
introduced from without, occasionally demand removal.
DIAGNOSIS.–The diagnosis is usually palpable to touch, but is con-
firmed by the urinary obstruction and by passing a sound.
FIG. 440.
‘Urethral foreign-body scoops.
FIG. 441.
Urethral foreign-body forceps.
b TREATMENT.-Elongated bodies can generally be caught and removed
Y. urethral forceps; round bodies by a scoop. Long pins can often be
extracted by forcing the point through the penis, reversing its direction,


45
706 DISE ASES AND IN J U RIES OF THE U R IN A R Y O RG ANS,
and pushing the head toward the meatus. If stricture is present in front
of the calculus it must be dilated at once, or in this or any other difficult
case direct incision upon the foreign substance through the lower urethral
wall may be made, removal effected, and the wound allowed to heal by
granulation. t
TUMoRs.
Vascular, fibromatous, neuro-fibromatous, papillomatous, and myxoma-
tous neoplasms occasionally develop from the walls of the urethra and
project into its cavity. Cancer and tubercle are almost never here located
as primary growths.
SYMPTOMS.—These are made up principally by those of obstruction,
localized pain, and, perhaps, hemorrhage. The growths may usually be
recognized by sight, palpation through the urethral walls, or by the
bulbous bougie.
TREATMENT.-The growths may be removed by forceps or snood if
near the meatus; otherwise by an incision through the urethral floor.
Fibro-vascular Tumors.
Fibro-vascular tumors at the orifice of the female urethra (urethral
caruncle or hemorrhoids) are quite common, exceedingly painful upon
motion, micturition, or sexual intercourse. They are
FIG. 442. easy to diagnose, as, in conjunction with the above
symptoms, there are seen at or surrounding the meatus,
one or more intensely red and sensitive hemorrhoidal
tumors of minute size.
TREATMENT.-Pick them up with a forceps or tenacu-
lum, snip the pedicle with scissors, and touch the wound,
which will bleed freely, with nitric acid or the cautery,
being careful not to let the former agent spread on to
contiguous parts.
INJURIES OF THE URETHRA.
Injuries of the urethra result from accidental, self.
inflicted, and surgical traumata. Severe contusions and
lacerations are apt to be followed by hemorrhage, ex-
travasation of urine, inflammation, sloughing, and the
subsequent formation of cicatricial or traumatic stric-
ture. Rupture of the urethra may be occasioned by
retention, pressure, or by falls upon the perineum, as
astride a plank. In either case the injury is promptly
followed by urinary extravasation. º
TREATMENT.-Most injuries of the urethra require
but treatment upon general principles. When rupture
Ó|) or other wound gives rise to extrayasation or retention
of urine, and a catheter cannot be passed, immediº
* * * * * resort to perimeal cystotomy must be made, all infil-
Type of ordinary trated tissues slit up, and later, when all swelling has
silver catheter, disappeared, a catheter is carried through the enº
urethra at frequent intervals as the wound heals. Sub-
sequently, a metal bougie should be passed as long as there is any º
of constriction.

O P E R A TI O N S U P O N T EI E U R ET H R A . 707
OPERATIONS UPON THE URETHRA.
Catheterization.
Catheterization can only be learned by practice, yet a few guiding direc-
tions may be laid down. Observe that the catheter is absolutely clean,
strong, and well oiled. The patient occupies a recumbent position with
the thighs separated. With the thumb and index finger of one hand
grasp the head of the penis gently and turn the organ up over the pubis
toward the abdominal wall. Then, with the other hand, insert the instru-
FIG. 443.
lò A& º %2.2% %3s
§§§4%Tºš º ſº
§ § % R \\\\ §§§ g g SS
º sº | | W *$ z. - N
\ & § \ \ § D %22% 4, § § … d N N N *
§ §: %//j sº §§§s §§ * * * * * N
%2.3%2XS '% §§§
2 §§§
%; ** §§ A. NA
Sºrº º § Tºº----— p
}...G # § §§ \,
º §ºğll M
3% ºf E
sº ºl, sº § tº:
º º
in)
2. Sºr Å
ºf ºº º
* § ºº::
- gº ºs
§º S-F
#ºft
%
º º:2% %
ſº º º:2% Ž %
º 3 º º
Sº - * *
Sº ' ' tº
º *-
tº
\\\\
QS
|$
Introduction of the catheter. (VoILLEM II:R.)
ment into the meatus and along the urethra until the point reaches the
perineal region, when, with the utmost gentleness, the handle is carried in
* Yertigal are toward the patient's feet until the bladder is entered and
urine flows. But if any resistance is felt in the deep urethra a finger
should be inserted into the rectum to act as a guide in carrying the instru.
ment through the deep urethra and prostate. Sºb






















708 DISE ASES AND IN J U RIES OF THE U R IN A R Y OR GANs,
Catheterization of the Female.
If the sight can be employed there will be no difficulty in finding the
meatus and still less in passing the catheter. But as this means is usually
inadmissible, the procedure may be accomplished as follows: Select a
straight gum or metal instrument. Insert an index finger into the vagina
and hold it, palmar surface up, rather firmly against the upper vaginal
FIG. 444.
=# =sº
ZŽ ſº
% £%
Urethrotome.
wall in the median line. Now, with
the disengaged hand, carry the catheter
along the flexor surface of the inserted
finger and it will almost invariably
enter the urethra.
Internal Urethrotomy.
The patient having been prepared
as for other urethral operations, and
the urethra suitably dilated, if neces-
sary, the urethrotome is marked at a
point showing the distance to the pos-
terior extremity of the stricture by a
FIG. 445.
Type of dilating bougie for female urethra.



O P E R A TI O N S U P O N T H E U R ET H R A. 709
rubber band, and inserted until the knife is one-fourth of an inch behind
the constriction. The canal and stricture are then put upon a moderate
stretch by screwing apart the dilating blades of the instrument, and the
knife blade is protruded one-eighth of an inch and drawn through the
entire length of constriction. The knife is then pushed back into its sheath,
the dilating blades half-closed (not wholly closed, for fear of catching
mucous membrane), and the instrument withdrawn.
If the stricture is quite thick, several incisions should be made in the
same line after each time separating the dilating blades to a greater extent,
until the stricture is cut to correspond with the normal urethral calibre.
All cuts should be made in the roof of the urethra except in the external
one and a half inches of the canal, where they should be made in the floor.
Immediately after division, a full-sized bougie should be passed, and inter-
mittent dilatation kept up for an indefinite time. Hemorrhage may follow
the operation, but it is usually slight. In other case, a catheter should
be passed, and a bunch of cotton bound more or less firmly about the penis.
External Urethrotomy.
When a grooved staff or other instrument can be inserted into the
bladder, this operation coincides almost precisely with median perineal
cystotomy. But if the stricture is impermeable a straight staff is carried
along the canal as far as it will go. Incision is then made in the perineal
raphé until the point of the staff is come upon and healthy urethra divided.
Each side of the split urethra is sutured and held by a silk thread.
Careful dissection is then made in the direction of the prostatic urethra,
a finger in the rectum serving as a partial guide, while at the same time
guarding that cavity, until the urethra, usually much dilated and of conse-
quence more readily found, is opened up. This event will be announced
by a gush of urine. Any well-marked cicatricial tissue is now trimmed
away, and the wound left to granulate and cicatrize. The passage of
bougies should be started a few days later.
Dilatation of the Female Urethra.
Dilatation of the female urethra is accomplished by the introduction
thereinto of increasing sizes of slightly conical, short, straight bougies or
plugs, Fig. 445, or by inserting one finger after another, beginning with
the fourth and ending with the index. Permanent paralysis may result
from extreme hyper-dilatation. Temporary incontinence usually follows
even slight dilatation.
O H A P T E R X. XIV.
DISEASES AND INJURIES OF THE REPRODUCTIVE ORGANS.
TEIE SCROTUM.
IN cases of complete hypospadias the scrotum is split into two halves,
each containing a testicle, or, as likely as not, one or both of these latter
organs may be undescended. Such cases, together with fissure or absence
of the penis, give rise to most instances of so-called hermaphrodism.
The veins coursing through the scrotal walls occasionally become vari-
cose to an extreme degree. When the annoyance or pain arising there-
from is not checked by wearing a suspensory, the vessels may be ligated
in several places or excised. Where great redundancy becomes a source
of discomfort, large oval portions of the scrotal integument may be cut
away and the wound-edges closely sutured without drainage.
Elephantiasis.
Elephantiasis is an unusual disease of the scrotum in this latitude, con-
sisting of an enormous hypertrophy of the skin and connective tissues.
The penis is almost always similarly involved. Febrile disturbance is
marked in the early stages, but lessens as the hypertrophy and concomi-
tant debility increase.
TREATMENT.-Certain favorable cases may be cured by excision, even
if the proportions of the growth are enormous. For this purpose the
mass is elevated and constricted at its base with a rubber band or other
tourniquet. The penis and testes are then exposed by deep incisions and
dissected from the mass, which is then cut away at its base. The wound,
after all bleeding points have been secured, is dressed antiseptically and
allowed to heal by cicatrization.
Lymph Scrotum.
Lymph scrotum is a variety of hypertrophy due to lymphatic obstrug-
tion caused by the presence of filaria sanguinis hominis in the higher
lymph vessels. Attempts to remove the worm are alone admissible in the
way of treatment.
Epithelioma.
Epithelioma (chimney-sweep's cancer) is prome to develop upon the
scrotum of those of any age who work amidst soot. Otherwise it is "
rare affection. The growth presents the same characteristics as do epi-
theliomata elsewhere situated. g
TREATMENT-Excise the mass and surrounding tissues embraging the
entire thickness of the scrotal wall. Suture the wound, if small, other
wise allow it to granulate under antiseptic protection.
T H E TU NIC A. W. A. G. IN A LIS. 711
Contusions of Scrotum.
Contusions usually give rise to extensive blood extravasations between
the layers of the scrotum, with great discoloration of the surface. Abscess
or sloughing may result.
Wounds.
Wounds are treated upon the general principles of wound treatment
already laid down. Should the testicle prolapse it should be cleansed,
returned to position, and the skin brought together over it, leaving in a
small drain-tube.
THE TUNICA VAGINALIS.
Hydrocele.
A serous effusion into the peritoneal sheath of the testicle. The affec-
tion may be (1) congenital or (2) acquired.
1. Congenital Hydrocele is almost always found in young children, and
is due to non-closure of the communication of the tunica vaginalis with the
peritoneal cavity. Congenital or early acquired hernia frequently com-
plicates the defect. There is fluid in the sheath which responds to the
light and succussion tests, disappears upon pressure and lying down, and
reappears upon removing pressure or standing up.
TREATMENT.-Spontaneous cure usually results by closure of the peri-
toneal communication at the neck of the sac. A truss should be worn
for hernial complication. Do not attempt tapping or injection in this
variety of hydrocele.
2. Acquired hydrocele is quite common in childhood and after middle
life. One or both sides may be involved—usually but one. Some form
of inflammation is generally the causative factor.
The cyst may contain from an ounce up to a quart
or more of fluid. This fluid is straw-colored, clear,
has a specific gravity of about 1030, coagulates
upon exposure or boiling, and is made up almost
Wholly of albumen. If the result of acute inflam-
mation the serum may be turbid and perhaps con-
tain blood and pus corpuscles; when milky the color
is due to the presence of spermatozoa, which have
come from the testicle as a result of rupture of a
cyst of the gland or epididymis into the vaginal
tunic. Cholesterine crystals commonly are present
and float upon the surface of the liquid.
. In recent cases little or no change can be observed
in the tunica vaginalis, but in those of long standing £º
and especially where many tappings have been ºr
made, the membrane is vascular, much thickened, Hydrocele of the vagi-
and excessively tough. Either lying loose in the mal tunic of the testicle.
Sac, attached to its walls, or even pediculated, are a testicle. (WYPTH, after
$ometimes found pea-sized or larger dense fibrinous LINHART.)
bodies; cases presenting which are apt to suffer
nuch pain or neuralgia and to persistently relapse in spite of all treat-
*ent until the bodies are found and removed. The shape of a hydrocele

712 T H E R E PRO DU CTIVE O R. G. A. N. S.
is usually pyriform but adhesions in the sac may cause it to assume other
shapes or even divide it into several separate cysts.
FIG 447.
Trocar for tapping hydrocele.
SYMPTOMS.–Swelling of the scrotum, which begins below; a sense of
weight and occasional dragging pain therein. Tension is not apparent at
FIG. 448.
Tapping a hydrocele.
(BRYANT.)
first but soon develops and becomes more and
more marked, while the tumor assumes a charac-
teristic pyriform shape. If very large—espec-
ially when double—the penis is entirely retracted
into the cyst wall and upon micturition the
urine runs down over the scrotum. Fluctuation
is marked and the tumor is seen to be translu-
cent when a light is held on one side of the
Swelling and looked at from the other, while a
hand shuts off all extraneous light from the
observer's eye. It cannot be reduced to the
abdominal cavity and gives no impulse when the
patient coughs. Occasionally it is impossible to
distinguish clouded or opaque hydroceles from
tumors of the testicle until incision is made.
TREATMENT may be (1) palliative, or (2)
radical.
1. Tapping. Cleanse the parts and by the light
test locate the position of the testicle. Grasp
the scrotum and make it tense while a clean
trocar of medium size is plunged into the cyst
so as to avoid scrotal veins and the testicle.
Withdraw the pin and allow the contents to
drain away through the canula. Subsequently
a small antiseptic dressing retained by an ad-
hesive strap will be required for a few days. .
2. Radical treatment includes: (a) tapping
and injection and (b) incision and drainage.
a. Injection is made by throwing into the sac through the canula, after
the contents have been withdrawn, from one to four drachms of pure ting-
ture of iodine or five to ten minims of liquefied carbolic acid crystals.


T H E TU NIC A. W. A. G. I. N A LIS. 713
These irritative agents—when carried into all portions of the sac—produce
inflammation and subsequent obliteration of the cyst cavity by universal
adhesion of its apposing walls. It is very generally successful unless the
fibrous bodies above mentioned happen to be present, when failure will
usually ensue; also it is quite safe and free from unpleasant consequences.
The attendant pain is not severe. The patient should recline in bed or
upon a sofa for a couple of days.
b. Incision and drainage, as a rule, prove most effectual, and are equally
safe if antiseptic methods are pursued. A two-inch incision is made
through the scrotum into the sac. Fibrous bodies are then carefully
searched for, and removed if present. The sac is wiped over with tinc-
ture of iodine, a small drain-tube inserted, the wound sutured about its
orifice, and an antiseptic dressing applied. The tube
should be removed in a week. This method must FIG. 449.
always be adopted when inflammatory complications asº
exist.
Hydrocele of the Spermatic Cord.
A collection of serous fluid in an unobliterated
portion of the peritoneal sheath of the cord.
SYMPTOMS.—A globular or oval, tense, fluctuating,
irreducible, freely movable tumor is located at some
point upon the spermatic cord external to the internal
abdominal ring.
TREATMENT.—The treatment is as for vaginal Exº~.
hydrocele, but the operator should make certain Encysted hydrocele
that no communication with the abdominal cavity of the cord. a. testicle.
exists before applying radical measures. (WYETH.)
Hydrocele in the Female.
Hydrocele in the female affects analogous parts, and in many respects
resembles hydrocele of the cord in the male. It consists of a localized
collection of serous fluid in some portion of the serous tunic of the round
ligament as it courses through the inguinal canal to be inserted into the
cellular tissue of the greater labium.
It must be differentiated from hernia, cysts, and varicosities of the
ºn. Treatment is identical with that of hydrocele of the spermatic
CO l'Ci.
Hematocele of the Tunica Vaginalis.
Effusion of blood into the tunica vaginalis. It may complicate any
form of hydrocele, or exist independently. The usual cause is contusing
Violence, injury by the trocar point, tearing of adhesions, or rupture of a
Velll.
SYMPTOMS.–A heavy, painful, pyriform (base downward) tumor dis-
tends the tunic, is fluctuating, flat upon percussion, while the scrotum is
apt to be tense, livid, and ramified by distended tortuous veins. The
testicle can be outlined below and behind. Pain later disappears, but
only to return should inflammatory complication arise. The tumor is
9paque to the light test, and does not transmit impulses when the patient
°oughs. The blood may be absorbed, break down into a viscid consist-
-


714 THE REPRODUCTIVE ORGANs.
ency, or, rarely, abscess may form. Calcification of the mass has been
observed.
TREATMENT.—Rest in bed, elevation of the scrotum, and cold affusions
thereto; leeches in the line of the cord are applicable to the acute or
formative stages. If at a later time resorption does not take place or
inflammation arises, incision, turning out the clots, and drainage as in
hydrocele should be resorted to. t
THE SPERMATIC VEINS.
Varicocele.
Varicosity of the spermatic and pampiniform veins of the spermatic
cord.
This condition is rare after the fiftieth year; early manhood and
the prime of life are the chief periods of origin. Occasionally the dis-
ease is double or upon the right side, but in the vast majority of cases
the left side, and it alone, is involved. The theoretical explanations given
to this fact are: the left spermatic vein is longer than the right, supplies
the larger testicle, opens into the renal vein at right angles, has no valve
at its renal outlet, and lies close upon the sigmoid flexure of the rectum,
and is thereby exposed to pressure from distention thereof. Great exer-
tion, strains, constipation, venery, pressure upon the cord of trusses, and
relaxed scrotum act as exciting causes.
SYMPTOMS.–When the cord is searched for in its usual position a mass
much resembling a bunch of worms is felt; it is compressible, can be emptied
by pressure or upon the patient's lying down, returns upon rising, and
greatly distends when he coughs or strains. In the mass can be felt and
isolated the whipcord or wire-like was deferens. Perhaps the tortuous
veins can be seen distending the scrotum. Pain of a dragging, dull, dis-
tressing, unnerving character, is usually present, and increased—as is the
varicosity—in warm weather, when the scrotum and other tissues are more
lax.
From malnutrition incident to impeded return circulation, the testicle
is apt to atrophy more or less, also to become tender and sensitive. Grave
mental distress—principally from fear of sterility—often accompanies the
disease.
TREATMENT.—In very many cases comparative relief and comfort can
be secured by regulation of diet and bowels, judicious exercise, tonics,
cold bathing and hip baths, and wearing a well-fitting suspensory bandage
or bag. Where such measures fail, ligation of the veins en masse should
be performed. This operation invariably gives immediate and permanent
relief and does not interfere with the nutrition or activity of the testicle.
Ligation of the Spermatic Veins.
The scrotum and surroundings having been rendered aseptic and shaved,
a vertical incision down to the veins, two to two and a half inches long,
is made upon the antero-external aspect of the scrotum. The was deferen:
is now recognized by its wire-like feel when rolled between the fingers and
isolated behind the thumb and index finger, while the veins are all kept
in front. A strong catgut ligature is now passed with an aneurism needle
between the veins and fingers, separating them from the was at the upper-
TEI E TESTI C L E . 715
most exposed portion, and tied tightly about the varicose mass. The
same is then repeated just above the epididymis, and a section of the mass
cut out between, leaving a good-sized button of tissue at each point of
ligation. A small catgut or rubber drain is inserted, the wound sutured
and dressed antiseptically. The patient must be kept upon his back in
bed for a week subsequently.
THE TESTICLE.
Congenital Abnormalities.
One or both testicles may be absent from their normal position, the scro-
tum, incident to non-descent from the abdominal cavity, retention in the
inguinal canal, or entire want of development. The was deferens or epi-
didymis may be absent or unconnected with the gland.
Malposition of the Testicle.
This is not a very uncommon anomaly. One or both may be affected,
but more usually only one, and that one the left. The organ may be re-
tained (1) in the abdominal cavity, (2) the inguinal canal, (3) situated
just without the external abdominal ring, or, very rarely, (4) in the peri-
Iléll IQ.
In all positions external to the internal ring, the gland is excessively
liable to injury and inflammation because of its fixed and constricted posi-
tion, and, as a rule, is imperfectly developed or rudimentary.
CAUSES.—The causes of malposition are: narrowing of the inguinal rings
or of the canal, premature enlargement of the organ, adhesions acquired
in the abdomen or in the descent, a short spermatic cord, and, possibly,
paralysis of the gubernaculum testis.
TREATMENT.-No treatment is applicable to testes remaining in the
abdominal cavity. When otherwise situated attempts may be made to
manipulate the organ into the scrotum or to suture it to the bottom
thereof, and afterward apply a truss to the external ring to prevent its
return or the development of hernia. If the gland becomes subject to
inflammation or is otherwise troublesome, it should be promptly excised.
Epididymitis.
, Epididymitis, or inflammation of the epididymis, is the most common
inflammatory affection of the testicle. It may be associated with orchitis,
but much more usually is independent. It may be acute or chronic,
single or double.
CAUSES.—Almost all cases are caused by septic (gonorrhoeal, etc.)
material travelling along the was deferens from the deep urethra; but
may follow instrumentation or injury, or arise in the course of syphilis.
SYMPTOMS.–Rather suddenly and with marked febrile reaction the
epididymis becomes swollen, painful, and exquisitely sensitive to pressure.
The pain is of a sickening, dragging, throbbing variety, and is in part
Referred to the loins and inguinal regions or thighs. The spermatic cord
is likewise enlarged and sensitive. The tumefaction is confined to that
portion of the testicle corresponding to the position and outlines of the
epididymis, which becomes hard, tense, and heavy. Hydrocele may
complicate the affection as well as its diagnosis. If gomorrhoea has been
716 T H E R E P R O DUCTIVE O R. G. A. N. S.
the cause, urethral discharge greatly diminishes or disappears tempo-
rarily. Abscess is an unusual termination.
In the course of a week acute symptoms begin to subside, but swelling,
some pain, and tenderness remain for weeks, months, or perhaps perma-
nently. When all symptoms have disappeared the testicle will usually
remain decreased in size and sterile. Double epididymitis may produce
complete sterility.
TREATMENT.-The treatment should consist of rest in bed, elevation of
and cold affusions to the scrotum, leeches along the spermatic cord, laxa.
tives, restricted diet, and opium and
FIG. 450. belladonna suppositories for pain.
Abscesses, when they arise, should
be promptly opened.
To eradicate the swelling and
hardness of the organ, which
usually persist for a long time after
the disappearance of acute symp-
toms, strapping of the parts by
gºsº strips of adhesive plaster or a long,
Method of strapping testicle. (SMITH,) thin rubber bandage applied to the
scrotum should be resorted to, and
the whole supported by a snugly-fitting suspensory bag.
Orchitis.
Inflammation of the secreting or gland substance of the testicle. This
is a less frequent affection than epididymitis, but often exists in conjunc-
tion therewith. One or both testes may be attacked.
CAUSES.—The causes, outside of those of epididymitis, are almost lim-
ited to injuries and metastasis in parotitis and pyemia.
SYMPTOMS.—The symptoms are mainly those of inflammation of the
epididymis, but the organ is heavier and assumes a more oval outline,
corresponding to the shape of the gland. The pain is more nauseating
and there is an almost intolerable sense of dragging weight. Later the
scrotum becomes tense and swollen, and not infrequently abscess forms.
The acute stage likewise lasts about a week, but if suppuration does not
occur, the gland then speedily resolves to a normal condition. Sterility is
an even more common sequence here than in epididymitis.
TREATMENT.-The treatment likewise corresponds with that of the
epididymal inflammation. When abscess forms and opens or is incised
the mass of glandular structure is apt to slough out as a whole. Chronic
inflammation, or continued purulent discharge from the testicle, may
demand its ablation.
Tuberculosis of the Testicle.
Tuberculosis of the testicle affects generally but one side, and in those
of tuberculous tendency, or as a complication of tuberculosis elsewhere in
the body; beginning as a rule in the epididymis, and subsequently involv-
ing the gland proper.
SYMProMs.—The epididymis becomes tumefied, but without marked
pain or tenderness, and later the testicle likewise enlarges, suppuration
with abscess formation supervenes and constitutional disturbance may or

T H E T E STIC L. E. 717
*
may not arise. Hydrocele may complicate. The gland may slough away
after opening of the abscess, but in any case obstinate fistulae with puru-
lent discharge are apt to follow the evacuation of these abscesses. It is
often absolutely impossible to diagnose tuberculosis, even at late stages,
from tumors of the testicle before incision is made.
TREATMENT.--Excision of the affected organ is alone admissible.
Tumors of the Testicle.
Sarcoma is the most common primary tumor of the testicle met with,
but carcinoma, adenoma, chondroma, dermoid and other cysts, and tera-
toma are of rare occurrence in this locality.
Sarcoma is usually small in size and of the round-celled variety, but if
large more usually is cystic and of spindle-cell construction.
Carcinoma occurs only in those advanced in life and is always encepha-
loid in type.
SYMPTOMS.–The symptoms of these two classes of tumors are almost
identical. The organ becomes tense, firm, heavy, globose, does not expand
upon coughing, is flat upon percussion, and is opaque to the light test.
The cord may also be more or less involved. Sarcoma in late stages often
assumes huge proportions and remains smooth and regular in contour.
The skin may slough over portions of the growth, but necrosis is limited
to the integument. On the other hand, carcinoma becomes nodular in
late stages and tends to involve every adjacent structure, while sloughing
extends deeply into the interior of the growth. Excision of the testicle
and growth should be performed at as early a stage as possible. Meta-
stasis and recurrence in the cord or elsewhere are usual.
Injuries of the Testicle.
Severe contusions and wounds of the testicle are accompanied by an
amount of shock totally disproportionate to the injury, owing to the great
sympathetic distribution to the gland. Profound syncope or even death
may be caused thereby. Inflammation and abscesses commonly follow
these injuries.
Evcision of the Testicle (Castration).
The parts having been properly cleansed and shaved, a vertical incision
is made from end to end through the antero-lateral portion of the scrotum
until testicle and cord are equally exposed in the wound. The organ is
now freed from its cellular attachments and lifted, without great traction
upon the cord, from the wound. A double strong catgut ligature is then
passed by a blunt needle through the middle of the cord well above the
testicle or tumor, and each half firmly tied off. The cord below the liga-
ture is now severed and the testicle removed. If the pedicle is very large
it should be tied off in small sections in similar manner. If subsequent
hemorrhage is feared the stump may be transfixed and held in the wound
by a steel pin. The wound is sutured, drained, and dressed in the usual
Iſla llllel”.
Spermatorrhoea.
A functional disease involving involuntary discharges of spermatic
fluid with slight or no sexual pleasure or orgasm. It must not be con-
718 T H E R E P R O D U CTIVE O R. G. A. N. S.
founded with mucous or gleety discharges from the urethra, with the
natural nocturnal emissions of continent health, or those produced by
strain, as at stool, forcing semen from overcharged seminal vesicles. The
real disease is dependent usually upon excessive irritability of the pros-
tatic urethra, brought about by venereal abuse, and is generally coincident
with a peculiar mental condition, either as cause or effect, together with
great excitability of and lack of inhibitory power in the venereal centres
of the brain and cord; or it may be but a symptom of grave structural
changes in the central nervous system.
TREATMENT-Treatment should be directed to improving the general,
physical, and mental condition, and to removal of the cause.
THE PENIS.
Congenital Abnormalities.
The penis may be absent, double, or tied down to the scrotum by a web
of skin or broad adhesion. Also portions may be absent or imperfectly
developed and produce, more especially during erection, curvations of
various degree and direction. A very short frenum may likewise pro-
duce curvation, Phimosis is frequently congenital. Acquired deformities
result usually from sloughing, incident to injuries and chancroidal sores.
Many cases of each variety above mentioned are capable of great im-
provement or entire cure by plastic operations, perhaps combined with
excision of portions of the Organ.
Phimosis.
Elongation of the prepuce with contraction of its orifice. It may be
congenital or acquired. In either case, but especially the former, the
mucous layer of the prepuce is apt to be more or less ad-
FIG. 451. herent to the glans penis, while smegma collects and de-
composes around the corona, producing great irritation.
Not uncommonly these sebaceous concretions calcify.
Acquired phimosis generally results from irritation, pro-
duced by long-continued uncleanliness, cicatricial contrac-
tion of the preputial orifice or gonorrhoea. A very acute
form of phimosis often has origin in the swelling, retained
Secretions, and inflammation incident to acute gonorrhoea
or chancroids beneath the prepuce.
The condition predisposes markedly to the acquisition
of venereal disorders; may give rise to obstruction to
sº: micturition, cystitis, or to reflex spastic palsy, general or
Phimosis. local spasms. As result of straining to pass water, pro-
(SMITH.) lapse of the rectum or hernia may occur. In adult life
phimosis may interfere with copulation or reproduction.
TREATMENT.-In every case where difficulty is experienced in retract-
ing the prepuce, or where adhesions or irritative collections of smegma
are present, operation for its permanent relief should be urged. For this
purpose either of two methods may be resorted to: 1. Slitting up the pre-
puce; or, 2. Circumcision. *
1. Insert a small grooved director into the preputial orifice and carry its
point gently over the anterior surface of the glans exactly in the median

T H E P E N I S. 719
line to the corona. Now with knife or scissors slit up the prepuce upon the
director, as a guide, to an equal distance. More frequently than not the
mucous layer of the prepuce will be pushed ahead of the director and
only the cuticular layer will be cut. If so, then reinsert the instrument
beneath the undivided portion and divide it likewise. When adherent to
the glans this flap is torn free to the corona on all sides with the fingers.
Now its corners are trimmed round and the two layers are sutured
together at a few points with catgut. A little iodoform is rubbed into
the wound and an antiseptic dressing with a button-hole cut in it is slipped
over the glans. A large wad of cotton is placed over the whole, retained
by a diaper or T-bandage, and changed as often as necessary. If the
penis is large the dressing may be applied around it and retained by a
narrow bandage.
2. Circumcision.—Without pulling the foreskin down, grasp it at the
middle of the glans in an antero-posterior obliquely downward and for-
ward direction with a pair of catch forceps. Fasten them, and with a
short knife or scissors cut through the grasped prepuce immediately in
front of the forceps. This will usually remove a circle of integument, but
leave the mucous layer embracing the glans tightly. This latter is
divided upon a director, as above described, and the two flaps thereby
formed are sutured at several points to the skin wound. Any bleeding
FIG. 452. FIG. 453.
Phimosis forceps. Circumcision. (ERICHSEN.)
should be controlled by suture or ligature, especially when from the
artery of the frenum. Dress as above described. Subsequent hemor-
rhage—which should be examined for at frequent intervals during the
first twenty-four hours—must be controlled by opening the wound and
ligating the bleeding point.
Paraphimosis.
Paraphimosis denotes that condition which exists when a tight fore-
skin becomes retracted behind the corona and there caught. Mild de-

720 T EIE R. E. P R O D U C T L V E O R. G. A. N. S.
grees, and all when early dealt with, seldom result in serious consequence,
but when the condition has lasted some time great swelling, inflammation,
or even gangrene, with severe constitutional involvement, may take place.
TREATMENT.—Paraphimosis can, as a rule, easily be reduced by grasp-
ing and making traction upon the penis with one hand, while the fingers
of the other make steady pressure upon
FIG. 454. the glans. Or, the glans may be tightly
wound about (as a top) with a cord,
which, when all Cedema has been re-
duced, is quickly taken away and the
IFIG. 455.
Reduction of paraphimosis. Dividing the constricting band in paraphimosis,
(PHILLIPs.) (BRYANT.)
swollen foreskin pulled over the glans. Again, when these measures
fail, or great swelling or inflammation is present, the band of constric-
tion should be divided in the median line in front. This incision will
always allow the prepuce to be brought down. No sutures are required.
Recurring paraphimosis should be treated by circumcision.
Inflammation of the Penis.
Inflammation of the penis may arise from injury or extension from a
virulent ulcer or contiguous parts. Either the body of the organ or its
integument may be affected. Either variety may progress to purulent
formation, gangrene, or extend to the scrotum, pubis, and abdominal
wall. Permanent induration, or calcification of portions of or the entire
penis, may result from chronic inflammation. Cases of inflammation of
the organ with great swelling, more particularly in children and where
no palpable cause exists, should be carefully examined for strings or bands
placed around the organ for mischief, and which subsequently have be-
come buried in the swollen tissues.
Balamitis
Inflammation of the mucous or inner surface of the prepuce. Retained
normal or pathological secretions (as gonorrhoeal pus) are the usual cause:
The affection almost always coexists with posthitis (then termed balano-
posthitis), an inflammation of the epithelial covering of the glans penis
arising from like causes.





T H E PEN I S. 721
TREATMENT.—The treatment consists of cleanliness and, so far as pos-
sible, removal of the cause. Astringent drying powders are of value.
Circumcision may occasionally be demanded.
Herpes.
Herpes upon the glans and around the preputial margin are of fre-
quent occurrence and of great annoyance because of the intense itching.
They resemble herpetic eruptions elsewhere and are caused usually by
decomposing or irritative secretions.
Treatment.—Scrupulous cleanliness, drying powders, zinc ointment, or,
for very persistent cases, circumcision. º
Chamere and Chancroid of the Penis.
Chancre and chancroid are much more commonly found situated upon
the glans penis and prepuce than anywhere else upon the body. The diag-
mosis and treatment of chancre have been already described (see Syphilis).
Chancroid (soft or non-infecting chancre) occurs most frequently at the
junction of the glans and prepuce upon the corona glandis. There may
be one, two, or more present. These sores present the following charac-
teristics: They begin within a few days or even hours after the deposit of
the poison as a pustule or irritated abrasion; several may develop succes-
sively and others are almost certain to develop at points of contact with
healthy skin or mucous membrane. Pus from one sore invariably pro-
duces a similar sore when inoculated elsewhere. When fully developed
chancroids appear as one-fourth to one half inch in diameter, vari-shaped,
but usually ovoid, rather shallow ulcers with clean-cut—punched out as
it were-edges, having a depressed floor of grayish slough from which
exudes profuse sanious discharge. They are surrounded by an undefined
Zone of bright red inflammatory infiltration, and upon irritation may
greatly increase in size and depth and cause extensive necrosis. The
inguinal glands always early become inflamed (bubo) and commonly
Suppurate. The nearer the sore is to the frenum, the more marked is the
glandular involvement of the corresponding side. Some chancroids heal
kindly without great gland inflammation in the course of a week or two,
while others take on more decided inflammatory action, increase much in
size and cause abscesses in one or both groins, while yet others, especially
in persons debilitated by bad food, exposure, or debauchery, become ex-
ceedingly severe and spread most extensively and destructively (phage-
denic ulceration or gangrene sometimes simply termed “phagedena.”).
The diagnosis between chancre and chancroid (see p. 79) cannot be
positively made except by the appearance or non-appearance, as the case
may be, of secondary syphilitic manifestations.
, TREATMENT-Most chancroids heal promptly when great cleanliness
is combined with liberal applications of iodoform powder. Indolent sores
should be stimulated by such applications as strong solutions of nitrate
9f silver; spreading sores by nitric acid; and phagedena by nitric acid,
bromine, or actual cautery to the entire affected area, supplemented by
Vigorous constitutional stimulation and support. Inflammation of the
inguinal glands may sometimes be aborted by leeches or blisters, but
When suppuration occurs prompt incision, curetting and packing should
be resorted to. Long-continued discharge from sinuses thereby resulting,
46
722 T H E R. E. P R O D U C T I W E O R. G. A. N. S.
or repeated formation of abscesses, should be met by excision of all the
affected glands.
A tight prepuce interfering with treatment, or causing retention of se-
cretions, should at once be slit up, and allowed to heal by granulation,
TUMIORS OF THE PENIS.
Papilloma.
Papillomata (warts) are very common about the glans and prepuce,
and are almost always of syphilitic origin. The corona and preputial
margin are the most usual points of development. The parts should be
kept clean and dry by application of powders of calomel and zinc oxide
(1 to 2) or tannic acid. This failing, they may be painted with nitric or
chromic acid, or, best of all, snipped off with scissors, and the base or
pedicle touched with nitric acid, or, should free bleeding occur, with the
cautery.
Carcinoma.
Carcinoma, usually of the epitheliomatous type, may attack the penis.
It may at first involve the glans or prepuce alone, but sooner or later all
portions of the penis are involved, and later, the inguinal glands and tis-
sues of the scrotum and pubis become likewise diseased. It can be mis-
taken in the early stages for manifestations of syphilis, but should the
FIG. 456.
Epithelioma of Penis. (Asn HURST.)
process not disappear under anti-syphilitic treatment the former diagnosis
is maintained. If glandular involvement has not taken place, prognosis
is fair, otherwise gloomy. Ablation of the penis well behind the affected
area, together with removal of all enlarged glands in the groin and
lymphatics leading thereto, is the only plan of treatment offering any
chance of success.

T H E W U L W A . 723
INJURIES OF THE PENIS.
Contusions and integumentary wounds call for no special description.
Rupture of the sheaths of one or both corpora cavernosa (“fracture of
the penis”), occasionally takes place as result of violence to the organ
while it is in the erect state, and constitutes a very grave accident. At
once there is a subsidence of the erection, great shock and pain, nausea,
and extravasation of blood into the penile tissues, and the whole organ
becomes greatly hypertrophied thereby. The blood may find its way into
the scrotum or upon the abdomen.
Suppuration and gangrene are apt to occur—more particularly when
urine is also at the time, or subsequently, extravasated into the tissues—
unless free incisions are at once made in all directions of extravasation.
When recovery takes place, traumatic stricture and an indurated deformed
organ, unfit for copulation, usually results.
ExCISION OF THE PENIs.
The parts having been cleansed and shaved in the usual manner, and
an umbrella ring or other tourniquet applied to the root of the organ, the
skin is drawn well forward, and a circular integumentary incision made
well above the diseased area.
The corpora cavernosa are then divided at the same level, and the
spongy body at a point half an inch nearer the glans. The latter portion
is now split for a distance of half an inch longitudinally, and each half
of the urethra sutured laterally to the skin of the corresponding side. All
hemorrhage is stopped, a catheter introduced, and an antiseptic dressing
applied. The catheter should be taken out on the second day, and natural
micturition may be permitted from that time on. If the stump is very
short the patient must be provided subsequently with a short canula or
catheter, through which to direct the stream of urine.
THE VULVA.
Adhesion.
Adhesion of the vulvar lips may be recognized upon separating the
labial folds, when no introitus vagina is visible, and a thin bluish mem-
brane connects the labia.
TREATMENT-After puncture with a knife the membrane may readily
be broken down with a finger introduced through the incision. Any
bleeding vessels should be ligated and the parts kept well separated by a
plug for twenty-four hours. 4.
Variæ.
Varix of the pudendal veins usually exists in conjunction with vari-
cosity of the leg veins, but may occur independently. The veins sometimes
attain great size, but as a rule cause little distress or danger, unless they
egome ruptured either spontaneously or by traumata, as in childbirth.
Subcutaneous rupture gives rise to hematocele, external rupture to vio-
lent bleeding.
724 T H E R E P R O DUCTIVE O R. G. A. N. S.
TREATMENT.--When laceration takes place, cold compression should
be applied to mild cases, ligation to more serious ones.
Hematoma.
Infiltration of the pudendal tissues with blood. This condition may
result from rupture of varicose veins or from subcutaneous injury, and
usually the tumor attains the size of an orange. The mass may be ab-
sorbed, become a blood cyst, or suppurate. Inflammation originating
therein may travel beyond the vulvar limits, even into the deep pelvis.
TREATMENT.-Cold and moderate pressure at first; later, if it persist,
incision and drainage—the latter always upon first signs of inflammation
or abscess.
VULVITIS.
Inflammation of the vulva is particularly apt to arise in the labia,
from such causes as contusions, wounds, uncleanliness, foul vaginal dis-
charges, or the presence of parasites (as oxyuris vermiformis), and as a
complication in low fevers or general depraved conditions. It may be acute,
chronic, or limited to the vulvar follicles. In certain acute cases abscess,
sloughing, or spreading gangrene (noma vulvae) may develop. The last
mentioned variety much resembles cancrum oris, is likewise almost con-
fined to strumous children, and in this situation becomes equally, if not
more dangerous.
TREATMENT.—Cleanliness, vaginal douching, and hot moist applica-
tions will alone be required for most cases. Abscesses should be opened
at an early stage, curetted, and packed. Spreading gangrene should be
met with liberal stimulation, quinine, and locally with free incisions and
applications of bromine or actual cautery.
Follicular Vulvitis.
Inflammation of the subaceous and hair glands of the labia and genito-
crural folds. It is quite common during pregnancy and in the unclean.
The parts are oedematous, hot, and subject to an intense burning itch.
The connective tissues are infiltrated and the follicles stand out hard, red,
and vesicular or pustular.
TREATMENT.-Cleanliness and applications of carbolic or lead-water
and laudanum lotions. Certain cases will defy all treatment until preg-
nancy ends.
Inflammation of the Vulvo-vaginal Glands.
This is a very common affection of this region. The glands lie one on
each side of the vaginal outlet in the base of the lesser labia between tWO
layers of the ischio-pubic fascia, and communicate with the surface at
the vulvo-vaginal junction by ducts one-half inch in length. They are
particularly liable to irritation by septic discharges travelling up these
ducts. One or both may be involved, and abscess is the usual result.
Diagnosis is made by palpating the bodies, or their location, between
one finger in the vagina and another upon the labium minor: a hard,
round, or fluctuating tumor is felt between them. e G
TREATMENT.—Hot applications until pus forms; then early incision
through the labium.
T EIB W U L W A . 725
Destructive Ulcers.
The vulva is liable to several forms of destructive and perhaps hyper-
trophic ulceration. These embrace lupus, tuberculosis, syphilis and epi-
thelioma, all of which are most prone to develop in cachectic, unclean
and loose women. Differential diagnosis is often impossible until late
StageS.
fºrussº-The treatment should include, according to the nature
of the process, general supportive and antisyphilitic measures, excisions
and cauterizations. Excepting in those yielding promptly to anti-Syph-
ilitic treatment the prognosis is unfavorable.
Chancre and Chaneroid.
Chancre and chancroid frequently develop upon the vulva—especially
in its deeper folds and at the vulvo-vaginal margin. Chancroids in this
region are prone to become phagedenic in type.
Elephantiasis.
Elephantiasis of the labia and clitoris occurs with more frequency than
do analogous troubles in the male organs. Syphilis would appear in this
case to be the usual cause. Diagnosis and treatment do not differ essen-
tially from those in the male.
Tumors.
The vulva is frequently the seat of syphilitic condylomata and warts,
papillomata, lipoma, fibroma and epithelioma, all of which, except epi-
theliomata, have a marked tendency to become pediculated and ulcerated.
Sarcoma is almost unknown. Cysts of the vulva almost invariably have
their origin in the vulvo-vaginal glands or from hematomata.
INJURIES.
Injuries of the vulva, excepting lacerations of the perineum, call for
no special description.
Laceration of the Perineum.
This occurs as an accident during labor, and may be of any degree,
from mere tearing of the fourchette to rupture down to or even through
the anal sphincter and for some distance up the rectum through the recto-
Vaginal septum. Tears down to the sphincter give rise to a sense of weak-
ness and to more or less prolapse of the pelvic organs from lack of their
natural support, while lesions involving the sphincter accentuate the
above symptoms and permit incontinence of flatus and feces.
TREATMENT-Every woman should be examined for possible lacera-
tion immediately subsequent to delivery. If such is found to exist deep
Sutures should at once be passed from side to side in a transverse direction to
the tear. Where healing of the laceration has already taken place the bowels
should be well cleared out by a purge and enemata. The patient is then
Placed in the dorsal position upon a table with the hips at the edge. The
Operator sits between the legs, facing the parts. Denudation with scissors
726 T H E R EP R O DU CTIVE O R. G. A. N. S.
or knife of all cicatrized areas and especially of those running backward
and upward on either side of the vagina is now made. . If the tear runs
into the rectum the edges are also here denuded thoroughly, and the re-
tracted ends of the sphincter exposed. Sutures of silkworm-gut are then
passed from apex to base of the vaginal denudations, there brought out,
reinserted and brought back to the lower edge of denudation in such
manner that when they are tied the edges of each lateral denudation are
FIG. 457.
N
Nº
N
N
**
-8- º#ºo
*. i%#N.
s
Diagram of denudation and suturing in operating for perimeal laceration. (KELLY.)
brought together on each side of the vagina near its outlet. These
sutures should be placed four to an inch, embrace no skin, and be tight-
ened, shotted, and cut off short. Then are inserted two or three stitches
which enter skin on either side and pass through all the tissues above
the sphincter, and emerge through skin on the opposite side; but if the
sphincter is torn, two or more sutures should include integument and its
denuded ends. The latter are now also tightened and shotted. A tea-
spoonful of iodoform is then placed in the vagina and rubbed into the
wound. No dressing is required. The urine must be drawn by catheter
until the patient can voluntarily pass it. The bowels should be kept
fluid after the first day by saline laxatives. Sutures may be removed on
or after the tenth day. If irritation or discharges develop, vaginal
douching should be employed.
THE WAGINA.
Congenital Abnormalities.
Congenital abnormalities of the vagina are chiefly important in the
interference which they may offer to the escape of menstrual dischargé,
to childbirth, and to sexual congress. They comprise: absence of or rudi-
mentary or double vagina, atresia, stricture, and imperforate or unusually




T H E W A G IN A . 727
jºr
well-developed hymen. The canal may also terminate anomalously in
the bladder or rectum. Stricture may also be acquired as result of cica-
trization of ulcers or wounds, or by organization and contraction of
inflammatory deposits.
TREATMENT.—Imperforate or persistent hymen can readily be relieved
by making a small incision into the membrane and tearing it up to the
vaginal wall. Hemorrhage must then be controlled and a large plug
of dressing kept in for a day or two. Stricture—whether congenital
or acquired—may be treated by dilatation, perhaps combined with incis-
ions, but these measures must be guided by the greatest prudence and
caution to prevent injury to the peritoneum, rectum, and bladder.
Retained Menses. -
Retained menses may be diagnosed when at the usual period of puberty
they do not appear, while each month there recur attacks of pelvic pain
accompanied by severe constitutional disturbance, and, upon inspection,
a tense, bulging, fluctuating tumor presents at the vaginal orifice, and may
extend even largely into the pelvis and abdomen. When this condition
is not promptly relieved a fatal result may ensue from peritonitis incident
to rupture of the accumulation into the abdominal cavity, or from suppu-
ration in the vaginal walls or neighborhood.
Vaginitis.
Vaginitis, either simple or specific (gonorrhoeal), is very common. The
latter variety corresponds to infectious urethritis in the male.
TREATMENT.-The treatment of both forms consists of cleanliness and
frequent removal of discharges by copious injections of hot antiseptic
fluids and, later, of astringent solutions. Vaginitis is generally quite
amenable to treatment and is rarely followed or accompanied by compli-
cations other than subsequent disease of the uterus (metritis) and its
appendages (salpingitis). -
Chamcre and Chamcroid.
Chancre and chancroid find their most common site in the female in
the vagina near its orifice, and are here liable to produce the same compli-
cations as when elsewhere situated.
Fistulae.
Fistulae between the vagina and bladder (vesico-vaginal), urethra
(urethro-vaginal), or rectum (recto-vaginal) are frequently met with.
They usually result from sloughing following difficult childbirth or from
Venereal and other ulcerations, although wounds, either surgical or acci-
dental, may give them origin.
Owing to the consequent incontinence of urine or flatus and feces and
the excessive irritation incident thereto, the patient's plight is indeed a
miserable one.
TREATMENT.-Very small fistulae may sometimes be induced to close
by repeated stimulation of their edges with a hot wire or caustic, but
Persistent or larger openings must be dealt with by a plastic operation.
728 T H E R E P R O DU CT I W E O R G A N S.
OPERATION.—The patient's bowels having been cleared out she is
placed in the lithotomy position for bladder, or the knee-chest attitude for
rectal, openings, and the vagina, if necessary,
IFIG. 458. is well exposed by a Sims's speculum. The
mucous membrane is then carefully dissected
for one-third of an inch in all directions about
the fistulous opening in the vagina with knife
or scissors. Now transverse sutures of silk, silk-
worm-gut, or wire are inserted, six to the inch,
in the following manner: The needle is en-
tered one-fifth of an inch beyond the denuded
area, carried through the muscular wall of the
vagina to the fistula margin; it is then brought
out and reinserted into the muscular coat upon
the opposite side of the fistula, carried through
it and brought out likewise one-fifth of an inch
beyond the denudation. The sutures thus in-
Serted are then tightened and fastened by tying,
shotting, or twisting, according to the suture
material employed. If a vesico-vaginal fistula,
% sº º a catheter should, Subsequent to the operation,
* * *-*--- - - - - be passed at frequent intervals or left in with a
Sims's speculum. tube attached running over the side of the bed
into a suitable receptacle. In any case the
bowels should be moved by a saline purge daily after the first twenty-four
hours. If the fistula is very extensive it may be necessary to turn flaps
from the vaginal wall into it and there suture them in similar manner.
Tumors.
Tumors of the vagina are rare. They may be cystic, papillomatous,
fibromatous, or carcinomatous.
Foreign Bodies.
Foreign bodies may, by accident, or lascivious, or other intent, find
their way into the vagina. No definite rules can be laid down for their
extraction.
Wourids.
Wounds of the vagina usually occur during childbirth or coitus, but
may also be caused by accidental, surgical, or criminal means. They are
extremely dangerous when the peritoneal cavity is entered.
TREATMENT.-The vulnerating body must be removed if still present,
the vagina thoroughly cleansed, drained, and its orifice well protected by
antiseptic dressings, which should be renewed each time that urination
occurs. Peritoneal inflammatory involvement will demand immediate
abdominal section, irrigation, and drainage.

C H A P T E R X. X. V.
DEFORMITIES, OR ORTHOPAEDIC SURGERY.
TORTICOLLIS, OR WRY-NECK.
PATHOLOGY..—Wry-neck is the name given to rotary deviation of the
head caused by contraction of the cervical muscles. The muscular spasm
may be spastic or permanent; or it may be spasmodic, and then is usually
accompanied by pain whenever the spasm producing the deformity occurs.
Hysterical contraction of the cervical muscles may give rise to hysterical
torticollis. A similar deviation of the head may be due to a paralytic
condition of one of the groups of muscles, and also to cicatricial con-
traction of the skin and subcutaneous structures after severe burns or
other destructive injury. The sterno-mastoid muscle is most frequently
the seat of the abnormal contraction, though in many cases the trapezius
muscle and the scalene muscles may be involved in the affection. In
some instances the splenius capitis and deep rotators of the head seem
to be the displacing agents. The affection usually involves one side of
the neck, but cases are described in which the cervical muscles of both
sides have been abnormally contracted. Congenital torticollis is a mal-
formation or is due to injury received at birth, but it is usually the
acquired form which comes under the surgeon's notice.
Torticollis results from the head being held for a long time in a strained
position, as in inflammation of the cervical glands; to myositis or inflam-
mation of the muscles due to rheumatism, gout, or other causes; to spasm
of the muscle induced, probably, by lesions of the central nervous system ;
to muscular spasm the result of injury, and reflex irritation, such as
intestinal worms. A mild form of torticollis occurs after exposure to
cold, and is called by the laity “stiff-neck.”
The distortion caused by caries of the cervical vertebrae is not strictly
torticollis.
The pathological changes which occur in long-standing cases are alter-
ations of the shape of the bones and ligaments, and degeneration of the
Contracted muscles.
SYMPTOMS.--Wry-neck, due to exposure to cold, occurs as a slight
rigidity of the cervical muscles, and is attended with pain on attempts
at motion. Typical torticollis, due to contraction of the sterno-mastoid
muscle of one side, causes the head to rotate, so that the face is turned
to the opposite side, and the chin slightly elevated. The muscle which
is the cause of the deformity is prominent and tense. The shoulder on
the side corresponding to the affected muscle is often somewhat elevated,
and a slight spinal curvature in the dorsal region is not uncommon. The
exact character of the displacement varies with the muscle or group of
muscles involved.
In the Spastic contraction there is little pain, but in the spasmodic
form the head, which is ordinarily in the normal position, is persistently
and violently jerked to one side, while severe pain is felt in the con-
730 DEFOR MITIES, OR OR THO PAE DIC SU R G E RY.
tracted muscle or muscles on the opposite side of the neck. In some
cases this painful spasm and rotary displacement of the head occurs
when the least attempt is made to walk or to use the arms. In other
cases the spasmodic contraction occurs at frequent intervals without
reference to voluntary movements.
TREATMENT—Mild rheumatic torticollis is cured in a few days by the
application of heat, by means of bags filled with hot water, sand, or salt,
and rubbing with stimulating liniments, aided perhaps by hypodermic
injections of atropia (gr. Tº to gr. Gº).
The spastic form may be relieved by general anaesthesia, and, if of
hysterical origin, will probably not return. In other cases a collar-like
apparatus may be so adjusted as to prevent a reproduction of the deform-
ity when the patient comes out of the anaesthetic state. Other cases
require myotomy or division of the displacing muscle. If this be the
sterno-mastoid the tenotome should be introduced beneath the muscle at
its internal edge, just above the clavicle, and as much of the muscle
divided as seems necessary. It may require two punctures with the teno-
tome to enable the surgeon to divide both the sternal and clavicular
heads of the muscle without running great risk of injuring the deep
vessels.
After the muscle has been divided, the head should be turned to its
normal position; but it is said to be well to return it to the abnormal
position and leave it there for two or three days before beginning active
manipulation or mechanical treatment to bring the head into the natural
position.
It is often difficult, in the more complicated cases, to decide what mus-
cles are responsible for the deformity. A careful study of the character.
of the rotary displacement is therefore demanded. It is especially im-
portant to recollect that in sterno-mastoid contraction the head is turned
to the side opposite to that of the affected muscle. Electricity and gym-
nastics will do a great deal here, as in other muscle deformities. Appa-
ratus, whether consisting of steel springs or rubber bands, may be avail-
able as accessory agents, but they can seldom take the place of active
and passive muscular movements. The spasmodic form is exceedingly
intractable. Myotomy and excision and stretching of the spinal accessory
nerve have been attempted with but moderate success. This nerve is
reached by an incision along the posterior border of the sterno-mastoid
muscle, after which the edge of the muscle is turned up and the nerve
found entering its lower surface. Excision of the upper cervical nerves
at the base of the occiput has been performed in at least one case where
the deep rotators were supposed to be at fault. The fluid extract of
gelsemium in very large doses has given fair results in Some cases.
Preparations of this drug vary greatly in strength, and minimum doses
should be used at the beginning of the treatment. I have, however, used
as much as thirteen minims every two hours during the day and night
for several weeks and found satisfactory results from it. Massage as well
as passive motion should be used as adjuncts.
SPINAL CURVATURES.
PATHology.—At birth there are no curves in the infant's spine, but
as the child assumes the sitting or erect posture, curves which are recºg-
nized as the normal vertebral curves, are developed. Weak muscles,
careless postures, the prolonged retention of positions causing abnormal
S PIN A L C U R W A T U R E.S. 731
curves of the spine and paralysis of special groups of spinal muscles are
causes of spinal curvature. Rickets and other agencies tending to inter-
fere with normal development of the growing skeleton are sometimes
causes of these distortions in the young.
Angular antero-posterior curvature of the vertebral column which is
due to caries or tuberculosis of the vertebral bodies, belongs to and is
discussed in the section on Joint Diseases. Its pathology is naturally
distinct from the spinal deviations now under consideration.
The rotary lateral deviation of the spine, to which the name scoliosis
is applied, is the most common form of spinal curvature. Kyphosis, the
form in which the convexity of the column is increased in a posterior
direction, is less common; whereas lordosis, or increased convexity
forward, is comparatively frequent.
These deviations of the spinal column are due to relaxation and debility
of the spinal ligaments and muscles, or to some vicious position assumed
while at work or at rest which has a tendency to maintain the spine in
an abnormal position for a considerable portion of the day. As a conse-
quence the bones, the inter-vertebral cartilages, and the ligaments become
more or less misshapen, and the deviation becomes confirmed. Congenital
curves of the spine are at times seen.
Rotary Lateral Curvature, or Scoliosis.
Rotary lateral curvature, or scoliosis, is particularly common in young
girls about puberty. There is some rotary twisting of the vertebral
bodies as well as a lateral curving. Ordinarily, there is a dorsal curve,
with its convexity to the right and a compensatory curve in the lumbar
region with the convexity to the left. There may be four curves in the
length of the spinal column, but this is uncommon. Sitting at school-
desks with one shoulder unnaturally elevated; carrying an infant con-
stantly on one side, and occupying a lolling position during the greater
part of the day, will tend to lateral curvature in growing girls about the
menstrual epoch. Inequality in the length of the legs, due to disease of
the joints, or to asymmetry in length, will equally lead to lateral curvature.
Deformity of the chest from pleuritis, wearing an artificial leg, and anky-
losis from hip disease may be similar factors in spinal distortion. Rickets
is a predisposing cause, as well as of Osseous deformities in other parts
of the skeleton.
Projection of the posterior border of one scapula and pain in the cor-
responding shoulder and the back may be the first symptoms to attract
attention. The pain may be scarcely noticeable during the day, but is
felt at night, or when lying down or sitting. The winged scapula, as this
deformity is termed, becomes more marked, next a deviation of the dorsal
spine in the lateral direction is observed, and soon a secondary compen-
Satory curve appears in the lumbar region. Rubbing the skin over the
Spinous processes of the vertebrae will cause red spots to appear over these
bony prominences, so that the surgeon can readily determine the absence
or extent of the spinal curvature. The spinous processes, however, are
in reality less displaced than the bodies of the vertebrae themselves, which
have undergone lateral and rotary displacement. The viscera may be
injured and compressed by the deformed skeleton, and some anatomical
change in the position of the vertebral ligaments may arise secondarily.
If the deformity is great a deep sulcus occurs between the lower ribs and
732 DE FOR MITIES, OR OR THO PAE DIC SURGERY.
the ilium on the side of the body corresponding with the convexity of
the dorsal curve. The ribs and ilium may actually override, and bursae
may be formed from friction,
Fig. 459. FIG. 460.
[.º
wº
ëW
º
W
|
º
|
-:
º
:
§
:
:
)
šs
Š
f
=
€,º
#
$E:
==
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==-
Fig. 459.-Vicious position during writing. (REEves.)
Fig. 460.-Right lower dorsal and left lumbar curvatures, showing unequal height or
shoulders and folding of the soft parts in the left ilio-costal region. The left hip is
higher than the right. (REEVEs.)
Jºyphosis.
Kyphosis, or round-back, is a bending of a part or whole of the spine
so that the convexity of the curve is backward, giving the patient the
appearance called round-shouldered. The term is not used in connection
with angular curvature due to tuberculosis of the vertebrae. Kyphosis
occurs in children and in old persons, and is commonly in the upper
portion of the dorsal region. In long-standing cases ossification of the verte-
bral joints, so that the bodies become ankylosed, may take place. Rickets
and faulty positions while at work, or at rest, may be the cause of the
deformity. It is an indication, also, of the increasing debility of the
tissues which occurs in the aged. Dyspnoea and other visceral symptoms
may be induced in aggravated cases.
Lordosis.
Lordosis, or hollow-back, is a spinal deviation in which the convexity
of the curve is forward; it is usually found in the lumbar region, due to
an aggravation of the normal lumbar curve. Congenital dislocation of
the hips gives rise to lordosis. Carrying heavy weights on the head is
another cause. Pregnancy and abdominal tumors give rise to temporary





S PIN A L C U R W A T U R E S. 733
lordosis, because the patient must bring the centre of gravity further back
in order to neutralize the weight in front of the median plane.
Hollow-back, whether occurring in the lumbar region or the cervical
region, is characteristic. When the patient lies upon a hard mattress the
arching of the spine is conspicuous. There may be compensatory kyphosis,
and in kyphosis there is often compensatory lordosis. Uterine and other
visceral trouble may occur secondarily.
TREATMENT.-The prevention of spinal deviation is exceedingly im-
portant in young subjects presumably liable to such a deformity. , Gym-
nastic exercises and abstinence from positions, whether at school or at
work, that tend to exaggerate the normal curves, should be enforced.
Even slight deviations should be subjected to treatment, because they may
be entirely cured. Absolute restoration of the outline is impossible when
the bones have been permanently deformed by pressure, or when ankylosis
between the vertebral bodies has occurred. The general health should
be improved by tonics and out-door exercise, and by abandonment of the
injurious habits which tend to confirm the deformily. Gymnastic exer-
cises to develop weak muscles or to draw the bones into proper position,
should be instituted, but they should not be permitted to be carried far
enough to fatigue the patient. Swinging by the hands from a trapeze, or
from the top of a door-way, will straighten out the curves by the traction
exerted by the lower limbs. The use of dumb bells and Indian clubs,
and massage, are valuable in developing the muscles. Propping up certain
portions of the trunk while lying down, or the use of a spring, such as is
shown in the diagram, to make pressure upon the distorted spine, will be
found at times efficacious in relieving the deformity.
The motions used in swimming are good exercise for a patient with
lateral curvature, and they may be performed in the air by having the
patient lie upon a proper support. All these mechanical measures must
be continued for many months before benefit can be observed.
Mechanical support is valuable as an adjuvant in developing the mus-
cular system, and may, therefore, be useful in the intervals when rest
from the more active treatment is re-
quired. In rotary lateral curvature a FIG. 461.
pelvic band with crutch heads extend-
ing up into the arm-pits may be worn.
Ajacket or cuirass of gypsum bandages
fitted to the patient when he is sus-
pended, to straighten out the curves,
has advocates. If these means pre-
vent increase of the deformity and aug-
ment normal muscular development,
the tendency to spinal deviation will
disappear as the patient grows older.
If the lateral deformity depends
upon one leg being shorter than the
other, the lower extremities should be
made of equal length by increasing the Diagram of dorsal kyphosis before and
thickness of the sole of the shoe on the after application of a spring corrector.
short limb. It is possible that making (REEVEs.)
the legs of unequal length by wearing
a high sole may be utilized as a treatment for correcting spinal curvature
from other causes than asymmetry of limbs.
Kyphosis requires a similar kind of treatment, though the muscular

734 DEFOR MITIES, OR OR THOP AEDIC SU R G ERY.
exercise should be adapted to the character of the deformity. The spring
corrector applied in many cases is represented in the figure.
If ankylosis of the vertebrae has occurred, cure is not to be expected.
Rupture of such osseous or fibrous bands has in some cases been attempted,
and has been successful. There is an element of danger in this forcible
method of treatment, which, of course, should never be applied in anky-
losis after tuberculosis of the spine or Pott's disease, which is sometimes
included under the term kyphosis.
Lordosis is managed in a similar manner, but the pressure from the
apparatus is so applied as to push forward and compress the dorsal curve.
The patient's shoulders and hips may be so elevated when lying in bed as
to diminish the lumbar curve, and thus tend to correct the deformity. It
must be evident that for the successful management of 'spinal curvature,
some ingenuity on the part of the surgeon will be required. Although
the aid of steel springs and rubber bands, and other mechanical appli-
ances is often essential, it is upon the muscles that dependence is to be
placed in preventing and overcoming the distortion. Much patience is
demanded on the part of the patient.
WEBBED FINGERs.
The term webbed fingers is applied to the congenital deformity in
which two or more fingers are fastened together by cellulo-cutaneous
FIG. 462.
Operation for webbed fingers. First two figures show lines of incision on back and
front of fingers. Third figure shows; a. The lines of the two incisions uniting so as to
divide the web and leave a flap on each side. b. The flaps detached from one finger
while adherent to the other. c. The flaps applied to the fingers and covering the raw
surfaces. (REEVES.)
bands extending across the inter-digital notch. The band may unite the
fingers throughout their entire length, or may join only small portions of

CL U B-F O O T. 735
them. The deformity is only relievable by operation. One of the best
plastic operations is to dissect a rectangular flap from the back of one of
the fingers extending as far as its middle line, and to raise a similar flap
from the palmar surface of the other finger extending as far as its middle
line. The base of each of these flaps is of course left attached to the
finger from which it is not taken, and extends over the web between the
webbed digits. The subcutaneous tissue uniting the fingers is then
divided, and the flaps carried around the sides of the two fingers in such
a way as to have the two cutaneous surfaces presenting toward each other
on the proximal sides of the previously united digits. If some such
method is not adopted the raw surface made by cutting the fingers apart
would unite at the base during cicatrization, despite the utmost care and
thorough dressing.
CLUB-FOOT.
PATHOLOGY..—Talipes, or club-foot, is a deformed position of the foot,
or part of the foot, in relation to the leg. It may be congenital or
acquired. Usually the muscles, fascias and ligaments are contracted;
sometimes the bones and cartilages themselves are misshapen. The de-
formity may depend upon congenital malformation of the structures of
the foot, upon spasm of the contracted muscles, upon paralysis of the
muscles which normally should oppose the contracted muscles, and upon
other displacing agencies. Wasting of the muscles occurs secondarily,
atrophy of the foot and leg results, and subcutaneous bursae are developed
at points upon which pressure comes during walking.
Congenital cases present a very great amount of distortion when the
child is allowed to attain adult age without the adoption of proper means
to cure the deformity.
Pes varus in the adult. (TREves.) Pes calcaneus. The foot before and after
section of the tendo-Achillis. (TREves.)
There are six varieties of talipes:
1. Pes varus; in which the inner side of the foot is raised, and the
anterior part of the foot and the sole turned inward.
2. Pes valgus. This condition is the opposite of pes varus, and in it
the outer side of the foot is raised and the sole turned outward.
3. Pes equinus. Here the heel is raised and the patient walks on the
tOeS.
4. Pes calcaneus is the opposite of pes equinus. The toes are, there-
fore, raised and the patient walks upon his heel.
5. Pes planus; in which the arch of the foot is sunken and the entire
sole rests upon the ground when walking.
6. Pes cavus is the opposite of pes planus. In it the arch of the foot
is increased and there is a great hollow in the sole.

736 DE FOR MITIES, OR ORT HOP AEDIC SURGERY.
These six forms of talipes are the types, but the forms may be variously
combined. For example: In equino-varus, the heel is raised and the
patient has the inner side of the foot elevated and the sole turned inward,
while pes calcaneo-valgus is a form in which the patient walks upon the
heel with the sole turned outward.
FIG. 465. EIG. 466.
Pes valgus, or flat-foot. (TREves.) Pes cavus, or hollow-foot. (TREVES)
TREATMENT.-The treatment of club-foot requires many months and
a combination of operative, mechanical, and physiological measures.
Manipulations carried on for months by the patient's nurse, by which the
muscles are developed and the foot forced in a normal condition, will fre-
quently cure slight degrees of the deformity. In other cases, tenotomy
of the tendons and fascias will be demanded, and will have to be supple-
mented with manipulations and apparatus in order to maintain the cor-
rected position obtained by operation.
The most confirmed and marked cases are found in adults who have
gone untreated. In these, and sometimes in very severe cases occurring
in the young, excision of some of the tarsal bones is the only means by
which a fairly good position of the distorted member can be obtained.
It is rather rare that this severe operation is demanded in cases of con-
genital club-foot which come under skilful supervision during infancy.
Cases of unsuccessfully treated club-foot, commonly called relapsed cases,
are more difficult to handle than others presenting similar deformity,
because after tenotomy has been done the patient's tendons and fascias
become more or less matted together by adherent inflammation. Of late
years, immediate correction of the deformity by great force, applied by
the hands, or by means of screws operating upon pads applied to the foot,
has become a favorite with some orthopaedic surgeons. The corrected
position so produced is maintained by the application of gypsum bandages
to hold the foot in place.
The operation of tenotomy may be done upon infants after two months
of life, if by this time efforts to overcome the deformity by manipulation
have been unavailing, and in cases where it is evident that these simple
measures will not be of service if they are kept up. After tenotomy the
foot and leg should be bandaged to a well-padded splint of zinc, copper,
or sheet iron, which will maintain the desired position. These flexible
splints are cheap and can be altered from time to time as the surgeon de-
sires. They facilitate greatly the change in position of the foot which is
the object of treatment. After six weeks' use of the splint it may be dis-
pensed with in congenital cases, but the little patient should be under the
surgeon's eye at intervals until able to walk, and should even be watched
by him after that date.

CLU B - F O O T. 737
The greatest care is necessary to see that excoriations are not produced
by the apparatus applied. Massage in its various forms should be con-
tinued during treatment. It is essential that the muscles of the leg be
subjected to the influence of massage as well as those of the foot.
FIG. 467. FIG. 468.
Reeves's universal talipes shoe. Reeves-Scarpa shoe for severe cases.
Pes Varus.
This is the most frequent form of congenital club-foot. There is inver-
sion of the anterior two-thirds of the foot, with turning-in of the sole and
elevation of the inner part of the foot, so that the patient walks upon the
outer part, or, in bad cases, actually upon the dorsum, of the tarsus.
In all cases of pes varus there is elevation of the heel, producing pes
equino-varus. The inversion is due to the anterior tibial and posterior
tibial muscles, and the long flexor muscles of the
toes, while the elevation of the heel is produced by FIG. 469.
the calf muscles acting through the tendon of
Achilles. The plantar fascia and other muscles
than those mentioned may at times be contracted,
and increase the deformity.
TREATMENT.-It is usually well in undertaking
operative treatment for this condition to divide the
operation into two stages if the deformity is a pes
equino-varus and not a simple pes varus. The in-
version of the foot should be first treated by ten-
otomy of the tibial tendon and of the posterior tibial
tendon. Perhaps the plantar fascia and some of the ſº
other tendons may require section. The second Diagram of a normal
stage, which is to relieve the elevation of the heel, foot and one with pes
should be undertaken several weeks later. If the equino-varus, to show
case is one of pure pes varus, the first procedure internal deviation of
alone is necessary. the anterior part of
After the deformity has been corrected by means foot. (SAyre.)
of tenotomy, the foot, of course, is dressed with the
flexible metal splints previously described, or possibly with gypsum ban-
dages. The latter, however, is not so desirable in infants as in club-foot
{\


47
738 DE FOR MITIES, OR ORTH OPAE DIC SURGERY.
of adults, because the skin is tender and more easily irritated. It is,
therefore, better, if possible, to use metal splints, which can be removed
daily, in order that the limb may be bathed and the condition of the foot
observed.
In pes varus or equino-varus, whether due to congenital or acquired
causes, more radical operations are sometimes demanded. Free tenotomy
of all the restricting structures, without reference to their names, accom-
panied in many cases by the removal of a wedge-shaped portion of the
tarsal bones, is at times the only method which will give a proper shaped
foot. Cutting out a wedge-shaped portion of bone is called tarsectomy,
and is performed by making a large elliptical flap to expose the bones,
and removing with a saw, or by disarticulating with a knife, all the bony
tissues that prevent the reposition of the foot. A drainage-tube is then
introduced, the flaps and such tendons as are not factors in causing de-
formity are united by sutures, and the limb dressed with gypsum im-
movable dressings. The dressing may be left in position for several
weeks, when, if the asepsis or antisepsis has been perfect, the wound will
be found healed, except at the point where the drainage-tube makes its
exit. The gypsum bandage may be removed, however, at an early
period, in order to take out the drainage-tube. After such operations the
foot is always shorter than the normal foot would be. This is due partly
to the removal of a portion of the tarsus, and partly to the fact that the
leg and foot are atrophied from imperfect development or from non-use
of the muscles. Tarsotomy is the term used when the bones are simply
cut through with a saw or chisel and no portion removed. This is some-
times effective. Occasionally, reposition of the inverted foot may be
accomplished by forcibly bending it into position by means of the hands
or strong screws attached to a suitably-shaped foot-clamp. Some slight
inflammatory reaction is to be expected after this violent treatment.
Apparatus or dressings of a retentive kind must be applied after the
operation.
Pes Valgus.
Pes valgus is the condition opposite to pes varus, and is the turning-out
of the sole, so that the patient walks upon the inner edge of the foot. It
is very frequently associated with flattening of the arch of the foot, be-
coming then pes plano-varus. It is sometimes combined with pes cal-
caneus, and is then called pes calcaneo-valgus. Mild cases are man-
aged by bandaging the foot into proper position by splints and pads
placed on the inner side of the ankle. In more severe cases tenotomy of
the three peroneal muscles, and of any other muscles tending to produce
displacement, may be required. If the sole is flat, it may be necessary to
insert in the shoe worn after the lateral deformity has been corrected,
such a pad as will restore the arch of the foot. Resection of the astragalo-
scaphoid joint may be required to restore the arch.
Pes Equinus.
This deformity is not often congenital. It is usually due to infantile
paralysis of the muscles of a part of the leg, or to abscess or injury caus-
ing contraction of the calf muscles. It is to be treated by tenotomy of
the tendon of Achilles.
CL U B-FOOT. 739
Pes Calcamews.
Pes calcaneus is another form of club-foot which is not commonly con-
genital, and, like pes equinus, is quite often due to infantile paralysis of
the muscles antagonistic to those producing the deformity. Pes calcaneus
is treated by tenotomy of the displaced muscles, or by apparatus so
arranged as to pull up the heel. Rubber bands are utilized in this as
in other forms of club-foot. It has been suggested to cut out a portion
of the tendon of Achilles and splice the two ends, in order to raise the
heel and shorten the tendon of the calf muscles.
Pes Plamus.
Pes planus, or flat-foot, is a flattened sole, due to obliteration of the
normal arch of the instep. This form of club-foot is well demonstrated
by covering the sole with shoe blacking and having the patient tread
upon a piece of white paper. The imprint of the foot shows the entire
foot coming in contact with the floor, and is a good diagnostic symptom
of the existence of the deformity. In the normal foot it is simply the
heel, outer edge, and the toes that touch the ground.
FIG. 470.
Impression of normal sole, with dotted lines Impression of the sole in pes cavus.
showing borders of the foot. (REEVEs.) (REEVEs.)
The pain produced by this giving way of the plantar arch is often
mistaken for rheumatism or neuralgia. This breaking down occurs in
persons of weak fibre, in those who are required to stand much upon
their feet, and in those who are very heavy. An ingrowing toe-nail
may cause it by reason of the manner of walking adopted to avoid pain
from the diseased nail. As previously stated, the condition is often as-
sociated with pes valgus. Much comfort is often given by placing in the
shoe a plate or pad to restore the arch of the foot. Muscular tone can
be given the long flexor of the great toe by gymnastic exercises to
develop the muscle. This may be done by having the patient raise
himself upon his toes a number of times each morning, so as to bring
these muscles into action. “Weak ankles” is a term often applied to
a tendency to the occurrence of pes valgus, and is due to the relaxa-
tion of the internal lateral ligament of the ankle-joint. Massage and
support of the ankle by a high-laced shoe, or some form of rubber or

740 DE FOR MITIES, OR OR THOP AEDIC SURGERY.
metal support, will, when combined with tonic treatment, usually be suffi-
cient for the correction of this weakness.
Pes cavus, or hollow-foot, is treated by subcutaneous division with a
tenotome of the plantar fascia, with or without division of the short
flexor muscle of the toes. Improvement in gait and relief from discom-
fort are sometimes obtained by building up the interior of the shoe so
that the sole will come in close contact with the excessive arch of the foot,
DEFORMITIES OF THE KNEE AND LEG.
PATHOLOGY..—Knock-knee, or genu-Valgum, is a deformity in which,
when the patient is standing, the knees are close together or touch,
while the internal malleoli are more or less widely separated. The
opposite condition, in which, when the internal malleoli touch, the knees
are more or less widely separated, is called genu-varum, or bow-legs.
This latter condition is frequently associated with bowing outward of the
tibias.
FIG. 472. Fig. 473.
§
f
º *Tºlº
§ §Iſº ºſſi;
#| ||
gll †
|
#
º
Apparatus for treating knock-knee. Apparatus for treating bow-leg.
The deformity in knock-knee disappears when the knees are bent so
as to bring the legs at right angles to the thighs. In this deformity
there is not much pain, but usually a feeling of weakness after prolonged
standing or walking, which may be associated with considerable discom-
fort. The deformity exhibited in the lower extremities, and the abnor-
mality in gait of the patient, are sufficiently diagnostic. The condition
may be due to rickets, but it may also occur from attempts at walking at
too early a period while the bones and ligaments are scarcely developed
in strength. Local paralysis, or a continuation of bad postures in early
life, may also be factors in the causation of genu-valgum. The knee-
joint shows a tendency to bend backward so that the popliteal space
scarcely exists. The inner condyle appears relatively larger when com-

D E FOR MITIES OF THE KN E E A N D L E G . 74.1
pared with the external condyle, but it is possible that this change of
relation is due to improper development of the shaft of the bone.
TREATMENT.--In the early stages such joint deformities are often reme-
diable by the use of apparatus which will, in case of knock-knee, draw
the knee outward, and in the case of bow-legs press the tibia or knee
inward.
In more advanced cases it becomes necessary to use more active meas-
ures. This consists in forcibly straightening the deformed limbs by
manual power or by performing osteotomy, followed by the application
of gypsum bandages to retain the fractured or cut tissues in their new
position.
Osteotomy is usually performed by means of a chisel or Osteotome. The
latter is an instrument much like a chisel, except that it is bevelled on
both sides instead of upon one. A saw is seldom used at the present time
for performing osteotomy.
FIG. 474.
In case of knock-knee the femur may be divided by a horizontal cut
just above the external condyle, or at the junction of the middle and lower
thirds. The relatively large internal condyle may be separated from the
rest of the femur by an oblique cut made with the osteotome, so that the con-
dyle will slip upward when the leg is brought inward to a normal posi-
tion. Some operators prefer condyloid section; others, section above the
condyles, or in the shaft. In performing Osteotomy it is proper that the
incision through the skin should be made in the long axis of the bone, in
order to divide as few muscular fibres and tendons as possible. The Osteo-
tome is introduced with its edge in the direction of the incision, but sub-
sequently it is turned to a right angle before it is struck with the mallet.
The bone should be divided for about two-thirds of its thickness. The
remaining portion of the bone is fractured, as the limb is bent into posi-
tion. In the condyloid section the instrument should not go entirely
through the condyle so as to enter the joint. Section through two-thirds
of the bone at this point will permit ready fracture of the remaining
osseous tissue; and the line of fracture is not so liable to cause inflamma-
tion of the joint as would one made by the instrument, although an aseptic
wound of this sort is not apt to cause any complication. Some surgeons
prefer to make the section through the shaft of the femur from the inter-
nal aspect of the thigh rather than through the external surface. By
Some operators it is thought advantageous to use one or two osteotomes,
each of lessened thickness, for the deeper parts of the bone section. The
thick osteotome makes the wound at the surface of the bone wide; the
thinner instruments cause a narrower cut as the deeper portion of the
bone is divided. This gives the wound in the bone when completed the
wedge-shape which is believed by them to render correction of the deform-
ity more satisfactory. This theoretical advantage does not seem to be
altogether sustained by practical experience, and the change of instruments
renders sepsis more possible.

742 DE FOR MITIES, OR OR THO PAE DIC SU R GERY.
Osteotomy is frequently required in cases of bow-legs. Sometimes it
is necessary to divide both the tibia and the femur.
It requires from four to six weeks for the divided bone to unite after
Osteotomy for genu-valgum or genu-varum. After this time the gypsum
dressing, which is usually applied over the antiseptic dressing immedi-
ately after the operation, may be removed. For a long time afterward
apparatus is demanded in order that a recurrence of the deformity, or
fracture of the bone at the point of operation, may not occur.
Various irregular deformities of the tibia may occur as a result of
rickets. These may demand for their alleviation numerous Osteotomies,
or in some cases excision of a wedged-shaped piece of bone.
C H A P T E R X. X W I.
AMPUTATIONS.
DEFINITION.—By amputation is meant the removal of a locomotor
extremity of the body.
VARIETIES.—Amputations may be single, double, or multiple; partial
or complete. Multiple when more than two extremities are removed at
the same sitting. When two or more operators at once remove separate
extremities the operation is termed synchronous amputation.
Complete when an entire extremity is removed, as the leg at the knee,
termed complete amputation of the leg; or the thigh at the hip, known
as complete removal of the thigh.
Partial when amputation is done within the extreme limits of an
extremity. Thus, an operation removing but a portion of the forearm
would be a partial amputation, but operation through the elbow-joint
would be a complete amputation of the forearm. Amputations are some-
times spoken of as in contiguity or continuity; in contiguity when done
between contiguous bones at joints, as amputations through the elbow-
joint; and in continuity when division is made in the continuity of bones
between joints, as in the middle of the thigh. Amputations may be
natural, as those produced in utero by the umbilical cord or other con-
stricting bands, or by the shedding of a part by gangrenous process;
traumatic, as when an extremity is cut or torn off by machinery or pro-
jectiles; or as surgical premeditated scientific procedure.
REAMPUTATIONS are either done subsequently to an unsuccessful ampu-
tation at a lower point, for disease of a stump, or to put into better shape
the result of a natural or accidental amputation. The mere trimming-up
of an extremity non-operatively removed should never be termed amputa-
tion or reamputation.
The objects of amputation are completely to rid the patient of a danger-
ous devitalized or impedimental extremity, which cannot otherwise be
treated with beneficial results, and in so doing to leave him as useful a
stump as possible. These being the objects of amputation it can readily
be understood why with the advance of surgical knowledge the operation,
especially for chronic disease and wound complications, is each year less
frequently employed.
INDICATIONS.–Amputation may be indicated when an extremity has
been hopelessly crushed, or, at a higher point, when an extremity has been
avulsed or torn off; when the limb is destroyed by heat, frost-bite, or gan-
grene; for certain encircling and other incurable ulcers, and for morbid
growths and deformities. *
CONTRA-INDICATIONS.—Amputations, unless extenuating circumstances
are present, should not be undertaken when shock, nephritis, diabetes,
pyemia, general tuberculosis, or atheromatous vessels are present. In
spreading gangrene it will often be the patient's only chance for life, but
in all other forms of the affection the operation should be delayed until
a line of demarcation can be distinctly recognized.
744 A M P UT A TI O N S.
TIME FOR AMPUTATIONS--According to certain constitutional condi-
tions which are present in cases demanding amputation the operation is
termed (1) primary, (2) secondary, or (3) tertiary.
(1) Primary amputations are those which are performed for injury at
Once, or before septic absorption and consequent constitutional disturb-
ance has taken place. The primary is the elective period if shock can
be subdued, and the general condition of the patient warrants. When
the injured part is kept aseptic the primary period can be indefinitely
prolonged, but otherwise it will terminate in not less than twenty or more
than forty-eight hours after injury, varying greatly with different indi-
viduals, the degree of shock, and the virulence of infection.
(2) Secondary or intermediary amputations are those performed while
the septic process is developing and in active progress. This period usu-
ally begins from twenty-four to thirty-six hours after injury, its duration
may be days, weeks, or months. There would be no secondary period
following traumata if the wounds could be treated early enough and
in thoroughly antiseptic manner. To the secondary period also belong
all premeditated amputations for acute septic disorders, such as spreading
gangrene, or abscess of a joint. Secondary amputations yield a very high
death-rate, and should only be undertaken for such desperate circum-
stances as rapidly extending gangrene, or where it is thought to be a
greater risk to allow the disorder to continue than to remove the extremity
at so dangerous a time.
(3) Tertiary (chronic) amputations are those performed after the septic
process has terminated or become chronic, and the patient well acclimatized
to his altered state; also those performed for growths, simple aneurisms,
chronic disease, deformities, and supernumerary extremities.
LOCATION OF AMPUTATION.—The point at which amputation shall be
made is determined by the nature and extent of injury; the presence of
multiple fractures; of bloodvessel implication, and innumerable other
circumstances which present with each individual case. But a good
general rule is to amputate as far from the trunk as is consistent with
thoroughness of removal, certainty of result, and subsequent utility of the
stump. The mortality of amputations rises as the seat of operation ap-
proaches the trunk. In each extremity there are situations which, for
various reasons, are more favorably regarded as points of election for
amputations than others. Thus, the lower middle of the leg is the point
of election for amputating the leg, because an artificial member can be
best adjusted at that situation; amputation just far enough below the
elbow to retain the tubercle of the radius, is vastly better than one through
the joint, as in the former the power of flexing an artificial forearm is
preserved. When operating for malignant disease, the site of amputation
must widely clear the affected area, and, if bone is involved, the extremity
should be removed at a point not lower than the first articulation above.
Every possible atom of the hand is worth preserving, but no risk is worth
taking to save toes or small portions of the foot.
The arm, forearm, thigh, and leg, are each divided into approximate
thirds, that the seat of amputation may be more accurately described.
Thus we speak of amputation in the lower third of the arm, the upper
third of the leg, or the middle third of the forearm.
INSTRUMENTS.-In addition to ordinary operating instruments, there
will be required for amputations various special saws and knives, a double-
edged knife (catlin) for dividing tissues between the bones of the forearm
and leg, cutting pliers and bone forceps. Also tourniquets, the hemostatic
O PE R A TI W E M ET H O I). 745
rubber bandage, and retractors for holding soft parts away from the saw.
These latter are made from a stout piece of gauze six or eight inches wide
and two feet long, torn through half its length into two tails, if but one
bone is present, or into three tails if two bones are to be divided. It is
applied in the latter case by covering each half of the divided tissues with
the outside strips, and slipping the middle one between the bones; by
traction upon the ends all tissues can then be drawn upward out of reach
of the saw.
FIG. 475.
==========s
#C#EEEEEz:#SONS
NNNSST RSºSSE, "TTE= . . . cº)
Aseptic amputation saw.
OPERATIVE METHOD.—Primary amputations will often be necessary
when the patient's condition is far from favorable, but in tertiary opera-
tions we should get him into the very best general and local condition
before operation is undertaken. In operating we should aim to Sacrifice
as little healthy tissue and lose as little blood as possible; to provide a
sufficient bone covering; to divide blood vessels and nerves transverely,
and to insure thorough drainage and asepsis of the wound.
FIG. 477.
lººk §§
§§
X
**.*
| | sºll
Š >> tº
a)
s
Esmarch’s avascularization apparatus.
More or less complete avascularity should be secured by the rubber
bandage, tourniquet, or other means, but only elevation and simple tourni-
quet should be employed when abscesses, gangrene, or malignant tumors
are present, for fear of producing metastasis.
Incisions are generally made from above downward, and from without












746 A M P U T A TION S.
inward to deep fascia, and the muscles divided at a higher point subse-
quently. But occasionally the method of transfixion, where the knife is
carried directly through the centre of the limb, and the muscles and in-
tegument divided en masse as the knife is brought to the surface, may be
employed with advantage. Incisions may be made in any manner or
direction, provided that they yield a well-mourished covering for the end
of the remaining portion of extremity. The coverings (the flaps) should
be so devised and proportioned that there shall be no tension upon them,
that they shall be well supplied with blood vessels, and that when the wound
has healed the resulting scar shall be
FIG. 47S. neither over the bone end nor so placed
; : as to interfere with the wearing of an
artificial limb. Ordinarily, the num-
ber of flaps should not exceed two;
º but where there is extensive destruc-
º_es tion of integument the surgeon may
- be driven to any kind of patchwork
to provide sufficient covering for a
stump, which otherwise must have been
made much shorter. Extra length of
Amputation through elbow-joint by cir- flaps is of little consequence, for they
cular method. can then be trimmed down, but the
greatest precaution must be taken to
have them not too short or narrow. A safe rule is to cut flaps so that their
combined length is not less than two-thirds the circumference of the limb
at the point of bone division. Their combined width should equal the
circumference at that point. They may be cut of equal size, or one long
and the other short, in varying degree; antero-posterior or lateral;
simply cutaneous or musculo-cutaneous.
When amputation is made by circular incision (the so-called circular
method) the skin of the extremity is grasped by the left hand, drawn
upward, and steadied, while the right hand holding a long amputating
knife is passed around the limb until the surgeon looks upon its dorsal
surface. The heel of the knife is then sunk through the integument,
and as the hand is brought back around the limb the incision is com-
pleted. A cuff of integument is then dissected up and turned back to
the proper distance to make a sufficient flap. All flap dissections in ampu-
tations should be done with the knife edge directed toward the muscles,
that the bloodvessels of the skin may be least injured. The muscles are
then divided to the bone by a similar circular sweep immediately below
the point up to which the flaps have been dissected, the retractor is applied,
and any interosseous tissue having been previously divided with a double-
FIG. 479.
º Fº-3 º sº
flºº. º ...Nº
ſºlº
ºšº §§§º
gºš
* º
2\}.
ºne" º
, 'l º -
|
§
*** §§
º w
§
º j &º. ºf
Q
W §
N
*~
*
*\s, , º º §
\\\\\\\\\\\\\ 18 Sº Sº *... .
\sº
Amputation of forearm by modified circular method. (BRYANT.)
edged knife, the bone or bones are sawed through at a slightlyihigher
level; the smaller one always being first divided. Any chips or sharp
spicules of bone remaining should be picked out or cut off with forceps







O P E R AT I W E M ETH O D. 747
and the bone ends left smooth. Some surgeons prefer to cut the muscles
at once down to periosteum rather than to cut the membrane at a lower
point and scrape it upward as a flap for the bone end, but I consider this
as of trivial importance. The removed part is then placed in a suitable
receptacle, the sawdust washed away with a stream of bichloride solution
and all attention given to seeking and tying the arteries. This accom-
plished, any redundant muscle or flap is cut away, the ends of tendons
and nerves drawn down and cut off, and the tourniquet loosened. Every
bleeding point should be separately grasped by forceps or tenaculum and
tied with catgut. Extensive or continued oozing can be controlled by
very hot water or alcohol applications. Bleeding from the bone medulla
should be arrested by the same means, pressure of a finger, packing with
catgut, or the cautery.
FIG. 480.
* * .
4. * f :- tº *
- _2^ - *~...~. *-
~...~~\º
w
3. w
.-- É 2 -
- ==#3 … wº-
2:3 ~
an *J `-
º - se:- - * *-* -
Stump; showing application of sutures and drain-tubes. A drainage-tube is shown
at the left. (SMITH.)
The flaps are now approximated over a sufficient drain by catgut
sutures and the dressing applied. Two flaps may be made after circular
incision by a vertical incision on each side (modified circular method).
When thus made the square corners of the flap should be rounded off.
Amputation by circular incision is only applicable to the arm and forearm.
The more usual method of amputation is that by double cutaneous or
musculo-cutaneous flaps, made almost square with round corners, exactly
rectangular, or oval. These are made usu-
ally by incision from above downward and PIG. 481.
from without inward, but may also—that gº-
is, the musculo-cutaneous—be made by
transfixion. Cutaneous flaps with circular
division of muscles are generally best.
Excepting in shape of flaps the cutaneous #
method is identical with that of circular
incision. So, also, the partially musculo- / )
cutaneous in which the muscles are simi-
larly divided, but at a point somewhat -- *-ºſ--"
below the origin of the flaps. Musculo- Nº
cutaneous flaps are made by transfixion, ‘N
but can be imitated by cutting the muscles Amputation by lateral flaps.





748 A M P UT A TI O N S.
obliquely to the bone in the lines of flap incision. The latter are not
popular or to be recommended, however, as they provide too voluminous
a stump and divide bloodvessels obliquely, or may notch them at a point
above where the ligature will be applied.
TEALE's METHOD of amputating consists in making two exactly rect-
angular musculo-cutaneous flaps: a long one, half the circumference of
the limb at the point of bone
FIG. 4S2. division and a short one, half the
length of the long one, or one-
fourth the circumference of the
member. In the typical Teale
operation the long flap is taken
from the anterior surface and
forms the bone covering, while
the shorter one is made upon the
posterior surface, and contains the
principal blood vessels. Each flap
is exactly half the circumference
of the limb in width. But prac-
tically the flaps can be taken
from any opposite sides, and can
be altered in length without ma-
Amputation by Teale's method. terially interfering with the ex-
cellent stump which almost inva-
riably results. Many surgeons of experience omit measurements and
approximate the dimensions of the flap by the eye, but usually careful
measurement and marking out with indelible pencil or nitrate of silver
should be done previous to operation. Teale's amputation is especially fit
for the forearm and leg, but may be adapted to the arm and thigh with
success. The sole objection to it is that sometimes more of the member
must be sacrificed by it than by other forms of amputation.
*T*-----, NS
SN
As
ºw. & Nº
FIG. 483.
*...'Yvº • . \\
. Nºw \\
s:...sº § Vº
*jºğW
s sº \ "|
** *.*.*
s §
*
\\
º
NNNNs
§§§.sºss \},NS/\!
§Nº sº §§§ §º
NºNº N Nºş §§ sº § § * …º. ſ
º, * … ºx *N $ º c º “cº-
...tº ſº s SSSR, s $* º
flºº!º §sº * R
tº- ||||}
§º iſºlº
Teale's amputation; completed flaps. (TEALE.)
AFTER-TREATMENT.-Happily, in these days of aseptic wounds, the
after-treatment of amputation wounds has become almost trivial, unless
by accident infection has taken place. Ordinarily, even largest stumps
need not be redressed for from two weeks (when rubber drains should be
removed) to a month. They should simply be kept quiet and somewhat




















A F FECTIONS OF ST U M PS. 749
elevated. In amputations of the leg or thigh the patient should be kept
in bed at for least three weeks, but in removal of upper extremities he
may usually be up much earlier. Antiseptic dressings should be kept
applied until even the drain sinuses have finally closed.
AFFECTIONS OF STUMPS.–If by the temperature record, pain, etc., it
becomes apparent that the wound is septic, the dressing should forthwith
be removed, all tension relieved by dividing sutures, the wound cavity
thoroughly washed out with antiseptic solution, perhaps more drain tubes
put in, and the dressing reapplied, or the extremity put under antiseptic
continuous irrigation. If abscesses form they should at once be opened,
curetted, and drained. Severe infection of an amputation wound would
call for re-opening, curetting, washing and dressing as a fresh wound.
Tissues and flaps appearing unharmed at the time of operation may sub-
sequently slough, and require either skin grafting or re-amputation.
Spreading or recurring gangrene imperatively indicates removal of the
remaining portion of the extremity at either its junction with the trunk or
at a point well beyond the affected area. Secondary hemorrhage in asep-
tic stumps is exceedingly rare. If moderate pressure by bandages and
pressure upon the artery of supply do not speedily check it, the wound
must be opened and the offending vessel tied.
Bones in stumps may be fractured by traumatism, and should be treated
upon the general principles elsewhere dwelt upon, or the fragment may
be excised. Osteomyelitis continuing
or developing in the bones of stumps FIG. 484.
should be treated by prompt re-amputa- 4.444 Assesses
tion not lower than through the first tº
joint above. \º | §
Aneurismal tumors or varices should Y sº º
be treated by excision of the vessel §§ § Nº
mass. Bulbous neuromata, which occa-
sionally develop upon the cut nerve-
ends and give rise to intense suffering,
should be excised, or, this failing, the
supplying nerves should be stretched or
cut at a higher point. So also should
be treated neuralgias due to entangle-
ment of nerve fibres in the cicatrix.
Occasionally great harm is done to a Sºss-cº
stump, or the life of the patient €VCI) Neuromata in stump. Large neur-
endangered, by intense muscular twitch- omatous mass at a ; opposite b the
ings, or the presence of actual chorea in tumors are more defined. (MILLER)
the extremity. Extension of the stump,
combined with tight temporary bandaging of the muscles, sedatives, anti-
spasmodics, and removal of irritating causes usually suffice for perfect
relief, but an occasional rare case will baffle all remedial efforts.
Because of poor surgery, or of unavoidable subsequent sloughing, the
flaps or cicatricial tissue may be drawn tightly over the bone end, which
may even come directly out, producing a typical form of what is called
“conical stump.” Removal of more bone, or re-amputation at a higher
point, will alone answer for the relief of this condition.
Chronic ulcers, eczema, or epitheliomata may develop in and about the
cicatrix, and require its excision or a re-amputation.
As in all aseptic wounds, tetanus is unheard of in properly-treated




750 A M P UT A TI O N S.
amputations. Its development would be an indication of infection and
demand exploration of the wound.
SPECIAL AMPUTATIONs.
Amputation through Shoulder-joint.
Hemorrhage is prevented by a rubber band tourniquet passed through
the axilla across the spine of the scapula and tied tightly down upon the
acromial end of the clavicle; by pressure of the thumb or a padded key in
the post-clavicular fossa, thereby compressing the subclavian artery upon
the first rib ; or, perhaps best, by having an assistant compress the axillary
vessel in the flap before it is finally severed. A primary incision is made
by splitting the deltoid into equal parts from its origin to insertion, and
Application of Esmarch’s tourniquot in amputation through shoulder-joint. (SMITH.)
carried down to the bone throughout; that is, from the acromion process
of the scapula directly downward for about three inches. Subsequent in-
cisions are carried from the base of this one in a slightly oblique and down-
ward directionſ to the anterior and posterior borders of the axilla, being
careful not to prolong either incision so far as to threaten the axillary
artery. The two lateral flaps thus made are then dissected up and freed
from the bone; the capsule is widely incised; the long head of the biceps
divided close to its insertion ; the attachments of the humeral tuberosi-
ties divided after being made tense by inward and outward rotation of
the arm, and the bone exarticulated by drawing the elbow across the
chest toward the opposite side. A trustworthy assistant now compresses
the axillary artery high up in the flap, the remaining bridge of tissue
containing the vessel is divided at a lower point, and the extremity re-
moved. With perhaps more certainty of avoiding loss of blood, particu-
larly in absence of a competent assistant, a tourniquet can be applied
to the arm high up and a circular amputation done at the insertion of the
deltoid muscle. The arteries are then secured, and an incision made
slitting the deltoid as before described, through which the remaining por-
tion of the bone is excised. If the tissues of the axilla are much injured,
a single large flap can be taken from the outer aspect of the member,

S P E CIA. L. A. M. P. UT A TI O N S. 751
including the entire deltoid, or, vice versa, a flap from the inner aspect can
be made to cover in the wound.
Amputation through shoulder-joint. Lines
of incision (usual or oval method). Lines of incision for modified oval
(LISTON.) method. (SMITH.)
FIG. 488.
/
A
|
FIG. 486. FIG. 487.
!
w
*
º
• I
Amputation through shoulder-joint.
§§§
§§§
(HEATH, from Béraud.) 1, biceps; 2,
Section through the middle of right arm.
cephalic vein; 3, brachial vessels; 4, musculo-cutaneous nerve; 5, median nerve; 6,
brachialis anticus; 7, ulnar nerve; 8, musculo-spiral nerve; 9, basilic vein with internal
cutaneous nerves: 10, Superior profunda vessels; Il, inferior profunda vessels; 12, triceps
with intra-muscular aponeurosis.



752 A M P UT A TI O N S.
Amputation of the Arm.
Amputation of the arm can be accomplished by double flaps from any
opposite aspects of the member, or by the single flap, the circular, or Teale
methods. The deltoid attachments should be retained if possible in high
amputations. Operation by internal and external flaps, the former a
little longer than the latter, or the formal Teale, are usually more satis-
factory. The member should be removed at as low a point as is com-
patible with vitality of the flaps.
Amputation through the Elbow-joint.
This is best done by antero-posterior rectangular or elliptical flaps, the
resulting stump being a most useful one, but nothing to compare with
that of removal a short distance below the joint, whereby the insertions
of the biceps and triceps muscles are preserved. The forearm being
supinated, incisions are made from the condyles of the humerus down to
and along the radius and ulna respectively for a distance of about four
inches, and their lower extremities are connected anteriorly by a third
transverse incision. The fleshy flap included between the incisions is dis-
sected up, keeping close to the bones, until the level of the condyles is
reached. Another incision is now made directly across the back of the
articulation down to the bone connecting with the primary incision on
each side. The knife is then passed between the head of the radius and
the humerus, and down through the joint, dividing the lateral ligaments;
after which the olecranon is either detached from its biceps attachments,
or else sawn through from above downward directly above the coronoid
process. If the latter portion of bone is uninjured it is better to allow it
to remain, as thereby the triceps insertion is preserved and a more service-
able stump secured. The ends of the flap are first sutured and then the
sides.
Amputation of the Forearm.
This may be done by the Teale or circular methods or by any other
variety of flaps. If no extra length is thereby sacrificed, the Teale opera-
tion should hold preference over all others. The upper portion of the
lower third of the member would be the point of election. Any pro-
jecting tendon ends should be well drawn down and cut off. Care must
be taken to ligate securely the inter-Osseous artery.
Amputation through the Wrist.joint.
This is performed by securing a large fleshy flap from the palm and a
smaller one from the dorsum of the hand. These may be either rectan-
gular or oval, but the nature of injury may compel the use of other shapes
or kind of flaps. Here, likewise, tendon ends must be drawn down and
cut off.
Inter-carpal and Carpo-metacarpal Amputations.
Inter-carpal and carpo-metacarpal amputations are never performed,
as they make useless and impedimental stumps, to which prothetic appa-
ratus cannot be adjusted.
SPECIAL A M P UT A TI O N S. 753
Amputation of the Hand.
Amputation of the hand through the metacarpal bones may sometimes
be done and a very useful stump secured. Oval or rectangular antero-
posterior flaps should be employed. Amputations through one, two, or
three metacarpals are done in a similar manner.
FIG. 489.
Section through the middle of the right forearm. (HEATH, altered from Béraud.)
1, anterior interosseous vessels and nerve; 2, radial vessels and nerve; 3, pronator
teres; 4, supinator longus; 5, flexor carpi radialis; 6, supinator brevis; 7, flexor sub-
limis digitorum; 8, extensores carpi radialis longior and brevior; 9, flexor carpi ulnaris;
10, extensor ossis metacarpi pollicis: 11, ulmar vessels and nerve; 12, extensor communis
digitorum; 13, flexor profundus digitorum; 14, extensor carpi ulnaris; 15, median merve;
16, posterior interosseous vessels and merve; 17, extensor secundi internodii pollicis.
Amputation through the Metacarpal Phalangeal Articulation.
Four fingers can be removed by antero-posterior flaps; two by oval
incision, entering the knife half an inch above the knuckle and cutting
downward around one side of one finger across the palm beneath both
and up the opposite side of the second finger to the point of origin, and
one finger by the same shape of incision, but limited to a single digit. If
strength of hand is desired the heads of the metacarpal bones should not
be disturbed, but if appearances alone are to be considered they should
be cut off by cutting pliers.
Amputation of the Thumb.
This is effected by an oval incision. The knife is entered just above the
articulation and carried down along the upper surface of the metacarpal
bone until its centre is reached, when it diverges, encircles the extremity

48
754 A M P UT A TI O N S.
just above the first inter-phalangeal joint, and again joins the primary
incision. Amputation of the thumb through its metacarpal bone may
also be made by oval incision, the point of the oval being directly over
FIG. 490. FIG. 49 [.
------rºFººd g zºº.
2 - 2:----~~~ 2% : r S v an *
- - *::::===º: sº §§§º -
#% Wº%
"I,"|| §§§º º
w NSºº
|
- -
v º:
”////zza
*11th - * / , >~.
SS - NºS
Removal of head of metacarpal bone. Amputation of thumb with its metacarpal bone.
(DRUITT.) Line of incision. (DRUITT.)
the bone just above the point where it is to be divided, which latter is
accomplished by strong cutting pliers. Amputation through the cor-
responding bone or joint of the little finger is executed by analogous
procedures at its carpo-metacarpal junction.
Amputation of Phalanges of Hand.
This is done either through the bone by antero-posterior or other incis-
ions, or through inter-phalangeal joints. In doing the latter operation it
is well to make a short anterior flap and a large posterior one from the
belly of the digit. The joint can always be opened readily by flexing
the finger and pressing the knife just below the head of the proximal
bone. Occasionally no anterior flap is made, but the knife is at once
pressed through the joint, and a large posterior flap cut as it is withdrawn
after passing through the joint. Ligatures are never required in finger
amputations; sutures including the vessels can be made to control all
hemorrhage. Drainage, as a rule, is not necessary. An India-rubber
umbrella-ring answers well as a tourniquet.
Amputation through the Hipjoint.
This is a dangerous and formidable operation, owing to the great
primary and subsequent shock, which an operation so near the trunk
dividing such huge vessels and nerves must necessarily involve.
The death rate of tertiary operations is high; that of primary opera-
tions exceedingly so. The limb having been rendered avascular by ele-
vation or rubber bandage, infinite care must be observed to prevent undue
hemorrhage. This can be done (1) by digital pressure upon the femoral
artery as it passes under Poupart's ligament; (2) by compression of the
corresponding iliac artery against the ilium by the fingers of a small hand
introduced into the rectum; or (3), by preliminary ligation of the femoral
just beneath Poupart's ligament. Abdominal tourniquets are unnecessary









SPECIA. L. A M P UTATION S. 755
and undesirable. The above methods of controlling hemorrhage apply
only to the older methods of making large antero-posterior flaps by trans-
fixion or otherwise. The nature of injury or disease may occasionally
render amputation by those methods necessary. The scrotum being held
out of the way, the sound leg well abducted, and the diseased thigh
having been slightly bent to slacken the anterior muscles and abducted, an
FIG. 492.
v.º.º. § #. Fºr
º º º º
- §§§ ºf
- Wºº -
ES &\! §§§
E-Crºss
Amputation through hip-joint by long anterior and short posterior flaps. 4. The
femoral and profunda vessels, with branches of anterior crural nerve. B. The great
sciatic nerve and its companion artery and branch. C. Muscular mass from tuber
ischii and obturator externus muscle, with large branches from profunda and gluteal
arteries on either side. D. The psoas and other muscles immediately in front of the
joint. (Hol.MEs.)
eighth-inch knife is entered just above the centre of the space between the
anterior superior spine of the ilium and the great trochanter; is pushed
obliquely downward and inward until the joint is touched; the handle is
then depressed until the knife point slips across the joint (thereby opening
up the capsule), when it is raised again and the point pushed on until it
emerges just in advance of the tuber ischii. By a downward, and,
finally, outward sawing motion, a large anterior flap is formed as the
knife is brought to the surface. Just before the outward stroke is made,
an assistant controls the femoral by grasping it firmly in the upper por-
tion of the flap. This vessel is then securely ligated; the flap is held up,
and, the thigh being rotated inward, the muscular attachments of the great
trochanter are divided. The limb is now hyper-extended and adducted,
thereby accomplishing exarticulation, while the knife continues its down-
ward course and cuts a fleshy posterior flap. Or, a large anterior cutane-
ous flap may be cut from without inward in the same lines as above, the
vessels isolated and tied in continuity, and then a division of the muscles
made down to and opening the joint, but below the point of ligation; the
subsequent steps being identical with the first described method. But for
chronic cases where the parts are much wasted, or where every particle

756 A M P UT AT I O N S.
of blood is of great importance, a more recent procedure (Forneaux-
Jordan method) is by far the best. This may be performed in several
ways:
1. A tourniquet is placed upon the highest situation of the thigh pos-
sible. A circular division of integument and muscles to the bone is then
made by a single sweep immediately below the tourniquet, the bone
divided, and all vessels secured as in a thigh amputation. These having
been ligated, a second incision is made from just above the great
trochanter downward until it runs at a right angle into the first. The
attachments of the trochanter are divided, the joint opened, the remainder
of the femur carefully dissected out, and the flaps sutured.
2. The vessels can be ligated after the circular incision without Sawing
the bone, which is removed entire through the second incision.
3. The operation may be done by oval or racket-shaped incision, pre-
cisely the same as amputation of the shoulder is performed. The down-
ward straight incision is made from the trochanter, and from its lower
extremity branches diverge forward and backward, concave downward,
terminating just before reaching the femoral vessels. . The flaps, thus
formed are separated from bone, and exarticulation is accomplished.
Finally, after an assistant grasps the vessel in it, the remaining bridge of
integument and tissue is divided and the vessels ligated. No tourniquet
is here required.
The hip may also be exarticulated by simple large antero-posterior
musculo-cutaneous flaps cut from above obliquely downward and upward
toward the joint. In this case the posterior flap should be made first,
and its vessels secured by forceps or ligatures before the anterior flap is
commenced. A large, flat, hot sponge pressed upon the cut surface may
answer temporarily for this purpose, however.
IFIG. 493.
2, 3, 16 is
Section of the right thigh at the apex of Scarpa's triangle : 1, profunda vessels; 2,
adductor longus; 3, femoral vessels; 4, superficial obturator nerve; 5, Sartorius; 6,
gracilis; 7, external cutaneous nerve; 8, pectineus; 9, rectus femoris; 10, adductor
brevis; 11, anterior crural nerve; 12, deep obturator nerve; 13, external circumflex
vessels; 14, adductor magnus; 15, tensor vagina femoris; 16, semi-membranosus;
17, vastus internus and crureus; 19, semi-tendinosus; 19, vastus externus; 20, Small
Seiatic nerve; 21, biceps femoris; 22, great Sciatic nerve. (HEATH.)

S P E CIA. L. A. M. PU TATION S. 757
Amputation of the Thigh.
This may be accomplished by ordinary flaps, antero-posterior or lateral,
or by the typical or modified Teale method. The latter is best when it
does not sacrifice length unduly.
Amputation through the Knee-joint.
This makes an excellent and serviceable stump. It may be done by a
large anterior flap, including the patella, and a short posterior one from
the fleshy portion of the upper calf. The
former is cut from above downward to bone, FIG. 494.
and dissected up above the condyles of the
femur. The knife is then sunk through the
joint as it is held flexed, and the posterior flap
is made as it is brought to the surface through
the subjacent tissues. The operation may also
be performed by lateral, single anterior, or single
posterior flaps, but, as a rule, not with so great
success. If the patella is diseased or badly in-
jured, it should be dissected from the flap. If
the uninjured integument is not sufficient to
cover the condyles, more or less of the latter
must be sawn off, and, if the patella is left in,
its under surface should be removed until can-
cellous structure is exposed, when it may be
nailed or sutured to the sawn femoral end, and
there expected to unite. If in so doing the
quadriceps tendon is made taut, it should be
divided from the under surface of the flap.
This may occasionally be necessary in any case.
Amputation of the Leg.
This should never be performed below the Amputation through knee-
centre of the limb, nor in close proximity to the joint by long anterior flap.
knee-joint; such removals result in worse than (ERICHSEN.)
useless stumps upon which prothetic apparatus
cannot be placed. The point of election is the junction of the upper and
middle thirds. The Teale method here finds an ideal application and re-
sult, but good results can also be obtained by almost any variety or com-
bination of flaps. After sawing the bones the sharp upper edge of the tibia
should be sawn off obliquely, that it may not subsequently press upon the,
at that point, necessarily thin flap.
Amputation through the Ankle-joint.
This is not favorably regarded by most surgeons, because of the numer-
ous failures caused by sloughing of flaps. . No amputation at this point
is justifiable unless a well-nourished single flap from the heel (Syme's
method) can be obtained. And it is the death of this very flap which
has required so many re-amputations in this situation and brought the

758 A M P UT ATION S.
operation into discredit. But a more clear understanding of the nutrient
supply of the heel and its surroundings has again revived this operation
FIG. 495.
;
*
s
R.
s
y
*
*
ſ
§
~----
15 13 it 9
A section of the right leg in the upper third. (HEATH, from Béraud.) 1. Tibialis pos-
ticus; 2. Tibialis anticus; 3. Flexor longus digitorum; 4. Extensor longus digitorum;
5. Internal saphenous vein; 6. Anterior tibial vessels and nerve; 7. Tendon of Plantaris;
8. Peroneus longus; 10. Flexor longus pollicis; 11. External Saphenous vein and nerve;
12. Soleus with fibrous intersection; 13. Peroneal vessels; 14. Gastrocnemius (outer half);
15. Communicans peronei nerve.
which, when successful, is eminently so. The foot is flexed to a right
angle, and from the centre of the internal malleolus an incision is carried
FIG. 496.
Amputation through ankle-joint. Syme’s method. (SKEY.)
down to the bone directly across the sole to a point over one-fourth of
an inch in advance of the external malleolus. The extremities of this



S P E CIA L A M P UT A TI O N S. 7.59
incision are then connected by a second, also carried down to the bone,
arching sharply upward across the dorsal surface of the ankle. Next the
foot is forcibly flexed and the ankle-joint opened through the upper incis-
ion. The lateral ligaments are divided and, the foot being still flexed,
the attachments of the astragalus and calcaneum are carefully dissected
off, the point and edge of the knife being kept toward the bones. Espe-
cially must caution be observed in dissecting about the lesser tuberosity
of the os calcis and inner portions of the ankle, that the vessels there
situated, and upon which the life of the flap mostly depends, may not
be injured. Finally, the dissection reaches the insertion of the tendo
Achillis. This is separated and the removal completed. The malleoli
and a thin slice of articular cartilage are then sawn from the tibia and
fibula, and, after tendon ends are retracted, the flaps are sutured.
Pirogoff’s amputation differs from the above in that, by this method, a
portion of the calcaneum is allowed to remain and is brought into contact
with the sawn ends of the tibia and fibula, where it usually unites by
bony union and makes a capital stump. The incisions are as above
described, except that the lower one in crossing the sole is carried from
one-half to three-quarters of an inch nearer the tip of the heel, nor by
FIG. 497.
Diagram of cutaneous incision on outer side (A), and lines of section of the bones (B)
in Pirogoff’s amputation. (STIMSoN.)
the same distance does the dorsal incision ascend the ankle. Each flap
having been dissected up about half an inch the joint is opened from
above. The foot being strongly flexed the astragalus is shot forward
from between the malleoli. Behind the astragalus is then inserted a
narrow-bladed saw and the os calcis sawn through in a direction obliquely
downward and forward. The soft parts are then dissected from the mal-
leoli, and so much of the latter is removed as to expose the cancellar
tissue of both leg bones. The flaps are then sutured, bringing the two sawn
surfaces in contact, where they are secured by a nail or two driven through
the flaps. Bony union is usual. Possibly the tendo Achillis may require
division. Pirogoff’s method affords a better, more useful and solid stump,
and with less shortening of the limb and liability of reamputation than
when the Syme operation is employed. A good result, including ankle-
joint motion, can also be obtained by leaving the astragalus in situ, sawing
off its under surface and bringing the divided portion of the calcaneum

760 A M P UT A TION S.
into contact with it. Syme's method may be modified so as to leave the
astragalus in position.
FIG. 498.
Pirogoff’s amputation. Lines of incision. (ERICHSEN.)
Amputation through the Medio-tarsal Joint. (Chopart's.)
* An incision is made across the dorsum of the foot, convex downward,
from midway between the external malleolus and the tuberosity of the
fifth metatarsal bone to a point just behind the prominence of the scaphoid.
The extremities of this incision are carried vertically downward well into
FIG. 499. FIG. 500.
#
s
:
sº
º
f
2:
Ø
2 ---
2- s:
º ---
sº
tº a
sº
*º
| §§§
i. Z W. W.
§ % | , , ºft.
w sº
\{|}}}
\\\\\\\#######
sº
2% §§º º
Stump after Pirogoff amputation. Amputation through medio-tarsal joint.
(ERICHSEN.) (BRYANT.)
§§
º ºg
§ §§ $º ºw it * 'i r
\\ º ŠA." tº
§ £3.
the ball of the foot, where these incisions are connected by a fourth
crossing the plantar surface. A fleshy plantar flap is then dissected up ;
the foot forcibly pressed down, and disarticulation effected at the medio-
tarsal junction. Division of the tendo Achillis to prevent subsequent
contraction of the flaps is expedient. The scaphoid bone is occasionally,
by accident, left behind, but gives rise to no inconvenience.



S P E CIA L A M P UT A TI O N S .
61
Amputation through the Tarso-metatarsal Joint. (Lisfranc's.)
In this operation a transverse dorsal incision, convex downward, runs
from the tuberosity of the fifth metatarsal bone.
as in medio-tarsal amputation.
outer and the first metatarsal bones are separated from the tarsus.
FIG. 501.
l Aº
* º \ \
* W gº == - *- t
wº, & \ ºff . g/// S \, º
% N S \ fºſſ/? t
% § { ºff" .. 2 - …”
§ W *\,..., 2%
§ § i ſ" tº g = 4 * *
's Z \ º” & /.2
ſº § Z * | i. s |9
º p w
3. /. $º. º .# j",
ſ ** % \ º º aft ſ 22*. *_*
§ \\ Z º," agazzº
\ss ºn 4 A ſº-º
*sº #A 22-
* -4
º gº W
; -º §
8 : º * *. R Wę2
* * . . º y |
Y ... r º §
J 'ſº sº
Y 6, 2. Լ
§ 2; . º § WY’s “ \,\!
º l wº
. . ; f WNº. L =
w grºß, * * N w) i. c=
--- |
º “ſif III'ſ, tº - ! / !
\ * /
ºff.: * "ºn. Z
º *... .
Q
Amputation through the tarso-metatarsal joint. (SKEY.)
and external cuneiform bones) is likewise separated by driving the point
of the knife between it and the internal cuneiform, and, the foot being
forcibly everted, carrying it around the joint.
gº Or, to avoid this latter
difficulty, the end of the second may be sawn off and left in situ after
the other metatarsals have been exarticulated (Hey’s amputation).
Amputation through the Metatarsus.
Amputation through the metatarsus, or metatarso-phalangeal junction,
as a whole, is accomplished by taking a short flap from above and a longer
fleshy one from the ball of the foot.
Amputations of the great or small toes at their metatarso-tarsal articu-
lation, also of one or more toes at the metatarso-phalangeal junctions, are
accomplished by the same racket-shaped incision method by which analo-
gous portions of the hand are removed. Amputations through the inter-
phalangeal toe-joints is performed by antero-posterior or lateral square or
oval flaps.
* * Amputation of toe phalanges should always be done through
a joint.
A plantar flap is made
The foot being pressed down, the three
Then
the second metatarsal (which projects into the space between the internal

C H A P T E R X. X W II.
D.ISEASES OF THE MAMMARY GLANDS.
NEUROSEs.
Mammary Neuralgia.
Neuralgia of the mammary glands is found especially in young
women, and is often associated with some ovarian or uterine difficulty.
Hyperaesthesia is often excessive, so that the mere contact of the clothing
gives rise to great pain. A similar neuralgic condition is at times
found as an accompaniment of small benign tumors of the breast or
of chronic mammary inflammation. It is often difficult to correct
this condition because of the nervous element involved. If the surgeon
can discover the cause of the nervous strain and remove it the disease
will disappear entirely. The fear felt by the patient that the condition
is one of malignant disease must be dispelled, as it has a tendency to
increase the pain. It should be recollected also that this affection, which
is one of no vital importance, is more painful than are malignant growths
in their early stages. At times there is a slight serous or blood-stained
discharge from the nipple when the mastodynia or neuralgia of the
breast accompanies a localized chronic inflammation.
TREATMENT.-The treatment consists in assuring the patient of the
innocent character of the disease; in distracting attention from the mam-
mary region; in relieving the source of the nervous wear and tear; and
in giving mental occupation of an agreeable nature. Valerianate of
zinc, iron preparations, and other tonics are the remedies indicated; in
fact, the line of treatment is that to be followed in cases of hysteria. If
there be any small inflammatory nodules within the breast it is proper to
remove them if the patient's anxiety is great enough to warrant such a
slight operative procedure. If the surgeon is in doubt as to the charac-
ter of these hardened tissues, operation is valuable by enabling him to
clear up the diagnosis. The question of malignancy can then be defi-
nitely settled by the microscope.
INFLAMMATION OF THE BREAST,
PATHOLOGY..—Inflammation of the mammary glands, called mastitis or
mammitis, may be acute or chronic. In the former condition, suppuration,
causing what is termed mammary abscess, may occur. This is very unu-
sual, however, excepting during lactation. The so-called cold abscess, due
to the tubercle bacillus, is rare, but may occur. Acute mastitis arises occa-
sionally as a complication of mumps, just as in the male we find orchitis
arising secondary to that inflammation of the parotid gland. Acute inflam-
mation of the breast, not connected with pregnancy and lactation, is
similar to the condition occurring as a complication of parotitis, and needs
no special mention. Puerperal mastitis occurs more commonly in primi-
I N F L A M M A TI O N OF T H E B B E A ST. 763
parae, and during the first three or four weeks of nursing, although it
may occur at the end of many months of suckling. It is not usual in
mothers who bring up their children by artificial feeding. The causes
are over-distention of the milk-ducts because there is more milk secreted
than can be drawn from the glands by the child, and sore nipples. In
instances of fissured or otherwise irritated nipples, the child is unable
freely to empty the breast, and by its efforts causes still further irritation
of the inflamed tissue. The inflammation so caused at the nipple travels
along the lymphatics into the interior of the breast, and adds, therefore,
its irritative influence to that due to distention of the milk-ducts from
retained lacteal secretion. The probability of microbic infection through
fissures of the nipple, especially when absolute cleanliness is not observed,
is easily understood. It is probable that freely washing the surface after
nursing with some form of non-poisonous antiseptic would prevent many
cases of mastitis.
SYMPTOMS.—Acute mammitis begins, as a rule, with a chilly sensation,
fever, headache, and local soreness of the breast, followed by heavy, aching
Sensation, with throbbing. Upon manipulation, the organ feels hard
and knotty in spots, because inflammation usually affects a few, not
all, of the lobules of the gland. As the disease progresses the whole
breast becomes swollen and hard, and the skin tense, shining, and livid.
If suppuration occurs it is usually preceded by a chill, after which the
skin becomes Oedematous. Soon there is evidence of pointing, and the pus
is finally evacuated spontaneously if the abscess is not opened by the sur-
geon's knife.
TREATMENT.—The treatment should be physical and functional rest.
The former is obtained by keeping the patient quiet, with the arm sup-
ported in a sling, and the breast held up against the thorax by a closely
fitting bandage. Functional rest is obtained, if the case is a puerperal
one, by preventing the child nursing. It is important that neither breast
be used for suckling. If the secretion of milk continues and causes pain
by distention, it is necessary to empty both glands by means of a breast-
pump carefully applied. Leeches may be used in persons of vigorous
health, and should be applied below the breast rather than above it.
Purgatives and antiphlogistic remedies are indicated in cases of sthenic
type, but if the patient is debilitated, tonic rather than depressing reme-
dies should be prescribed. Hot-water fomentations, applied by means of
a conical sponge laid over the breast several times a day, will often be a
great comfort to the patient. An antiseptic dressing covered with rubber
tissue to prevent evaporation, makes a good emollient dressing. The ex-
tract of belladonna made into a paste with a little water, and spread upon
the surface of the breast, lessens the pain and may aid in diminishing the
Secretion of milk. Lotions of lead-water and laudanum are at times
serviceable. Some surgeons believe that the application of ice-bags is
good practice. In some cases inflammation subsides by resolution, and
after two weeks' time the patient may resume nursing. If suppuration
occurs, free incision and curetting must be adopted at a very early period.
This will be discussed under abscesses of the breast. Acute mastitis may
run on to a stage of chronic inflammation, which must be managed in the
same manner as cases which assume a chronic type from the beginning.
764 D IS E A SES OF T H E M A M M A R Y G L A N D S.
Chronic Inflammation of the Breast.
PATHOLOGY AND SYMPTOMS.-Chronic inflammation of the breast
usually attacks only one, two, or three lobules of the gland and exhibits
itself as a hard, irregular mass accompanied by a moderate degree of
pain. The process is a sort of cirrhosis. The inflammatory process in-
volves the connective tissue, which becomes increased in amount and com-
presses the glandular structure of the breast until it becomes more or less
atrophied. Since the whole gland is not affected, there is a certain resem-
blance between this lobular mastitis and carcinoma, because in each case
there is no sharp outline felt between the growth and the normal gland,
and because the two conditions are most common about the menopause.
The points of diagnosis are that the inflammatory induration is not as
hard as carcinoma ; the integument is not adherent to the mass nor
dimpled by it. Moreover, carcinoma is apt to attack single portions of
the breast, whereas inflammatory involvement of two or three lobules is
not uncommon. Again, the inflammatory condition may be found in
both breasts at the same time; this condition is exceedingly rare in car-
cinoma. Retraction of the nipple, which occurs in carcinoma situated
directly below the nipple, does not occur in inflammation. There is
slight probability of inflammation being followed by involvement of the
axillary lymphatic glands, but such involvement is common in carcinoma.
Chronic mastitis is also differentiated from carcinoma by the fact that it
improves under treatment. Non-malignant tumors of the breast are
diagnosticated from chronic mastitis by being more defined in outline.
TREATMENT.-The treatment of chronic mastitis is carried out by hot-
water applications made by means of a conical sponge laid upon the
breast two or three times a day; by anointing the skin with oleate of
mercury ointment (about 10 per cent.); or by using some form of counter-
irritation such as is obtained by painting the parts with tincture of iodine,
or by the application of a blister. Pressure should be made upon the
diseased gland by covering it with cotton wadding and carrying a bandage
of elastic webbing around the chest so as to support and press the gland
against the ribs. The turns of the bandage should be started below the
breast and carried upward. Friction, or pressure by corsets or other
articles of clothing, should be prevented. The arm should be kept quiet
as much as possible, or carried in a sling. The support of the breast,
associated with equable pressure, is probably the most important part of the
treatment. Potassium iodide may be given internally as an absorbifacient.
This line of treatment should be continued for months, since improve-
ment is usually slow.
ABSCESSES OF THE BREAST.
PATHOLOGY..—Suppuration may occur between the breast and the skin,
within the gland itself, or between the gland and the pectoral muscle.
The first condition is called supra-mammary abscess; the second mam-
mary abscess; the third, sub-mammary abscess. It is possible also to
have tubercular disease of the breast causing the so-called “cold abscess.”
Acute abscess of the breast is due here, as in all other places, to the en-
trance of pyogenic bacteria, which gain admission, probably, through the
ducts of the nipple, or through fissures of the nipple or integument.
P A G. ET’S DISE ASE OF THE BR E A ST. 765
Supra-mammary abscess presents no special symptoms needing descrip-
tion.
Abscesses behind the breast push the breast forward, giving it a very
conical appearance. The pus may, after a period of protracted suffering,
burrow beneath the breast and finally cause a spontaneous opening at the
circumference of the gland, or even near the axilla. Occasionally, evacua-
tion occurs through the substance of the gland.
Mammary abscess may occur at several points and riddle the breast
with pus pockets and sinuses. If operative evacuation is to be done, it
should be undertaken at an early period.
Suppurative mastitis is an affection causing great pain and exhaustion,
and is usually found during lactation. Abscesses in connection with the
mammary glands may also be the result of necrosis of the underlying
rib, or may be due to spontaneous opening through the chest wall of a
pulmonary abscess or suppurative pleurisy.
TREATMENT.-The measures to be employed in acute, non-suppurative
mastitis have been discussed under the treatment of that affection. When
pus has evidently formed, it should be evacuated by one or more free
incisions; after which the pus cavity should be well scraped out with a
curette. The incision should be made in the areola alone, or entirely
outside of it, because an incision extending from the areola into the
encircling skin beyond is apt to be followed by unsightly pigmentation at
the circumference of the areola. Ashhurst prefers to make the incision,
when possible, in the upper part of the breast; because the compression
bandage, subsequently applied, can then better bring the walls of the
abscess into apposition, since firm pressure is best obtained by band-
aging from below upward. A drainage-tube should be placed in the
wound and the incisions sutured. This operation should be done under
ether and with the strictest antiseptic precautions. This method of treat-
ment is identical with that for treating abscesses in any other region.
It is, indeed, possible that very many abscesses of the breast could be
entirely prevented if firm support were given to all breasts after parturi-
tion, and if care were taken that no pyogenic germs gained access to the
fissures upon the nipple or to the milk ducts. Thorough cleansing after
each nursing, and bathing the breast at such times with some non-
poisonous, antiseptic lotion would probably efficiently meet the latter
requirement. After spontaneous opening of a mammary abscess, the
sinuses remaining must be laid open and scraped out under antiseptic pre-
cautions. Moderately firm compression with bandages cut to fit the chest,
or composed of elastic webbing, and applied over an ordinary gauze
dressing, is an efficient adjuvant. It is astonishing to see how a breast
freely incised becomes, under such conditions, an efficient organ for nurs-
ing after subsequent pregnancies.
PAGET's DISEASE OF THE BREAST.
This affection is a peculiar granular inflammation of the nipple and
the areola, which is apt to be followed by malignant disease. If the
condition is recognized, the diseased structures should be excised to pre-
vent the occurrence of any further malignant involvement.
766 D IS E A S E S OF T H E M A M M A R Y G. L. A. N. D.S.
TUMoRS OF THE BREAST.
PATHOLOGY AND SYMPTOMs.—Tumors of the male breast are rare.
The female breast is the seat of all forms of tumor, some of which are
more common than others. Carcinomas, sarcomas, and adenomas are the
most common growths found in the breast. In not a few cases the tumor
is a mixed one, but these mixed tumors usually contain adenoid tissue as
one of the elements, and are, therefore, adeno-fibromas, adeno-cystomas,
and adeno-sarcomas. It is said that about three-fourths of the tumors
found in the breast are carcinomas. The commonest benign growth in
this situation is an adeno-fibroma, which is usually called a fibroma or
an adenoma. It is, as a rule, however, a mixed tumor, and not a pure
fibroma or a pure adenoma.
These adeno-fibromas are very slow in their growth and occur in young
women. They are movable, hard, and encapsulated, and are easily enu-
cleated when removal is attempted. The growth is well defined in outline,
which is quite different from chronic lobular inflammation, with which it
might be confounded. It produces no pulling in of the skin, and no
involvement of the lymphatic glands. It is painless, except in persons
of a nervous temperament, when neuralgic pain is often present. A
tensely filled mammary cyst may very much resemble an adeno-fibroma.
The diagnosis is accurately determined by puncturing the obscure tumor
with a hypodermic needle, through which fluid will escape if it is a cyst
or an adeno-cystoma.
The adeno-cystomas are formed by occlusion and dilatation of the
irregularly developed acini and ducts, which occurs in the adenomatous
structure. They may consist of one or more large cysts, containing often
a great many smaller cysts growing inward from the outer wall of the
original tumor. The solidity of the mass depends upon the relative
quantity of the brownish fluid and the cyst wall. These tumors do not
infiltrate the surrounding tissues, they are encapsulated and do not cause
lymphatic involvement; they may, however, develop fungous masses, the
surface of which may bleed. Such tumors present to the naked eye the
appearance of malignant disease; but such is not their character. After
removal they show no tendency to return.
Mammary sarcomas vary very much in their degree of malignancy, and
are at times combined with adenoid structures. The round-cell sarcomas,
with little intercellular substance, are probably the most malignant of all
tumors occurring in the breast. Sarcomas are found, as a rule, in early
life; from twenty to thirty-five years being the average age at which
this disease is found. Such tumors have a smooth surface, are elastic,
mobile, isolated, and rapid in growth, and the cutaneous vessels are often
enlarged. The skin finally gives away, and a fungous protrusion occurs;
but the lymphatic glands are not involved until the disease has made
great progress. Recurrence after removal is very apt to take place about
the line of incision. Secondary growths in other parts of the body are
very usual in the late stages of the disease.
Carcinomas are frequently found in this region, and are believed
sometimes to follow prolonged irritation, such as Paget's disease of the
nipple, or chronic lobular inflammation of the gland. Traumatism has
been assigned as a cause of carcinomatous disease, and from thirty-five to
fifty years is the period of life in which its occurrence is most frequent.
Scirrhus or hard carcinoma is a very hard tumor without definite outline.
TU MO R S OF T H E B R E A ST. 767
It is at first movable, but it soon becomes adherent to the skin and to the
pectoral muscle; and the gland is thereby finally fastened to the chest
wall. The skin over the growth is pulled in, and on account of this re-
tracting influence exerted upon the hair follicles, a characteristic dimpled
appearance, often called “pig skin,” is produced. If the tumor is directly
below the nipple, the nipple is slowly pulled in by the retraction until its
appearance is somewhat like that of the navel. This retraction of the
nipple occurs only when the tumor is situated directly beneath the nipple ;
hence its absence does not indicate that the mammary growth is not a car-
cinoma, unless the tumor is subjacent to the nipple. In some cases of
mammary carcinomas there is a slight discharge of fluid from the nipple.
The absence of pain or tenderness in the early stages of the disease
often misleads the patient as to its dangerous character, and this error is
enforced by the comparatively slow increase in size of the lump found in
the breast. In the later stages of the disease, the pain may become great,
and seriously so when the axillary glands become the seat of secondary
infiltration and produce pressure upon the nerve-trunks in the arm-pit.
Instead of scirrhous carcinomas being nodular, they may at times occur
as a rapid infiltration of the breast.
Gradually the skin overlying the tumor becomes ulcerated, and from
the surface of this foul sore escapes a thin, and often bloody, discharge.
Severe hemorrhage may supervene from such an ulcer, but is readily
stopped, as a rule, by slight pressure. The carcinomatous ulceration may
slowly spread over the whole front of the chest. The lymphatic glands of
the axilla are usually quite early involved, though the enlargement may
not be perceptible through the skin until they have attained quite a large
SIZ62.
The cervical glands are not involved until some time after the axillary
glands have become the seat of carcinomatous infiltration. Pain and
swelling of the arm from pressure upon the nerves, veins, and lymphatics,
is one of the late symptoms. Secondary growths occur in the liver, lungs,
and bones, and finally death supervenes.
In cases where there is great increase in the fibrous tissue of the tumor,
the pathological condition is called atrophic scirrhus. This form of the
disease may exist with very little, or no progress, for months or years.
This quiescent form of carcinoma is simply one of very slow growth, and
its final result differs in no way from that of other cases.
Hard carcinoma is a disease most common in women about forty to fifty
years of age. Soft carcinoma, or encephaloid, occurs at an earlier period
of life.
Soft carcinomas are much more rapid in their growth, and much more
malignant, than hard carcinomas; and appear as round movable tumors,
situated deeper in the breast than scirrhus. On examination, such growths
feel knobby, but are not exceedingly hard ; they are elastic, and at some
places feel almost as fluctuating as cystic tumors. The integument overlying
them becomes red and Oedematous, and suggests the occurrence of suppu-
ration. Ulceration soon supervenes and portions of the tissue become
detached, though there is not the same tendency to fungous protrusion as
is found in some other tumors. The disease is accompanied with com-
paratively little pain, but the lymphatic glands and viscera are affected
quite early. In the space of eight or ten weeks these growths may assume
the size of a cocoanut.
The clinical difference between hard and soft carcinoma resides in the
comparative hardness and the chronicity of progress of the former. The
768 T) IS E A SES OF T H E M A M M A Hº Y G L A N D S.
round-cell sarcoma resembles, clinically, the soft carcinoma, but is circum-
scribed and encapsulated, while the latter is an infiltrated growth. The
average duration of soft Sarcoma is from six to twelve months, while that
of a hard carcinoma is about two and a half years.
Cystic or colloid degenerations may occur in both forms of carcinomas,
and occasionally small abscesses may develop in connection with them.
Cystic tumors of the breast are not infrequently found. They may
occur during lactation, and then often contain milk. Glandular cysts of
various kinds occur in the organ, and contain fluid varying in color from
a light straw to a red. These benign tumors are smooth in outline, and
do not involve the lymphatic glands, or ulcerate. These are sometimes so
hard as to give the surgeon's fingers the impression of a solid growth. At
other times they may be distinctly fluctuating. It is at times good policy
to puncture the tumor before attempting to remove it by the knife, for I
have seen simple cysts excised under the impression that they were carci-
nomatous nodules. The surgeon must carefully distinguish a benign cyst
from a malignant tumor which has undergone cystic degeneration. -
TREATMENT.-Simple cysts are treated by evacuation of the fluid with
an aspirator, and then setting up an irritation by scraping the interior of
the wall with the point of a needle, or by introducing some counter-irri-
tant, such as the tincture of iodine, or a 5 per cent. Solution of carbolic
acid. If this does not produce obliteration of the cyst, it may be incised
and packed with antiseptic gauze in order to make it granulate from the
bottom. If the tumor is a large one, or if there are various cysts, prompt
cure will be better obtained by enucleating the cyst from the breast tissue
by means of an ordinary straight or elliptical incision through the skin.
The breast itself should not be removed unless its structure is practically
riddled with hard cysts. Excision of the breast is then justifiable be-
cause a return of the enlargement would seem to indicate a malignant
tumor, and would, therefore, give great anxiety to the patient.
Clinically, it is frequently impossible to diagnose with certainty sarcoma
from carcinoma, or either of these from mixed adenoid growths. It is
the surgeon's duty to be guided in treatment more by the clinical symp-
toms than by the supposed microscopical or histological structure of the
tumor.
The hard, lobulated, slow growth, which does not draw in the skin, is
probably innocent. An elastic, rapid growth is almost certainly malig-
nant. Experience has taught me that any growths in the breast, which
do not, after a few weeks' treatment, show evidence of diminishing in
size, had better be removed by operation. If the tumor is a small one, a
single incision will enable the operator to enucleate it from the gland
tissue without mutilation of the organ. If it is innocent, the patient's
mind will be relieved, and the slight operation will be fully justified by
the mental relief given to the patient. If these small growths thus early
removed prove to be malignant, both the surgeon and the patient are put
upon their guard, and warned of the absolute necessity for instant re-
moval of the entire breast and all the axillary glands upon the first signs
of recurrence.
Sarcomas may be as malignant, or more malignant, than carcinomas.
It is of little interest to the patient to know from which she suffers, hence
these two forms of tumor must be treated alike. Pure fibromas are not
apt to recur, if all the tumor structure is removed; but this form of tumor
is rare. The removal of adeno-fibromas and adeno-cystomas may be
advisable, since the difficulty in diagnosing them, before microscopical
|E X CISIO N OF T H E B R E A S T . 769
examination is made, is great. Pregnancy hastens the development of
tumors in the breast; undoubtedly because of the increased blood-supply
to the organ.
Excision of the Breast.
When there is the slightest reason to believe that the tumor is a malig-
nant one, it is proper to perform excision of the mammary gland. It is
only in benign growths, or in those which are expected to prove them-
selves benign when subsequent histological study is made, that partial
removal of the gland is justifiable. The accepted belief that malignant
growths are originally local and not the result of constitutional change is
a strong argument in favor of early and radical operation. Operation
should not be performed when the disease has become so extensive that it
is evidently impossible to remove all the tissue visibly infiltrated; nor in
patients who presumably cannot stand the shock of the operation. Under
our present methods of operation, however, excision of the breast is
almost devoid of danger. I feel, therefore, that it is justifiable to attack
these growths under nearly all circumstances, and to follow the first
operation by other operations when recurrence takes place, until it is
manifestly impossible for the knife to get beyond the limits of infiltration
as discernible by the naked eye. It is the tendency to postponement on
the part of the patient, and the encouragement which such delay receives
at the hands of some physicians, that prevent the best surgical aid being
given until the whole gland is involved in the disease. Patients in whom
it is evident that the cervical glands are involved, as well as the axillary,
and in whom secondary visceral lesions have occurred, are not proper
subjects for operation.
In proceeding to attack the growth, the surgeon must recollect that
any small portion of the infiltrated tissue left behind is a source of immi-
ment risk, and his incision must, therefore, be made so far beyond the
limit of the growth as to avoid, as far as possible, such contingency. It
is an imperative rule that the axilla be opened freely and all the lymph-
atic glands of that region enucleated in every case of malignant tumor
of the breast subjected to operation. I have often found the glands high
up in the axilla, and those surrounding the axillary vessels involved
in the disease, when no evidence of such glandular implication was de-
tected through the skin. I am, therefore, never satisfied until I have
laid bare the axillary vein, and carried my finger as far up as the clavicle
in the effort at finding these glandular foci of malignant disease.
The operation of excision of the breast is performed by carrying a
circular or elliptical imcision around the gland, about three-quarters of
an inch from the circumference of the breast, making, what has been
called by Gross, a dinner-plate incision. After this extensive incision,
the whole gland is dissected from the fascia covering the pectoral muscle,
and I prefer always to remove this fascia as well as the breast.
If there is evidence of infiltration of the underlying muscle, the greater
and lesser pectorals should be removed, since the stiffness of the arm left
after such mutilation is preferable to early return of the disease.
An incision from an inch and a half to two inches long is then carried
up into the axilla a little below the edge of the greater pectoral muscle.
All the lymphatic glands, and a large portion of the fatty tissue, are then
scraped out of the axilla by means of the finger and by the very careful
use of the scalpel and forceps. The majority of the glands lie close to
49
770 TU M O RS OF T H E B R E A ST.
the ribs, and should be looked for in that situation, though every portion
of the axillary space and that beneath the clavicle should be thoroughly
searched for Small glands. It is wise to clear away the tissue around
the axillary vein freely first, in order that its location may be clearly
appreciated. Laceration of the vein gives rise to copious hemorrhage.
It is easily arrested, however, by lateral ligature, by suturing the
opening in the vessel with fine catgut, or by grasping the margin of
the tear with hemostatic forceps, which should be allowed to remain in
the wound for forty-eight hours. The skin covering the posterior por-
tion of the axilla should be perforated for the admission of a rubber
drainage-tube, which will permit the exit of wound fluids while the
patient lies upon her back. The axillary wound is then closed by
sutures, and the raw surface left by the removal of the breast somewhat
contracted by strong sutures carried across it. A considerable degree of
approximation can be obtained if the skin and subcutaneous tissue are
separated from the chest wall by dissecting up the edges a short distance.
It is well to place over the open surface a piece of perforated rubber
tissue, or Lister protective, before applying the gauze dressing, because
the gauze placed directly over the raw surface becomes adherent from the
drying of the secretions, and gives pain when the dressing is removed.
Skin grafts or skin shavings can be applied to hasten healing after granu-
lation has been established—say at the end of ten days. Grafts of frog
skin have been applied by me for this purpose, but without much success.
The first dressing should be changed at the end of twenty-four hours,
since there is much oozing from this large, open wound. Subsequent
dressings are made when pain, fever, odor, or soiling by the secretions
indicate their necessity.
--------------
BDOMEN, aspiration of, 576
exploratory incision of, 57.1
method of operating upon, 572
section of, 572
tapping of, 576
wounds of, 57.1
Senn's hydrogen test for, 57.1
Abdominal abscess, 577
cavity, drainage of, 573
irrigation or washing out of, 573
drain-tube, 573
operations, method of performing,
after-treatment, 574
purgatives after, 575
section, 572
surgery, 572
Abscess, 39
abdominal, 57.7
acute, 52
alveolar, 557
atheromatous, 262
cerebral, 186
chronic, 53
cold, 53
in caries, 313
contents of, 52
definition of, 51
diagnosis of, 53
diffused, 51
drainage of, 54
embolic, 66
fluctuation in, 53
hyper-distention of, 54
in amputation stumps, 749
in bones, eradication of, 316
incision of, 54
injection of, 54
in spinal tuberculosis, 458
intermeningeal, 186
ischio-rectal, 642
metastatic, 53, 65
of antrum, 533
of bone, arthritis from, 317
of chest, 543
of frontal sinuses, 534
of joints, 449
of kidney, 658
tubercular, 660
of liver, 603
of mammary glands, 764
of mediastinum, 547
of pancreas, 607
i
t
Abscess of rectum, 642
of teeth, 557
of thyroid gland, 551
of tongue, 559
of tonsils, 562
of vulva, 724
opening of, 54
parietal, 578
pelvic, 577
perineal.
tal.)
perinephritic, 659
peri-rectal, 642
phlegmonous, 53
pointing of, 53
psoas, 453
pulmonary, 547
putrefaction in, 52
residual, 52
retro-pharyngeal, 563
spontaneous opening of, 52
subcranial, 186
treatment of, 54
tubercular, 53
of bones, 317
varieties of, 52
Absorbents. (See Lymphatics.)
Absorption of spine. (See Spondylitis.)
Acetabulum, fracture of, 379
perforation of, in hip disease, 463
Achilles, tendon of (See Tendo Achillis.)
Acromion, fracture of, 386
Actinomycosis, 559
Actual cautery, 143
Acupressure, methods of applying, 236
of arteries, 235
of varicose veins, 247
Acupuncture, 143
in neuralgia, 208
Adams's osteotomy saw, 517
Adenitis, 250
Adenocele. (See Adenitis.)
Adenoid tumor. (See Adenoma.)
Adenoma, 101
of pharynx, 531
Adhesions of vulvar lips, 723
Air-bed, in fractures, 337
Air in veins, 241
Air-passages, diseases of, 534
foreign bodies in, 534
Alae nasi, restoration of, 533
Albuminous degeneration.
Oedema.)
(See Abscess, ischio-rec-
(See Myx-
772
IN DE X.
Allis's test for femoral fracture, 421
for hip dislocations, 507
Alopecia in syphilis, 77
Alteratives in inflammation, 49
Alveolus, abscess of, 557
Amputation, 743
after-treatment, 748
antipyretic. (See Amputation, pri-
mary.)
bleeding from bone-end in, 747
by lateral flaps, 747
carpo-metacarpal, 752
Chopart's, 760
circular method, 746
modified, 746
chronic, 744
contra-indications for, 743
definition, 743
drainage in, 747
flaps, 746
for ankylosis, 472
for bone tumors, 320
for elephantiasis, 161
for gangrene, 63
for phalangeal fractures, 415
Hey's, 761
in caries, 317
indications for, 743
in secondary hemorrhage, 239
instruments required for, 744
inter-carpal, 752
intrapy retic. (See Amputation, sec-
ondary.)
Lisfranc's, 761
location of, 744
metacarpo-phalangeal, 758
metapyretic. (See Amputation, in-
termediate.)
metatarso-phalangeal, 761
necrosis of bones after, 309
Pirogoff's, 759
points of election in, 744
primary, 744
of arm, 752
of breast. (See Excision of mam-
mary glands )
of forearm, 752
of hand, 753
of leg, 757
of penis. (See Penis, excision of.)
of phalanges, of foot, 761
of hand, 754
of thigh, 757
of thumb, 753
saw, 745
secondary, 744
site of, 744
stumps, abscesses in, 749
aneurism in, 749
chorea of 749
conical, 749
diseases of, 749
drainage and dressing oſ, 747
epithelioma of, 749
fracture in, 749
|
|
i
;
}
i
!
Amputation stumps, injuries of, 749
necrosis in, 749
osteomyelitis in, 749
redressing of, 749
spasm in, 749
ulceration of, 749
varix of, 749
Syme's, 757
tarso-metatarsal, 761
Teale's method, 748
tertiary, 744
through ankle-joint, 757
elbow-joint, 752
hip-joint, 754
knee-joint, 757
medio-tarsal joint, 760
metatarsus, 761
shoulder-joint, 750
wrist-joint, 752
time for, 744
transfixion in, 747
varieties of, 743
mussat's method of colotomy, 597
naesthesia, 128
accidents during, 128
chloroform, 129
cocaine, 129
ether, 130
in aneurism, 267
local, 128
nitrous oxide, 129
Anal fissure, 642
fistule, 643
Anastomosis, intestinal, 602
after resection of intestine, 603
Anel's method of ligation, 280
Anemia, acute, bandaging of limbs in,
227
compression of aorta in, 227
from hemorrhage, 227
transfusion in, 228
Aneurism, 563
anaesthesia in, 267
aphonia in, 267
bruit in, 269
causes of, 265
cirsoid. (See Arterial varix.)
course of, 271
diagnosis of, 269
dissecting, 264
fusiform, 264
laminated fibrin in, 267
murmur in, 269
neuralgia in, 267
pain in, 267
paralysis in, 267
pathology of, 266
pulsation of, 267
pulse in, 268
racemose. (See Arterial varix.)
recurrent pulsation in, 283
sacciform, 264
special. (See Individual arteries.)
symptoms of, 267
terminations of, 271
A.
A.
I N DE X.
773
Aneurism, thrill of, 268 ;
traumatic, 255 !
treatment of, 272
by arterial compression, 273
by direct compression, 273
by excision of sac, 273 |
by flexion of joints, 277
by ligation of arteries, 279 |
by tourniquets, 276
contra-indications for ligation
in, 282
indications for ligation in, 282
varicose, 256
veins in, 267
varieties of, 263
venous occlusion in, 267
Aneurismal varix, 256
Aneurismoid varix, 257
Angeioleucitis, 248
Angeioma, 96
cavernous, 96 |
treatment of, 97 :
Angular curvature of spine, 453 -
extension in dislocations, 485
in hip disease, 464
Animals, rabid, bites of. (See Hydro-
phobia; poisoned wounds.)
Ankle-joint, amputation through, 757
dislocations of, 512
excision of, 525
Ankles, weak, 733
Ankylosis, 470 -
continuous extension in, 472
excision in, 516
from burns, 162
in arthritis, 449
of elbow, after fractures, 399
of spine, 455
passive motion in, 472
rupturing of adhesions in, 472
Anodynes in inflammation, 47 |
Anterior tibial artery. (See Artery.)
Antero-posterior curvature of spine, 454
Antipyretic amputation. (See Amputa- |
tion, primary.)
Antrum, abscess of, 533
Antisepsis, 134 !
Antiseptics in inflammation, 47
Anus, artificial, 592
repair of, 593
eczema of, 633
fissure of, 642
imperforate, 632
malformations of, 632
painful ulcer of. (See Anus, fissure
of.)
prolapse of. (See Rectum, prolapse
of. )
ſ
i
|
|
|
pruritus of, 633
tumors of, 652
ulceration of, 648
Aphasia in brain injury, 190
Aphonia, from foreign bodies in oesoph-
agus, 565
in aneurism, 267
i
|
|
|
|
Apostoli's treatment of uterine tumors,
608
Apparatus, aspiration, 515
extension, 342
for spinal curvatures, 733
to prevent semilunar dislocations, 514
Appendicitis, 594
Appendix vermiformis, inflammation of,
594
Arm, amputation of, 752
Arterial hematoma, 252
varix, 300
Arteries, atheroma of, 262
acupressure of, 235
calcareous, ligation of, 262
calcification of, 262
collateral circulation in, 282
degenerative changes in, 260, 262
inflammation of, 259
ligation of 232
for elephantiasis, 161
in continuity, 285
in lingual cancer, 560
in secondary hemorrhage, 238
special. (See Individual arte-
ries.)
ossification of, 263
torsion of, 234
varicose, 300
wounds of, 222, 252
Arteriotomy, 144. (See also Bleeding.)
Arterio-venous fistules, 256
sacculated, 258
wounds, 256
Arteritis, 259
idiopathic, 261
rheumatic, 261
syphilitic, 261
traumatic, 260
Artery, anterior tibial, ligation of, 295
axillary, ligation of, 290
brachial, ligation of, 289
brachio-cephalic. (See Artery, in no-
minate.)
common carotid, ligation of, 293
iliac, ligation of 297
external carotid, ligation of, 294
iliac, ligation of, 297
femoral, ligation of 297
intercostal, hemorrhage from, 543
rupture of, in rib fractures, 373
treatment of, 373
internal carotid, ligation of, 294
iliac, ligation of, 200
posterior tibial, ligation of 295
radial, ligation of, 289
subclavian, ligation of, 291
ulnar, ligation of, 289
Arthrectomy. (See Joints, excision of.)
in caries, 317
Arthritis, 449
acute and chronic, 449
atrophic, 469
deformans, 468
from bone abscess, 317
774
IN DE X.
Arthritis, gonorrhoeal, 450
of hip-joint, 461
abscess in, 463
deformity in, 463
perforation of acetabulum in,
463
posture in, 463
treatment of, 464
of sacro-iliac articulation, 460
of vertebral articulations, 451
diagnosis of, 454
treatment of, 456
rheumatoid. (See Osteo-arthritis.)
suppurative, 449
syphilitic, 467
tubercular, 450
of special joints.
vidual joints.)
prognosis of, 451
treatment of, 451
Arthrotomy. (See Joints, exploration of.)
Articular changes in dislocations, 478
in hysteria, 570
in locomotor ataxia, 469
in neuralgia, 470
Artificial anus, 592
menopause, 608
Asepsis, 133
Aseptic wound-fever, 65
Aspiration, 144
hypodermic, 144
of abdomen, 576
of bladder, 683
of hydrocephalus, 183
of joints, 515
of kidney, 665
of liver abscess, 604
of ovarian cysts, 610
of pericardium, 220
of pleura, 545
Aspirator, 144, 515
Asthenic fever, 44
Astragalus, dislocations of, 512
Astringents in inflammation, 47
Asymmetry of lower limbs in spinal
curvatures, 732
Ataxia, locomotor, joint-changes in, 469
Atheroma, 260
Atlo-axoid dislocations, 488
Atony of bladder, 674
Atrophy of bones, 318
Auscultation of oesophagus, 568
Awl, Horner's, 254
Axillary artery. (See Artery.)
glands, infiltration of, in mammary
carcinoma, 767
(See Indi-
ACILLUS tuberculosis, 71
Bacteria, 37
varieties of, 38
Balanitis, 720
Balano-posthitis, 720
Bandage, for hand and heel in lithotomy,
687
Bandage, Barton's, 368
Esmarch's, 475
for fractured ribs, 376
Morton's, 376
Bandages, 142
gypsum, 844
rubber, 142
Barbadoes leg. (See Elephantiasis.)
Barker-Willard irrigation curette, 518
Barton's bandage, 368
Basedow's disease. (See Goitre, exoph-
thalmic.)
Battey's operation. (See Oöphorectomy.)
Bed, air, in fractures, 337
fracture, 337
water, in fractures, 337
Bedsores from splints, 343
in spinal inflammation, 200
Bifid spine, 198
uvula. (See Palate, cleft.)
Bigelow's litholapaxy apparatus, 687
lithotrites, 684
Bistoury, 126
Bites of rabid animals.
phobia.)
Bladder, aspiration of, 683
atony of, 674
calculi in, 676
congenital defects of, 668
displacements of, 671
exstrophy of, 669
fistulae of 674
inflammation of, 671
neuroses of, 674
operations upon, 683
paralysis of, 674
ribbed and sacculated, 672
sounding of, 678
tuberculosis of, 674
tumors of, 675
urinary, examination of, 668
washing out of, 673
Bleeding, 144
in treatment of hemorrhage, 228
Blenorrhagia. (See Urethritis, specific.)
Blood, coagulation of, in hemorrhage,
224 et seq.
extravasation of, 221
hyperinosis of, 41
inflammatory, 41
in inflammation, 41
-letting, 143
in inflammation, 47
transfusion of, 228
Bloodclot, healing by, 313
organization of, 225
Bloodless method of operating, ES-
march's. (See Bandage, Esmarch's.)
Blood vessels, in inflammation, 40
Bodies, foreign, in nose, 526
in tongue, 560 •
loose, in hydrocele of tunica vagi-
malls, 711
in joints, 472
melon-seed, 176
(See Hydro-
I N I) E X.
775
Bodies, rice-like, 176
Body, thyroid, diseases of, 548
Boil, gum, 557
Boils, 155
Bond's splint, 412
Bone-cutting pliers, 516
Bone drill, 524
forceps, 516
death of. (See Necrosis.)
grafting of, 311
inflammation of, 304
plates, Senn's decalcified, for anasto-
mosis, 602
softening of, 319
transplantation of, 311
ulceration of. (See Caries.)
Bones, atrophy of, 318
bending of, 321
caries of, 313
cold abscess in, 313
drilling of, in abscess, 317
in ununited fracture, 349
erosion of. (See Caries.)
exfoliation of, 309
hypertrophy of, 318
injuries of, 320
in osteomalacia, 321
mortification of, 307
necrosis of, 307. (See also Necrosis.)
of face, fracture of, 365
resection of, in ununited fracture,
349
sclerosis of, 304
tuberculosis of, 313, 317
tumors of, 320
amputation for, 320
central, 320
endosteal, 320
periosteal, 320
ulceration of, tuberculous, 313
wiring of, in ununited fracture, 350
Bony ankylosis. (See Ankylosis.)
Bougie, bulbous, 701
dilating, 703
exploring, 701
filiform, 704
for female urethra, 708
osophageal, 569
introduction of, 569
rectal, 651
whalebone, 704
Boutonnière operation on urethra.
External urethrotomy.)
Bowel. (See Intestines.)
Bow-legs, 740
Brachial artery.
Brachio-cephalic artery.
(See
(See Artery.)
(See Artery,
innominate.)
Brain, abscess of, 186
compression of, 195
trephining for, 197
concussion of, 193 i
contusion of, 193 |
dropsy of (See Hydrocephalus.)
fungus of, 192 |
|
|
!
Brain, hernia of, 192. (See also Fungus
...)
congenital, 182
inflammation of, 183
operative treatment, 186
sequelae, 186
symptoms, 184
treatment, 185
injuries of, 191
aphasia in, 190
Cheyne-Stokes respiration in,
190
choked disk in, 190
laceration of 193
lesions, localization of, 186
trephining for lesions of, 189
tumors of, 198
wounds of, 192
Breast. (See Mammary glands.)
diseases of, 763
Briddon's arterial compressor, 277
Brisdor's method of ligation, 281
Broca's square, 188
Bronchocele, 549
exophthalmic, 549
Bruise. (See Contusions.)
Bruit, in aneurism, 268
Bryant's fractured clavicle apparatus,
384 tº
rectangle, 421
Bubo, syphilitic, 76
Bubonocele, 625. (See Hernia, inguinal.)
Bulbous bougie, 701
Bullets, extraction of, 125
Bunion, 180
Burns, 161
constitutional effects of, 162
deformity from, 162
duodenal ulcer from, 163
erysipelas in, 163
erythematous, 162
from chemicals, 161
from electricity, 161
necrotic, 162
prevention of cicatricial contraction
in, 164
treatment of, 163
vesicating, 162
Bursa, adventitious, 179
inflammation of, 178
Bursitis, 178
chronic, 179
treatment of, 180
Butcher's saw, for excisions, 518
excision pliers, 518
Button-hole operation for urethrocele,
698
ALCULI, crushing of, 683
encysted, 679 -
in gall-bladder, 605
in urachus, 670
renal, 661
urethral, 705
776
IND EX.
Calculi, vesical, 676
causes of, 676
construction of, 676
diagnosis of, 678
number of, 676
sounding for, 678
symptoms of, 677
treatment of, 679
solvent, 679
varieties of, 677
Calibre of urethra, method of determin-
ing, 702
Callous ulcer, 57. (See, also, Ulcer.)
Callus, in joint fractures, 336
in repair of fractures, 335
provisional, 335
Canal of Nuck, hydrocele in, 713
Xancer, 106. (See, also, Carcinoma; epi-
thelioma.
colloid, 108
hard, 107
soft, 108
Canula, chemise, in lithotomy, 690
tracheal, 539
Caput obstipum. (See Torticollis.)
Carbuncle, 156
incision of, 157
Carcinoma, 105
colloid, 108°
encephaloid, 108
of bladder, 675
of mammary glands, 766
of penis, 722
of rectum, 652
scirrhous, 107
Caries, 45
amputation in, 317
arthrectomy in, 317
central, 317
dry, 304
of bone, 313
sicca. (See Ostitis.)
Carotid artery. (See Artery.)
Carpal bones, excision of, 521
fractures of, 413
Carpus, dislocations of, 502
excision of, 521
fractures of, 413
Cartilage, epiphyseal, inflammation of,
3.18
Cartilages, dislocations of, 512
costal, 512
ensiform, 513
epiphyseal, 325
semilunar, 523
fractures of costal, 372
laryngeal, 370
nasal, 365
repair of, 386
loose, in joints, 472
Castration, 717
Catarrh, nasal, 528
purulent, 39
Catgut ligatures, 137
rings, for intestinal anastomosis, 602
Catgut sutures, 136
Cathartics in inflammation, 48
Catheter, double or two-way, 673
silver, 706
Catheterization, in spinal inflammation,
of ureters, 668
of urethra, 707
in female, 708
Catlin, 744
Cauliflower growths, 100
Cautery, 143
in neuralgia, 208
in neuritis, 205
Cellular erysipelas, 64
Cellulitis, diffuse, 64
Cerebral abscess, 186
fungus, 192
hemorrhage, 186
localization, 186
Cerebritis, 183
Cerebrospinal fluid, escape of, in cranial
fracture, 359
Cervical glands, infiltration of, in mam-
mary carcinoma, 767
Chain saw, 517
Chancre, diagnosis of, differential, 79
hard, 75
infecting, 76
of lip, 555
of mouth, 559
of vagina, 727
of vulva, 725
phagedenic, 76
syphilitic, 75
Chancroid, diagnosis of, differential,
79
of penis, 721
of vagina, 727
of vulva, 725
Charbon, 122
Charcot's disease, 469
Chemicals, burns from, 161
Chest, abscesses of, 542
contusions of, 542
diseases of, 542
sinus of, 547
wounds of, 543
Cheyne-Stokes respiration, in brain in-
jury, 190
Chilblain, 165
Chimney-sweep's cancer, 710
Chloroform anaesthesia, 129
Choked disk in brain injury, 190
Cholecystectomy, 606
Cholecystotomy, 605
Cholelithotomy, 605
Chondroma, 91
Chopart's amputation, 760
Chordee, 700
Chorea, in stumps, 749
Chronic abscess, 53
ulcer, 57
Chyluria, 683
Cicatrices of neck, treatment of, 548
I N DE X.
Cicatricial contraction, prevention of,
164
treatment of, 165
Cicatrix, contracting, from burns, 162
keloid in, 162
Circulation, collateral, 225
in lymphatics, 248
venous, 227
Circumcision, 718
Cirsocele. (See Varicocele.)
Cirsoid aneurism. (See Arterial varix.)
Clamp, for hemorrhoids, 640
for resection of intestine, 599
for semilunar dislocations, 514
Clap. (See Gonorrhoea.)
Clavicle, dislocations of, 491
fracture of, 381
treatment of, 383
Clavus, 154
Clitoris, erection of, in spinal fracture,
354
Closed ulcer, 53
Cleeman's test for femoral fracture, 421
Cleft palate, 554
Cloacae in necrosis, 308
of bones, 309
Clove-hitch knot, 483
Club-foot, 735
bursae upon, 181
operative treatment of, 737
Coagulation-necrosis, 60
Coagulum, 225
Cocaine anaesthesia, 129
Coccygodynia, from coccygeal fracture,
380
Coccyx, dislocations of, 489
fracture of, 379
coccygodynia from, 380
Cold abscess, 53. (See, also, Abscess.)
Cold in inflammation, 46
Colectomy, 599
Colic, renal, 662
Collapse. (See Shock.)
Collar-bone. (See Clavicle.)
Collar for spinal disease, 459
Collateral circulation, 225
in arteries, 282
in lymphatics, 248
venous, 227
Colles's fracture. (See Radius, fracture
of.
Collodion dressing, 142
Colloma, 108
Colon, excision of, 599
Colotomy, 596
Amussat’s method, 597
inguinal. (See Laparo-colotomy.)
in stricture of rectum, 652
Littré's method, 598
lumbar, 597
Columella, nasal, absence of, 554
Columna of nose, restoration of, 533
Compound fractures. (See Open frac-
tures.)
Compression in aneurism, 274
Compression in inflammation, 47
of brain, 195
Compressors, arterial, 275
Concussion of brain, 193
of spinal cord, 203
Condyle of lower jaw, excision of, 519
Condylomata, 77
| Congenital deformities of joints, 446
dislocations, 446
hernia, 614
Congestion, 33
Constipation in strangulated hernia, 616
Continuous suture of intestine, 600
Contraction, cicatricial, 164
| Dupuytren’s, 174
Contusion of brain, 193
of chest, 542
Cord, spinal, concussion of, 203
contusion of, 203
inflammation of, 200
laceration of, 203
wounds of, 203
Corns, 100, 154
excision of, 154
Costal cartilages, dislocations of, 513
fractures of, 372, 377
Counter-irritation, 143
by blisters, 143
by cautery, 143
in inflammation, 47
Cowper, glands of, inflammation of, 700
Cowperitis, 700
Coxalgia. (See Hip-joint, tuberculosis
of.
Coxitis. (See Hip-joint, tuberculosis of.)
Cranial fractures, bleeding from ear in,
359
Cranium, fractures of, 356
treatment of, 359
trephining in, 360
Crepitation, auscultation of, 330
in fracture, 329
in thecal cysts, 177
Crepitus, in dislocations, 481
in fractures, 329
in the citis, 171
Cross-leg deformity, 463
Cupping in inflammation, 47
Curette, Barker-Willard, 518
irrigation, 5.18
Curvature of spine, antero-posterior. (See
Spondylitis.)
Cutaneous erysipelas, 64
Cutting off blood-supply in inflamma-
tion, 47
Cyphosis. (See Spondylitis.)
Cyrtonmeter, Wilson's, 190
Cyst, thecal, 176
Cystitis, 671
acute, 671
chronic, 672
in spinal fracture, 354
Cystocele, vaginal, 671
Cystoma, 110
Cystoscope, 668
778
INI) EX.
Cystotomy, perineal, 687
supra-pubic lateral, 687
Cysts, 111
congenital, 111
hydatid, 111
of liver, 604
of jaw, 558
of kidney, 664
of mammary glands, 766
of mouth, 556
of ovary, 608
rupture of, 610
tapping of, 610
of pancreas, 607
of spleen, 607
of thyroid gland, 550
Dºº bone plates, 602
Deformities of bladder, congenital,
668
of nasal septum, 531
operations for, 532
of nose, 531
Deformity after fracture at ankle, 437
angular, of spine, 452
cross-leg, 463
division of muscles in, 173
of tendons in, 173
from muscular paralysis, 172
from nasal fracture, 365
from spastic paralysis, 172
from tenosynovitis, 171
gunstock, in humeral fractures, 396
immediate correction of, after te-
notomy, 174
in dislocations, 480
in fractures, 328
in hip disease, 463
of joints, congenital, 446
Deligation. (See Ligation.)
Delirium, febrile, 216
nervous, 215
traumatic, 215
asthenic, 215
inflammatory, 215
septic, 215
tremens, mechanical restraint in,
traumatic, 214
treatment of, 217
Demarcation, line of, 61
Depressants in inflammation, 48
Diaphoretics in inflammation, 48
Diaphragm, paralysis of, in spinal frac-
ture, 355
Diastasis, 325 *
at Symphysis pubis, 378
Diathesis, hemorrhagic, 227
Diet, in inflammation, 49
Diffuse cellulitis, 64
Diffused abscess, 51,
Suppuration, 52
Dilatation of female urethra, 709
of Oesophagus, 569
Dilatation of oesophagus in stricture, 568
of rectal strictures, 651
of stomach in pyloric cancer or
stricture, 584
of urethra, 702
continuous, 702
Dilated osophagus, 568
Dilator for female urethra, 708
Oesophageal, 569
tracheal, 539
urethral, 703 et seq.
Dinner-plate incision of breast, 769
Diphtheritic inflammation, 45
Director, Levis’s hernia, 622
Disarticulation. (See Amputation
through joints.)
Disk, choked, in brain injury, 190
Dislocation, 476
congenitai, 446
crepitus in, 481
definition of, 476
deformity in, 480
false joint in, 479
in hip disease, 466
of ankle-joint, 512
of astragalus, 512
of atlas, 488
of axis, 488
of carpus, 502
of cartilages, 512
costal, 512
ensiform, 513
semilunar, 523
of clavicle, 491
of coccyx, 489
of elbow, 499
of femur, 505
of fibula, 512
of hip-joint, 505
of humerus, 493
of jaw, 489
of knee-joint, 511
of maxilla, 489
of metacarpal bones, 503
of metatarsal bones, 512
of muscles, 170
of patella, 511
of phalanges of hand, 503
of toes, 512
of radius, 499, 501
of ribs, 489
of scapula, 492
of shoulder, 493
of special joints, 487 et seq
of sternum, 491
of tarsal bones, 512
of tarsus, 512
of tendons, 170
of thigh, 505
of thumb, 504
of tibia, 511
of ulna, 499, 502
of vertebrae, 487
of wrist-joint, 502
old, 476
IN DE X.
779
Dislocation, old, treatment of, 486
pathology of, 478
prognosis of, 482
reduction of, 484
force in, 485
symptoms of, 480
treatment of, 483
Dissection wounds, 122
T)iuretics in inflammation, 48
ſ)ivision of tendons. (See Tenotomy.)
Dorsal dislocations of femur, 506
Douche for foreign bodies in nose, 526
for nasal disease, 528
Drainage in amputations, 747
in empyema, 545
in suppurating joints, 449
of abdominal cavity, 573
-tube in empyema, 545
Drain-tubes, abdominal, 573
glass, 573
Dressings, 140
collodion, 142
fixed. (See Gypsum dressings.)
gypsum, 344
plaster-of-Paris, 344
Drill, bone, 524
Dropsy of joints, 449
Dry gangrene, 60
Duodenal ulcer, from burns, 163
Duodenostomy. (See Intestinal anasto-
mosis.)
Dupuytren's contraction, 174
Dura mater, fungus of. (See Fungus
cerebri.)
Dysphagia, from aneurism, 367
from foreign bodies in oesophagus,
564
from oesophageal obstruction, 564
in retro-pharyngeal abscess, 563
Dyspnoea, from foreign bodies in oesopha-
gus, 564
in kyphosis, 732
in retro-pharyngeal abscess, 563
in spinal inflammation, 201
BURNATION of bone. (See Ostitis.)
Ecchymosis in fractures, 331
Ecrasèur, in removal of tongue, 561
Ectropion, 151
Effusion, pleural, 545
purulent, 39, 51.
Eiloides. (See Elephantiasis.)
Elbow-joint, amputation through, 752
ankylosis of, after fracture, 399
dislocations of, 499
excision of, 520
Electricity, burns from, 161
in neuralgia, 208
in uterine tumors, 608
Electro-cautery, 143
Elephantiasis, Arabian, 160
Grecian, 160
of scrotum, 710
of vulva, 725
Elephantiasis, treatment of, by arterial
ligation, 161
by nerve section, 161
Embolic abscess, 66
Embolism, fat, in fractures, 333
Embolus, 67
venous, 67
Emetics in inflammation, 48
Emphysema, from clavicular fracture,
381
in chest wounds, 544
in nasal fractures, 365
in neck wounds, 548
in wounds of oesophagus, 564
Emprosthotonus in tetanus, 210
Empyema, treatment of, 545
Encephalitis, 183
Encephalocele, 182
Encephaloma, 108
Enchondroma, 92
Encysted calculi, 679
Endostitis, 307
Ensiform cartilage, dislocation of, 513
Enterectomy, 599
Entero-cholecystotomy, 606
Enterocele, 614
Entero-epiplocele, 614
Enterorrhaphy, 586
Enterotome, 594
Enterotomy, 591.
Enucleation. (See Individual organs;
excisions.)
Epididymis, inflammation of, 715
Epididymitis, 715
Epilepsy, trephining for, 363
Jacksonian, 187
Epiphyses, acromial, separation of, 386
fractures of, 325
of humerus, 388
separation of, 325
in ostitis, 304
Epiphysitis, 318
Epiplocele, 614
Epistaxis, 526
Epithelioma, 106, 108
columnar, 110
in stumps, 749
of larynx, 537
of lip, 555
of oesophagus, 566
f of penis, 722
of rectum, 652
of scrotum, 710
of tongue, 560
of vulva, 725
squamous, 108
| Epulis, 557
Erasion of joints, 515
| Erysipelas, 64
cellular, 64
| cutaneous, 64
: in burns, 163
in wounds, 64
phlegmonous, 64
simple, 64
780
IN DE X.
Erysipelas, symptoms of, 64
treatment of, 65
Fry thema nodosum, 249
Eschar, 162
Esmarch's avascularization apparatus,
745
Estlander's operation.
treatment of.)
Ether anaesthesia, 130
Evacuator, Bigelow's litholapaxy, 686
Exarticulation. (See Amputations
joints.)
Excision for ankylosis, 516
for disease, 515
of ankle-joint, 525
of carpal bones, 521
of carpus, 521
of elbow-joint, 520
of Fallopian tubes, 613
of hemorrhoids, 640
of hip-joint, 522
anterior method, 523
posterior method, 522
of interphalangeal joints, 522, 525
of intestine, 599
in hernia, 623
of jaw, for epithelioma of lip, 556
of joints, 515
for ankylosis, 472
for injury, 516
method of, 516
of kidney, 666
of knee-joint, 524
of loose bodies from joints, 473
of mammary glands, 769
of metacarpo-phalangeal joints, 522
of metatarso-phalangeal joints, 525
of metatarso-tarsal joints, 525
of nerves, in neuralgia, 208
in tetanus, 212
of ovarian cysts, 611
of penis, 723
of pylorus, 583
of rectum, 653
of ribs, in empyema, 546
of shoulder-joint, 519
of special joints. (See Individual
joints.)
of spermatic veins, 715
of spleen, 607
of tarsal bones in club-foot, 787
of temporo-maxillary joint, 519
of testicle, 717
of thyroid gland, 550
of tongue, 560
of tonsils, 562
of tunica vaginalis, 713
of uterus, 608
of vermiform appendix, 596
of wrist-joint, 520
Exfoliation of bone, 309.
Necrosis.)
Exomphalos. (See Hernia, umbilical.)
Exophthalmic goitre, 549
Exostoses. (See Bones, tumors of.)
(See Empyema,
at
(See, also,
Exostoses in Osteo-arthritis, 468
Exostosis, 93
Exploration of abdomen, 572
of oesophagus, 565
of stomach, 578
of urethra, 701
Exploring needle, 144
Exstrophy of bladder, 669
operations for, 670
urinal for, 669
Extension apparatus, 342
Indian puzzle, 504
Lewis's, for finger dislocations,
Đ04
Morton’s, 466
Sayre's, 457
of inflammation, 40
plate, Levis's, 351
vertical, in femoral fractures, 429
Extirpation. (See Excision.)
Extravasation of blood, 221
Extroversion of bladder, 669
IExudation in inflammation, 38 et seq.
of lymph, 41
ACE, fracture of bones of, 365
Fallopian tubes, diseases of, 612
excision of, 613
inflammation of, 612
False ankylosis, 470
joint, in dislocations, 479
Fascia lata, relaxation of, in femoral
fractures, 421
palmar, contraction of, 174
division of, in Dupuytren's con-
traction, 175
Fat embolism, in fractures, 333
Fecal fistule, 592
Feces, impaction of, in rectum, 634
incontinence of, in spinal inflam-
mation, 201
Femoral artery.
hernia, 628
Femur, dislocations of, 505
anterior, 508
backward, 506
dorsal, 506
forward, 508
ileo-femoral ligament in, 505
iliac, 506
ischiatic, 506
obturator, 508
old, 510
posterior, 506
pubic, 509
thyroid, 508
fractures of, 415 et seq.
capsular, 417
cervical absorption in, 418
epiphyseal, 416, 429
extension apparatus for, 426
Allis’s test for, 421
Cleeman’s test for, 421
Morris's test for, 421
(See Artery.)
IN DE X.
781
*
Femur, fractures of, impaction of, 417
of condyles, 429
of neck, 416
of shaft, 425
treatment of, 424 et seq.
vertical extension in, 429
section of, in knock-knee, 742
Fever, aseptic, of wounds, 65
asthenic, 44
inflammatory, 44
Sthenic, 44
suppurative. (See Pyaemia.)
surgical, 44. (See, also, Pyaemia )
symptomatic, 44
traumatic, 44
typhoid, rupture or perforation of
intestine in, 585
urethral, 704
Fibrin, laminated, in aneurisms, 267
Fibrinous inflammation, 39
Fibroma, 90
Fibro-myoma, 95
|Fibula, dislocations of, 512
fractures of, 436
Filiform bougies, 704
Fingers, Dupuytren's contraction of, 174
webbed, 734
(See Union,
First intention, union by.
primary.)
Fissure of anus, 646
of Rolando, localization of, 189
Fistula or fistule, 55
anal, 643
treatment of, 645
arterio-venous, 256
biliary, 606
fecal, 592
of vagina, 727
recto-urethral, 646
recto-vesical, 646
treatment of, 55
recto-vaginal, 646, 727
renal, 663
salivary, 563
urethral, 705
urethro-vaginal, 727
vesical, 674
vesico-vaginal, 727
Fixed dressings. (See Dressings.)
Flaps, by transfixion, 746
in Teale's method of amputation, 748
musculo-cutaneous, 747
Flat-foot, 739
Floating kidney, 656
operations for, 656
Fluctuation in abscess, 53
Foot, club, 735
flat, 739
Forceps, bone, 516
bone-cutting, 516
gnawing, 362
hemostatic, 126
phimosis, 719
rongeur, 362
Stromeyer's, 491
| Forceps, Tait's cholelithotomy, 606
* Thornton's T-shaped, 611
urethral, 705
Forearm, amputation of, 752
fracture of bones of, 400
Foreign bodies in air-passages, 534
: in bladder, 680
in intestines, 584
removal of, 584
in nose, 526
in Oesophagus, 564
* in rectum, 634
i in stomach, 579
in tongue, 560
in urethra, 705
in vagina, 728
in vermiform appendix, 595
Formation of pus, 50
Fraenum of tongue, short, 559
Fragilitas ossium. (See Osteomalacia.)
Friction in inflammation, 47
Fracture bed, 337
Fracture-box, application of, 439
elevated, 441
inclined plane, 428
suspension of, 440
Fracture of bones in stumps, 749
of penis. (See Rupture of.)
Pott's. (See Fibula, fractures of.)
Fractures, 321
t blood extravasation in, 331
causes of, 321
closed, 322
comminuted, 323
complete, 324
compound or open, 322
repair of, 336
crepitus in, 329
definition of, 321
deformed union in, 350
deformity following, 350
in, 327
delayed union in, 347
diagnosis of, 332
differential, 332
* displacement in, 326
dressing of, 339
ecchymosis in, 331
epiphyseal, 325
| repair of, 336
extension apparatus for, 342
fat embolism in, 333
j green-stick, 324
+ gunshot, of joints, 347
impacted, 323
incisions for swelling in, 338
incomplete, 324
into joints, treatment of, 345
method of examination of, 327
muscular spasm in, 381
oblique, 324
Oedema in, 333
of acetabulum, 379
of acromion, 386
of bones of face, 365
782
I N D E X .
Fractures of bones of foot, 444
of forearm, 400
near elbow-joint, 400
of carpal bones, 413
of cartilages, costal, 372
nasal, 365
repair of, 386
of clavicle, 381
of coccyx, 379
of costal cartilages, 377
of cranium, 356
bleeding from ear in, 359
escape of cerebro-spinal fluid in,
359
paralysis in, 359
of epiphyses, 325
of femur, 415
condyles, 429
head and neck, 416
shaft, 425
of fibula, 436
of humerus, condyloid, 394
lower extremity, 393
supra-condyloid, 394
upper extremity, 391
of hyoid bone, 370
of ilium, 379
of innominate, 378
of ischium, 378
of jaw, lower, 366
upper, 365
of joints, 345
of larynx, 870, 534
of malar bone, 366
of malleolus, 438
of maxillary bones, 366
of metacarpal bones, 413
of metatarsal, bones, 445
of nasal bones, 365
of nose, 365
of olecranon, 400
of patella, 431
of pelvic bones, 377
of pelvis, 377
of phalanges of fingers, 414
of toes, 445
of pubis, 378
of radius, 403, 406
of ribs, 374
of sacrum, 378
of scapula, 385
of skull, 356
of special bones.
bones.)
of spine, 352
of tarsal bones, 444
of tibia, 486
of trachea, 534
of ulna, 405
of vertebrae, 352
of zygoma, 366
open, 322
or compound, treatment of, 345
amputation for, 346
pathology of, 325
(See Individual
Fractures, preternatural mobility in, 328
prognosis of, 333
reduction of, 338
repair of, 384
retention of urine in, 343
setting of, 337
simple, 322
special, 352
splints, 340
sprain, 825
stiffness after, 333
swelling in, 331
symptoms of, 327
constitutional, 332
transverse, 324
treatment of, 386 et seq.
air and water beds in, 337
beds for, 337
extension in, 341
transportation in, 337
ununited, 347
treatment of, 348
Van Wagenen's dressing for, 443
varieties of, 322
vicious union in, 350
Frontal sinus, abscess of, 534
Prostbite, 165
erythematous, 165
necrotic, 166
treatment of, 166
vesicular, 165
Functional changes in inflammation, 44
Fungous ulcer, 57
Fungus cerebri, 192
of brain, 192
Furuncle, 155
Purunculosis, 155
ALL-BLADDER, fistule of, 606
incision of, 605
wounds and injuries of, 604
Gall-duct, obstruction of, 605
Gall-stones, removal of, 605
Galvano-puncture in neuralgia, 208
Ganglion, 176
compound, 177
Gangrena oris. (See Stomatitis, gan-
grenous.)
Gangrene, 45, 59
amputation for, 63
causes of, 60
dry, 60
from tight bandaging, 343
hospital, 63
in aneurism, 267
line of demarcation in, 61
moist, 60
of bone. (See Necrosis.)
of intestine in hernia, 616
pulmonary, 547
senile, 61
symptoms of, 60
treatment of, 62
incisions in, 62
* IN D E X.
783
Gangrene, varieties of, 60
Gangrenous stomatitis.
ulceration, 63
Gaping, dislocation of jaw from, 489
Gastro-enterostomy, 584, 602
Gastrorrhaphy, 583
Gastrostomy, 580
feeding aſter, 582
Gastrotomy, 582
Gathering. (See Abscess.)
Gººl organs, diseases and injuries of,
10
Genu-valgum, 740
Genu-varum, 740
Gladiolus, fractures of, 371
Glanders, 122
Glands, axillary, infiltration of, in mam-
mary carcinoma, 767
cervical, infiltration of, in mammary
carcinoma, 767
inflammation of, 548
tuberculosis of, 548
lymphatic, inflammation of, 250
mammary, diseases of, 763
vulvo-vaginal, inflammation of, 724
Glottis, oedema of, 534
Glass liquid. (See Sodium silicate.)
Gleet, 699
Glioma, 104
Glossitis, 559
syphilitic, 559
Glottis, scarification of, 534
Goitre, 548
excision of, 550
exophthalmic, 549
Gonococci, 699
Gonorrhoea, 698
chronic, 699
complications of, 700
Gonorrhoeal arthritis, 450
urethritis, 698
in the female, 698
Grafting of bone, 311
of trephine buttons, 364
Grafts of omentum, in abdominal opera-
tions, 600
Granny knot, 137
Granulating surfaces, union of apposed,
164
Granulation, 117
and cicatrization, 117
changes in, 39
healing by, 117
tissue, 39
Gravel. (See Calculus, vesical.)
Graves's disease. (See Goitre, exophthal-
mic.)
Green-stick fractures, 324
Gum, abscess of, 557
diseases of, 556
lancing of, 557
Gum-boil, 557
Guillotime, for tonsils, 562
Gullet. (See CEsophagus.)
Gumma, of tongue, 560
Gumma, syphilitic, 78
(See Stomatitis.) Gunshot wounds, 123
of abdomen, 57.1
Gunstock deformity, 397
Gurgling in hernia, 616
Gustatory nerve, division of, in lingual
cancer, 560
Gypsum bandages, 344
dressings, 344
splints, 341
AIR, falling of, in syphilis, 77
Hand, amputation of, 753
Hard cancer. (See Carcinoma, scirrhous.)
chancre. (See Chancre, syphilitic.)
Harelip, 552
operations for, 553
suture, 137
Heart, wounds of, 219
suture of, 220
Hemato-salpinx, G12
Hematuria in kidney injuries, 664
Hemarthrosis, 448
Hematocele of tunica vaginalis, 713
Hematoma, arterial, 252
of vulva, 724
Hematophilia, 227
Hematuria, 682
Hemorrhage, 221
anemia from, 223
arrest of, Nature's method, 224
arterial, 222
bandaging of limbs in, 227
capillary, 222
causes of, 222
cerebral, 186
checking of, permanent means, 225.
temporary means, 224
compression of aorta in, 227
constitutional effects of, 222
during operations, 135
from ear in cranial fracture, 359
from intercostal artery, 543
from nose, 526
from tonsils after excision, 562
from uterus, 607
from venous sinuses in trephining,
364
intermediary, 221
intermeningeal, 186
into cerebral ventricles, 186
ligation of arteries in, 232
parenchymatous, 222
primary, 221
secondary, 221
amputation in, 239
treatment of, 237
subcranial, 186
subcutaneous, 221
traumatic, 221
treatment of, 227
bloodletting in, 228
cautery in, 230
constitutional, 227
784
IN DE X.
Haemorrhage, treatment of, hot water in,
230
local, 229
pressure in, 230
rubber bandage in, 231
styptics in, 230
tourniquet in, 231
varieties of, 221
venous, 222, 239
treatment of, 240
vicarious, 222
Hemorrhagic diathesis, 227
Hemorrhoids, 637
bleeding from, 688
external, 641
hemorrhage from, 638
internal, 637
Oedematous, 642
operations for, 639
urethral, 706
Hemostatic forceps, 126
Hepatic duct, obstruction of, 605
Hepatotomy, 604
Hermaphrodism, 710
Hernia, 613
causes of, 613
congenital, 614
diaphragmatic, 614
director, Levis's, 622
femoral, 628
gangrene of, 616
of intestine in, 616
incarcerated, 615
incomplete, 625
inflamed, 614
inguinal, 624
irreducible, 615
obstructed, 615
obturator, 614
of brain. (See Fungus cerebri.)
congenital, 182
of muscles, 169
pathology, 614
radical operations upon, 619
reducible, 614
sac of, 614
strangulated, 620
strangulation of, 615
symptoms of, 616
taxis in, 620
treatment of, 617
trusses for, 617
umbilical, 630
Herniotomy, 621 *
Herpes of lip, 555
of penis, 721
Hey’s amputation, 761
High operation for stone.
omy, suprapubic.)
Hip disease. (See Tuberculosis of hip-
joint.)
IIip-joint, amputation through, 754
dislocations of, 505
excision of, 522
anterior method, 522
(See Lithot-
Hip-joint, amputation through, posterior
method, 522
tuberculosis of, 461
diagnosis of, 461
symptoms of, 462
treatment of, 464
Hodgkin's disease, 95, 251
Hollow back, 732
Hooks, patellar, 434
Horner's awl, 254
Hospital gangrene, 63
Housemaid’s knee, 179.
sitis.)
Humerus, dislocations of, 493
diagnosis of, 496
downward, 493
subclavicular, 495
subcoracoid, 495
subglenoid, 493
subspinous, 495
treatment of, 497
varieties of, 493
fractures of, 387 et seq.
Hunter's method of ligation, 279
Hydatid cysts, 111
Hydrarthrosis, 449
Hydrencephalocele. (See Meningocele.)
Hydrocele in the female, 713
of canal of Nuck, 713
of neck, congenital, 548
of spermatic cord, 713
of tunica vaginalis, 711
acquired, 711
congenital, 711
incision and drainage of 713
injection of, 712
loose bodies in, 711
tapping or aspiration of, 712
treatment of, radical, 712
Hydrocephalus, 182
acute, 182
aspiration of, 183
puncture of ventricles in, 183
treatment of, 183
Hydrogen test, Senn's, 57.1
Hydro-nephrosis, 656
intermittent, 657
treatment of, 657
Hydrophobia, 212
treatment of, 214
Hydrops articuli. (See Hydrarthrosis.)
Hydrorachis, 198. (See also Spina bifida.)
Hydrothorax. (See Pleural effusion.)
aspiration of, 545
Hyoid bone, fracture of, 370
Hyperemia, 33,
inflammatory, 34
Hyperdistention of abscesses, 54
Hyperinosis of blood, 41
Hyperpyrexia in tetanus, 210
Hypertrophy of bone, 318
of tonsils, 562
Hysterectomy, 608
vaginal, 608
Hysteria of joints, 470
(See, also, Bur-
IN DEX.
C.E. (See Cold.)
Idiopathic inflammation, 34
Ileo-colotomy, 620
Ileo-femoral ligament, in hip disloca-
tions, 505
Iliac artery. (See Artery.)
dislocations, 506
of femur, 507
Ilium, fracture of, 379
Impaction of feces in rectum, 634
Imperforate anus, 632
rectum, 632 *
Impulse in coughing in hernia, 616
in varicocele, 714
Incision, dinner-plate, of breast, 769
Incisions in general, 128
Incontinence of feces in spinal injuries.
(See Spine, injuries of.)
of urine, 682
in spinal injuries.
injuries of.)
Indian method of rhinoplasty, 533
puzzle, 504
India-rubber rings for intestinal anas-
tomosis, 602
Indolent ulcer, 57. (See also Ulcer.)
Induration of chancre. (See Chancre,
hard and soft.)
Infantile hernia.
tal.)
Infiltration, purulent, 39, 51
Inflamed hernia, 620
Inflammation, 33
blood in, 41
blood vessels in, 40
causes of, 34
constitutional symptoms of, 44
definition of 33
diphtheritic, 45
discoloration in, 43
disordered function in, 44
extension of, 40
fibrinous, 39
general symptoms of, 44
idiopathic, 34
metastatic, 40
microörganisms of, 37
nerves in, 40
of arteries, 259
of bladder, 671
of bones, 304
of cervical glands, 548
of epididymis, 715
of epiphyseal cartilages, 818
of Fallopian tubes, 612
of glands of Cowper, 700
of kidney, 658
of lymphatic glands, 250
of lymphatics, 248
of mammary glands, 763
of nerves, 203
of oesophagus, 565
of penis, 720
of periosteum, 302
of peri-renal tissues, 659
(See Spine,
(See Hernia, congeni-
Inflammation of rectum, 633
of spinal cord, 200
of testicle, 715
of theoa, 170
of tongue, 559
of urethra, 698
of vagina, 727
of veins, 242
of vermiform appendix, 594
of vulva, 724
pain in, 42
pathology of, 40
productive, 39
redness in, 43
resolution of, 45
results of, 45
serous, 38
suppurative, 39
symptoms of, 42
temperature in, 43
terminations of, 45
tissues in, 42
traumatic, 34
treatment of, 45 et seq.
alteratives in, 49
anodynes in, 47
antiseptics in, 47
astringents in, 47
cathartics in, 48
cold in, 46, 48
compression in, 47
constitutional, 48
counter-irritation in, 47
cupping in, 47
cutting off arterial supply in, 47
depressants in, 48
diaphoretics in, 48
diet in, 49
diuretics in, 48
emetics in, 48
friction in, 47
heat in, 46
leeching in, 47
local blood-letting in, 47
massage in, 47
necrotics in, 47
position and rest in, 46
sanitary measures in, 49
specifics in, 49
stimulants in, 47
tonics in, 48
venesection in, 48
Inflammatory blood, 41
exudate, 41
fever, 44
lymph, 41
swelling, 43
Ingrowing toe-nail, 167
Inguinal hernia, 624
Injection of abscesses, 55
of hydrocele, 712
In nominate bone, fracture of, 378
Inoculation of rabies, 214
Insects, stings of (See Wounds, poi-
soned.)
50
786
IN DE X.
Instruments. (See Various operations.)
cleansing of, 127
general consideration of, 126
sterilization of, 128
Intercostal artery, hemorrhage from, 543
treatment of, 548
laceration of, in rib fractures, 373
Intestinal anastomosis, 602
obstruction, 587
wounds, 585
Intestine, excision of, 599
foreign bodies in, 584
internal strangulation of, 589
obstruction of, from stricture, 589
operations upon, 591
perforating ulcer of, 585
resection of, in hernia, 623
rupture of, 585
stricture of, 589
suture of, 586.
tumors of, 591
wounds of, 584
gunshot and stab, 584
Intervertebral joints. (See Vertebrae.)
Intoxication, septic, 65
Intrapy retic amputation.
tation, secondary.)
Intubation of larynx, 541
Intussusception, 588
Intussusceptum, 588
Intussuscipiens, 588
Invagination of intestine.
susception.)
of sequestra. (See Necrosis.)
Involucrum of bone, 312
Irrigation, curette, 518
of abdominal cavity, 573
of pleural cavity, 546
Ischiatic dislocations of femur, 506
notch or foramen, dislocation into,
506
Ischio-rectal abscess, 642
Ischium, fracture of, 378
Italian method of rhinoplasty, 533
(See Ampu-
(See Intus-
ACICIET, leather, 458
plaster, application of, 457
Jacksonian epilepsy, 187
Jaw, cysts of, 558
dislocations of, 489
excision of, for epithelioma of lip,
556
fracture of, 366 et seq.
locked. (See Tetanus.)
necrosis of, 558
tumors of, 557
Jejuno-ileostomy, 602
Joints, abscess of, 449
amputation through.
vidual joints.)
ankylosis of, 470.
losis.)
aspiration of, 515
changes in, in locomotor ataxia, 469
(See Indi-
(See also Anky-
Joints, Charcot's disease of, 469
contusions of, 473
deformities of, congenital, 446
dropsy of, 449. (See also Hydrar-
throsis.)
effusion into, 449
erasion of, 515
excision of, 515. (See also Indi-
vidual joints; excisions.)
for ankylosis, 516
for disease, 516
for injury, 516
method of, 516
exploration of, 515
false, in dislocations, 479
fractures into, repair of, 336
treatment of, 345
gunshot fractures oſ, 347
hemorrhage into, 448
hysteria of, 470
inflammation of.
arthritis.)
injuries of, 473
irrigation of, 515
loose bodies in, 472
neuralgia of, 470
operations upon, 515
scrofula of. (See Arthritis, tuber-
cular.)
sprains of, 474
(See Synovitis;
stiff. (See Ankylosis.)
suppurating. (See Arthritis, suppu-
rative.)
syphilis of, 467
tuberculosis of, 450
special, 451
tumors of, 448
wounds of, 474
| ELOID, in burn cicatrices, 162
Kidney, abscess of, 658
tubercular, 660
aspiration of, 665
calcull in, 661
fistulae from, 663
congenital malformations and dis-
placements of, 655
cysts of, 664
excision of, 666
incision of. (See Nephrotomy.)
methods of examination, 655
movable or floating, 656
movable, suture of. (See Nephror-
rhaphy.)
simple misplacement of, 655
suppuration in, 658
tuberculosis of, 660
tumors of, 663
wounds of, 664
Rinee, diseases and injuries of
Rnee-joint.)
housemaid’s 179
Knee-joint, amputation through, 757
dislocations of, 511
(See
IN DE X.
787
ICnee-joint, excision of, 524
ICnee-pan. (See Patella.)
ICnife, lithotomy, 688
tenotomy, 173
Knives, 126
Rnock-knee, 740
Knot, clove-hitch, 483
noose, 484
Staffordshire, 612
Ryphosis, 731
ACERATION of brain, 193
of perineum, 725
Laparo-colotomy, 598
Laparotomy, 572
Laryngectomy, 537
Laryngotomy, 537
Larynx, epithelioma of, 537
excision of, 537
foreign bodies in, 534
fracture of, 370, 534
tracheotomy in, 371
intubation of, 541
tuberculosis of, 536
tumors of, 536
Lateral anastomosis.
intestinal.)
spinal curvature, 731
Laughing gas. (See Nitrous oxide.)
Lavage of stomach, 570
Leather jacket for spine disease, 458
Leeches, 143
in inflammation, 47
Leg, amputation of, 757
Leio-myoma, 95
Lembert's suture, 586
Leucoma, 560
Lewis's extension apparatus for finger
dislocations, 504
plate, 351
patella hooks, 434
pulley, 427
splint for fracture of radius, 411
Ligament, ileo-femoral, in hip disloca-
tions, 505
Y. (See Ligament, ileo-femoral.)
Ligaments, laceration of. (See Sprains.)
Ligation of arteries, Anel's method, 280
of arteries, Brasdor's method, 281
calcareous, 262
distal, 281
for elephantiasis, 161
for hemorrhage, 232
Hunter's method, 279
in aneurism, 279
in continuity, 285
in lingual cancer, 560
in secondary hemorrhage, 238
proximal, 280
Wardrop's method, 281
of hemorrhoids, 640
of varicose veins, 246
of veins, 240
spermatic, 714
(See Anastomosis,
Ligations in aneurism, 279
complications from, 282
contra-indications for, 282
gangrene in, 284
indications for, 282
pyemia in, 284
secondary hemorrhage in, 284
suppuration of sac in, 284
Ligature, 138, 232
method of tying, 232
varieties of, 232
Line of demarcation, 61
Lingual nerve, division of, in lingual
cancer, 560
Lip, chancre of, 555
epithelioma of, 555
hare-, 552
herpes of, 555
lupus of, 555
tuberculosis of. (See Lupus.)
Lipoma, 90
Lips, operations upon, 151
Liquid glass. (See Sodium silicate.)
Lisfranc's amputation, 761
Lister's wound treatment.
sepsis.)
Lithectasy.
bladder.)
Lithoclysmy.
treatment of.)
Litholapaxy, 683
Bigelow's apparatus for, 687
Litholysis. (See Calculus, solvent treat-
ment of.
Lithotomy knife, 688
lateral, 687
position, 687
staff, 688
Lithotrite, 684
Bigelow’s, 684
Lithotrity, 683
Littré's method of colotomy, 598
Liver, abscess of, 603
hydatid cysts of, 604
operations upon, 604
tumors of, 604
wounds of, 603
Lobster-tailed trachea tube, 541
Lock-jaw. (See Tetanus.)
Loose bodies in joints, 472
excision of, 473
in tunica vaginalis, 711
Lordosis, 732
Lower jaw. (See Jaw.)
Lung, incision into, 547
wounds of, 543
Lupus, 71, 158
of lip, 555
of vulva, 725
Luxation. (See Dislocation.)
Lymph, exudation of, 41
inflammatory, 41
Lymphadenitis, 250
of cervical glands, 548
septic, 251
(See Anti-
(See Calculus, in female
(See Calculus, solvent
788
IN L) E X .
Lymphadenitis, tubercular, 250
Lymphadenoma, 251
Lymphangeioma, 251
cavernous, 97
treatment of, 100
Lymphangitis, 248
Lymphatic glands, inflammation of, 250
Lympºſe collateral circulation in,
48
diseases of, 247
inflammation of 248
varicose, 251
wounds of, 247, 252
Lymphoma, 94
malignant, 95, 251
Lymphorrhagia, 252
ALAR bone, fracture of, 366
Malformations. (See Deformity;
Congenital affections; Ortho-
pedic surgery.)
special. (See Individual parts.)
Malgaigne's patella hooks, 434
Malignant pustule, 122
Malleolus, fractures of, 438
Mammary abscess, 764
glands, abscess of, 764
diseases of, 762
excision of, 769
inflammation of, 763
Paget's disease of, 765
tumors of, 766
Mammitis, 763. (See also Mastitis.)
Manubrium, fractures of, 371
Marriage of syphilitics, 75
Massage in club-foot, 736
in inflammation, 47
Mastitis, 763
chronic, 764
tuberculous, 764
Maxilla. (See Jaw.)
dislocations of, 489
Maxillary bones, fracture of, 366 et seq.
Mediastinum, abscess of, 547
tumors of, 547
Meigs-Case suspension chair, 459
Melon-seed bodies, 176
Meninges, congenital tumors of, 182
Meningitis, 183
spinal, 200
Meningocele, 182
spinal, 199
Menopause, artificial, 608
Menses, retained, 727
Merocele. (See Hernia, femoral.)
Metacarpal bones, dislocations of, 503
fractures of, 413
Metacarpus, fractures of, 413
Metapyretic amputation. (See Amputa-
tion, intermediate.)
Metastasis, of gonorrhoea to joints, 450
Metastatic abscess, 53, 66
inflammation, 40
Metatarsal bones, dislocations of, 512
Metararsal bones, fracture of, 445
Metatarsus, fractures of, 445
Microörganisms of inflammation, 37
of suppuration, 50
Morbus senilis. (See Osteo-arthritis.)
Moist gangrene, 60
Mollites ossium, 319
Morbus coxae, or coxarius.
joint, tuberculosis of.)
Morris's test for femoral fracture, 421
Mortification, 59
Morton's extension apparatus, 466
fractured rib corset, 376
Motor neuritis, 204
Mouth, chancre of, 559
cysts of, 556
diseases of, 552
tumors of, 556
Mucous patches, 77
ulcers, treatment of, 59
Murmur, aneurismal, 269
Muscles, dislocation of, 170
division of, for deformity, 173
hernia of, 169
rupture of, 169
section of, in torticollis, 730
spasm of, in fractures, 331
tenotomy in, 174
suture of 169
wounds of, 169
Mºlar paralysis, deformities from,
17
Myelitis, 200
Myelocele, 199
Myoma, 95
fibrous, 95
Myosuture, 169
Myotomy, 173
for torticollis, 730. (See Tenotomy.)
Myxoedema, 548
Myxoma, 93
of bladder, 675
of nasal chambers, 529
(See Hip-
AEVI, 96
l treatment, 97
Naevus maternus, 96
Nail, toe, ingrowing, 167
Nares. (See Nostrils.)
plugging of, 527
Narrowing rectum for prolapsus, 636
Nasal bones, fracture of, 365
cartilages, fracture of, 365
catarrh, 528
polyps, 529
tumors, 529
Navel. (See Umbilicus.)
ruptured. (See Hernia, umbilical.)
Neck, congenital cysts of, 548
diseases of, 547
hydrocele of, 548
wounds of, 547
Neck, wry, 729
Necrosis, 45
INT) E X.
789
Necrosis, pyaemia in, 310
superficial, 308 j
cloacae in, 308
coagulation-, 60
in tenosynovitis, 179
of bones, 307 i
after amputation, 309 .
central, 308
operations for, 311 |
pathology of, 308
prognosis of, 310
symptoms of, 309. :
total, 308
treatment of, 310
of jaw, 558
of stumps, 749
phosphorus, 558
Necrotics in inflammation, 47
Needle, exploring, 144
Needles, 126
Nélaton's line, 421
probe, 124
Nephrectomy, 666
abdominal or anterior, 667
lumbar or posterior, 667 |
Nephritic colic, 662
Nephritis, suppurative, 658
tubercular, 660
Nephro-lithotomy, 666 .
Nephrorrhaphy, 665
Nerve, lingual, division of, in lin
cancer, 560 |
gustatory, division of, in lingual
cancer, 560
Nerve-stretching, 208
in neuralgia, 208
in neuritis, 205
in tetanus, 212 {
Nerves, division or excision of, 200
inferior dental, 209
infra-orbital, 209
in tetanus, 212
supra-orbital, 209
trifacial, 209
inflammation of, 203
in inflammation, 40
injuries of, 205
reunion of divided, 205
section of, for elephantiasis, 161
spinal accessory, stretching and di-
vision of, in torticollis, 730
suture of, 206
transplantation of, 206
wounds of, 205
Neuralgia, 206
from cicatricial pressure, 206
in aneurism, 267
of joints, 470
of mammary glands, 763
reflex, 207
Neurectomy, 208
in tetanus, 212
palsy after, 208
Neuritis, 203
cautery in, 205
gual
|
t
| Normal ovariotomy.
Nostrils.
Neuritis, chronic, 204
motor, 204
nerve-stretching in, 205
sensory, 204
Neuroses of mammary glands, 763
vesical, 674
Neuroma, 96
Neurotomy, 208
for neuralgia, 208
Nipple, Paget's disease of, 765
Nitrous oxide anaesthesia, 129
Noma. (See Stomatitis, gangrenous.)
Noose knot, 484 :
(See Oöphorec-
tomy.)
Nose, deformities of, 531
foreign bodies in, 526
fracture of, 365
hemorrhage from, 526
reconstruction of, 151, 533
tip-tilted, or turned up, 531
tumors of, 529
(See Nares.)
Nuck, canal of, hydrocele of, 713
BSTRUCTION, intestinal, 587
of bowels in rectal stricture, 650
Obturator dislocations of the femur, 508
Occipito-atloid dislocations, 488
Occlusion. (See Imperforate; obstruc-
tion.)
of anus. (See Anus, imperforate.)
of arteries. (See Artery.)
CEdema of glottis, 534
QEdematous swelling, 48
CEsophageal bougie, 569
introduction of, 569
|
CEsophagismus, 567
CEsophagostomy, 566
CEsophagotomy, 566
external, 569
in lingual cancer, 560
internal, 569
CEsophagus, auscultation of, 568
dilatation of, 569
dilated, 567
epithelioma of 566
exploration of, 565
foreign bodies in, 564
inflammation of, 565
rupture of, 564
spasm of, 567
stricture of, 567
cicatricial, 567
organic, 567
tumors of, 566
wounds of, 564
Old dislocations, 486
of femur, 510
of humerus, 498
treatment of, 486
Olecranon, fracture of, 400
Omentum, grafts of, in abdominal opera-
tions, 600
790
IN DE X .
Omentum, tumors of, 591
Omphalocele. (See Hermia, umbilical.)
Onychia, 167
Onychitis, 166
Oöphorectomy, 613
Open fractures, treatment of, 345
Opening an abscess. (See Abscess, treat-
ment of.)
Operation, preparation for, 133
Operations, constructive. (See Plastic
surgery.)
plastic, 146
upon intestines, 591
upon joints, 515
Operative method, 135
Opisthotonos in tetanus, 210
Orchitis, 716
Organic stricture. (See Stricture.)
Orthopedic surgery, 729
Osteo-arthritis, 468
Osteoclast, 351
Osteomalacia, 319
Osteoma, 93
Osteomyelitis, 304
central, 307
cortical, 307
infective, 306
in stumps, 749
Osteophytes, 93
Osteotomy, 741
Adams's saw for, 517
for ankylosis, 472
Ostitis, 304
deforming, 304
rarefying, 303
symptoms of, 305
treatment of, 306
periosteal incision in, 307
trephining in, 307
Ovarian cysts, 608
Ovariotomy, 611
normal, 613
trocar, 611
Ovary, cysts of, 608
rupture of, 610
tumors of, 608
Ozaena, 529
pagºs disease of nipple and mam-
mary gland, 765
Painful ulcer of anus. (See Anus, fissure
of.
IPalate, cleft, 554
age for operation, 555
defects of, 554
Palmar fascia, contraction of, 174
Panaris. (See Paronychia.)
Pancreas, cysts of, 607
injuries of, 607
Papilloma, 100
of bladder, 675
Paquelin's cautery, 143
Paracentesis abdominis, 576
of pericardium, 220
Paracentesis thoracis, 545
Paralysis in aneurism, 267
in cranial fracture, 359
in spinal fractures, 353
tuberculosis, 453
muscular, deformities from, 172
of bladder, 674
spastic, deformity from, 172
Paraphimosis, 719
Parietal abscess, 578
Paronychia, 167. (See also Felon.)
Patches, mucous, 77
Patella, dislocations of, 511
fractures of, 431
hooks, 434
wiring of, 435
Pedicle, management of, in ovariotomy,
611
in abdominal operations, 572
Pelvic abscess, 577
bones, fractures of, 377
Pelvis, fractures of, intra-rectal pressure
in, 380
laceration of urethra in, 378
Penile fistula. (See Urethra, fistulae of.)
Penis, amputation of. (See Penis, ex-
cision of.)
carcinoma of, 722
chancre of, 721
chancroid of, 721
congenital abnormalities of, 718
fracture or rupture of, 723
herpes of, 721
inflammation of, 720
injuries of, 723
strings tied about, 720
tumors of, 722
webbed, 718
Perforating ulcer of intestines, 585
Perforation of palate. (See Palate,
cleft.)
of vermiform appendix, 595
Pericardicentesis, 220
Pericardium, aspiration of, 220
incision of, 220
wounds of, 219
Perineal abscess.
rectal.)
Perineorrhaphy, 726
Perinephritic abscess, 659
Perinephritis, 659
Perineum, laceration of, 725
Periosteum, incision of, in ostitis, 307
inflammation of, 302
Periostitis, 302
acute infective, 302
circumscribed, 303
symptoms of, 803
syphilitic, 308
treatment of, 303
incisions in, 303
Perirectal abscess, 642
Perirenal abscess, 659
Peritoneum, purulent effusion in, 578
toilet of, 572
(See Abscess, ischio-
I N DE X.
7.91
Peritonitis after abdominal operations,
circumscribed, 576
diffused or general, 577
purgative treatment of, 575
traumatic, 575
Perityphlitis, 594
Permanent stricture.
urethra, organic.)
Pernio, 165
Pervious urachus, 670
Pes calcaneus, 739
equinus, 738
planus, 739
valgus, 738
varus, 737
Phagedena of vulva, 725
sloughing, 63
Phalanges, fractures of, of fingers, 445
of fingers, amputation of, 754
of hand, dislocations of, 503
of toes, amputation of, 761
dislocations of, 512
fractures of, 445
Pharyngotomy, 566
Tharynx, adenoid vegetations of, 531
Phimosis, 718
forceps, 719
Phlebectasis. (See Varix.)
Phlebitis, 242
septic, 243
thrombosis in, 245
treatment of, 243
Thleboliths, 245
Phlebotomy, 144
Phlegmonous abscess, 53
erysipelas, 64
Phosphorus necrosis, 558
Piles. (See Hemorrhoids.)
oadematous, 642
Pirogoff’s anputation, 759
Plaster-of-Paris dressings, 344
jacket, application of, 457
shears, 345
splints, 341
Plastic operations, 147
surgery, 146
displacement of flaps in, 147
interpolation of flaps in, 148
methods used in, 147
retrenchment of flaps in, 148
sloughing of flaps in, 150
transplanting of flaps in, 148
T’lates, Senn's decalcified anastomosis, 602
Pleura, aspiration of, 545
drainage of, 546
effusion into, 545
irrigation of, 546
wounds of, 548
Pleurosthotonos in tetanus, 210
Pliers, bone-cutting, 516
Butcher’s excision, 518
Plugging of nates, 527
Pneumectomy, 547
Pneumotomy, 547
(See Stricture of
Pneumouria, 683
Pointing of abscesses, 53
Poisoned wounds, 120
Polyps, nasal, 529
Polypus, 529
Posterior tibial artery.
Posthitis, 720
Potain's aspirator, 144
Pott's disease, 451
fracture. (See Fibula, fractures of.)
Poultices, antiseptic, 142
flaxseed, 142
Powder marks, treatment of, 125
Prepuce, slitting of 718
Priapism in spinal fracture, 354
in spinal inflammation, 201
in vesical calculus, 678
Probe, Nélaton, 124
Probes, 127
Proctectomy, 653
Proctitis, 633
Proctotomy, 651
Productive inflammation, 39
Prolapse of anus. (See Rectum, pro-
lapse of.)
of rectum, 635
operations for, 636
I’rotective, 141
Provisional callus, 335
Pruritus of anus, 633
Pseudarthrosis, 317
Psoas abscess, 453
Ptomaines, 65
Pubic bone, fracture of, 378
Pubis, aspiration of bladder above, 683
dislocation of femur upon, 509
Pulmonary abscess, 547
gangrene, 547
Pulsation in arterial varix, 301
Pulse in aneurism, 268
Puncture, of bladder, 683
of intestine, 572 -
Purgative treatment of peritonitis, 575
Purulent catarrh, 89
effusion, 39, 51
infiltration, 39, 51
Pus, calcification of, 52
caseation of, 52
composition of, 50
corpuscles, 51
encapsulation of, 52
formation of, 50
tests for, 51
varieties of, 51
Pustule, malignant, 122
Pyarthrosis. (See Arthritis, suppura-
tive.)
Pyennia, 65
in necrosis of bones, 310
|Pylorectomy, 583
Pylorus, divulsion of 584
excision of, 583
stricture of, 584
Pyo-nephrosis, 658
(See Artery.)
Pyosalpinx, 612
792
IN ID E X.
TJILT suture, 600
Quins.y, 562
| ABID animals, bites of. (See Hydro-
phobia.)
Rabies. (See Hydrophobia.)
Racemose aneurism. (See Aneurism by
an astomosis)
Rachitis, 84
adultorum. (See Osteomalacia.)
Radial artery. (See Artery.)
Radical treatment of hydrocele, 712
Radius, dislocations of, 499, 501
fractures of, 403, 406
Ranula, 556
Rarefying ostitis, 304
Reamputations, 743
Rectal speculum, 648
Recto-urethral fistule, 646
-vaginal fistule, 727
-vesical fistule, 646
Rectum, abscess of, 642
carcinoma of, 652
dilatation of, 634
diseases of, 632
excision of, 653 \
foreign bodies in, 631
hemorrhoids of, 637
impaction of feces in, 634
imperforate, 632
operation for, 632
inflammation of, 633
malformations of, 632
prolapse of, 635
operations for, 636
stricture of, 649
colotomy in, 652
treatment of, 651
tumors of, 652
ulceration of, 648
Reduction of dislocations, 483
of prolapsed rectum, 636
Redundancy of scrotum, 710
Reef knot, 137
Reeve's universal talipes shoe, 737
Refracture for vicious union, 350
Renal calculi, 661
colic, 662
fistulae, 663
Reproductive organs, discases and inju-
ries of, 710
Resection. (See Excision.)
of bones, in ununited fracture, 349
of intestine, 599
anastomosis aſter, 603
|Besidual abscess, 52
Resolution of inflammation, 45
Respiration, Cheyne-Stokes, in brain
injury, 190
|Results of inflammation, 45
Retained menses, 727
Retention of urine, 681
in spinal fracture, 354
in stricture, 701
Retractor, for amputations, 745
Retro-pharyngeal abscess, 563
Reunion of nerves, 205
Revulsion. (See Counter-irritation.
Rhabdo-myoma, 95
Rhinoplasty, 533
Ribs, dislocations of, 489
excision of, in empyema, 546
fracture of, 372
symptoms of 374
treatment of, 375
Rice-like bodies, 176
Rickets, 84
Risus sardonicus. (See Tetanus.)
Rizzioli’s osteoclast, 351
Roberts's aseptic trephine, 362
operation for recial prolapse, 636
pericardial trocar, 220
segment trephine, 363
IRolando, fissure of, 189
Rongeur forceps, 362
Rotary lateral curvature of spine, 731
Round back, 731
shoulders, 732
Rubber rings for intestinal anastomosis,
602
Run-around. (See Onychia.)
Rupia, syphilitic, 78. (See also Syphi-
litic eruptions.)
Rupture of bladder, 680
of intestines, 585
of muscles, 169
of Oesophagus, 564
of penis, 723
of perineum, 725
of quadriceps tendon, 435
of stomach, 579
of tendons, 169
of urethra, 706
ACCULATED arterio-venous fistule,
258
Sac of hernia, 614
contents of, 614
Sacro-iliac articulation, separation of, 377
Sacrum, fracture of, 378
Saliva, tests for, 563
Salivary fistule, 563
Salpingectomy, 613
Salpingitis, 612
Sanitary measures in inflammation, 49
Sapraemia, 65
Sarcoma, 102
alveolar, 104
giant cell, 105
melanotic, 105
myeloid, 105
round-celled, 103
spindle-celled, 104
Sardonic grin of tetanus, 211
Saw, Adams's, 517
aseptic amputation, 745
Butcher's excision, 518
chain, 517
I N D EX. 793
Sayre's clavicle apparatus, 384
extension apparatus, 457
Scalds, 161
Scalpel, 126
Scalp wounds, 191
Scapula, dislocations of, 492
fractures of, 385
Scars. (See Cicatrix.)
Schede's method of healing by blood-
clot, 313
Schizomycetes, 37
Schneiderian membrane.
nasal.)
Schirrus, 107
Scleroderma (See Elephantiasis.)
Screw, Stromeyer's, 472
Scrotum, 710
elephantiasis of, 710
epithelioma of 710
lymph, 710
redundancy of, 710
split, 710
varix of, 710
Scoliosis, 731
Scrofulides, 72
Scrofula, 71. (See also Tuberculosis.)
of joints. (See Arthritis, tubercular.)
Scrofulous affections. (See Tuberculosis.)
Searcher for vesical calculi. (See Sound,
vesical.)
Secondary hemorrhage, ti eatment of 237
Second intention, union by. (See Union,
secondary.)
Section of abdomen, 572
of arteries. (See Artery; arteriot-
omy.)
of bone in amputations.
putations.)
in excisions, 517
of nerves in tetanus, 210
of tendons. (See Tenotomy.) -
of veins in varicocele. (See Wari-
cocele.)
in varix. (See Varix.)
Semi-lunar cartilages, dislocation of, 513
Senile gangrene, 61
Senn's decalcified bone plates for anas-
tomosis, 602
hydrogen test, 57.1
Sensory neuritis, 204
Septic intoxication, 65
wounds, 119
Septicaemia, 65
causes of, 67
diagnosis of, 68
from venous wounds, 240
pathology of, 66
symptoms of, 68
treatment of, 69
Septum, nasal, deformities of, 531
Sequestrotomy, 311
Sequestrum, 308
Serous inflammation, 38
Serum, transudate of, 41
Seton, in ranula, 557
(See Catarrh,
(See Am-
Setons, 143
Setting of fractures, 336, 337
Sexual organs, diseases and injuries of,
i 710
Shock, 114
treatment of 115
Shortening, Allis's test for, 507
Shot, extraction of, 125
Shoulder-joint, amputation through, 750
dislocations of, 493
excision of, 519
injuries of, diagnosis of, 389
Signorini’s tourniquet, 277
Silver-fork fracture. (See Radius, frac-
tures of.)
Sims's vaginal speculum, 728
Sinus, 55
of chest-wall, 547
Skin-grafting for ulceration, 57
method of, 57
Skin-grafts, 57
Skull, fractures of, 356
Sloughing phagedena, 63
ulcer, 57
Smith's wire splint, 429
Snake bites, 121
Soft cancer. (See Carcinoma, medullary.)
chancre. (See Chancroid.)
Softening of bones. (See Osteomalacia.)
Soluble glass. (See Sodium silicate.)
Solvent treatment of calculus, 679
Soot cancer. (See Scrotum, cancer of.)
Sound, vesical, 678
Sounding the bladder, 678
Sounding-board, 679
Spanish windlass. (See Tourniquet.)
Spasm, muscular, in stumps, 749
of muscles, in fractures, 331
of Oesophagus, 567
of sphincter ani, in fissure, 647
tetanic, 210
Spastic paralysis, deformity from, 172
Specifics in inflammation, 49
Speculum, rectal, 648
vaginal, 728
Spermatic veins, excision of, 715
ligation of, 714
varix of, 714
Spermatorrhoea, 717
Sphacelation. (See Gangrene.)
Sphacelus. (See Slough ; gangrene.)
Sphincter ani, division of, 648
relaxation of, in hemorrhoids,
638
spasm of, in fissure, 647
stretching of, 648
Spina bifida, 198
Spinal accessory nerve, stretching and
section of, in torticollis, 730
cord, concussion of, 203
contusion of, 203
inflammation of, 22
in meningitis, 200
laceration of, 203
sclerosis of, in myelitis, 200
794
IN DE X.
Spinal cord, wounds of, 203
curvatures, 730
meningitis, 200
meningocele, 199
Spine, angular curvature of, 453
ankylosis of, 455
antero-posterior curvature of, 454
bifid, 198
curvatures of, 730
lateral, 731
rotatory, 731
treatment of, 733
apparatus in, 733
fracture of, prognosis, 355
fracture of, 352
retention of urine in, 354
treatment of, 355
trephining in, 356
Pott's disease of, 451
trephining of, in spondylitis, 459
tuberculosis of, 451
Splay-foot, 739. (See also Talipes valgus.)
Spleen, cysts of, 607
excision of, 607
injuries of, 607
Splenectomy, 607
Splenotomy, 607
Splint, bedsores from, 343
Bond's, 412
gypsum, 341
in fractures, 340
interdental, 367
Lewis's, for fracture of radius, 411
moulded, 341
plaster-of-Paris, 341
Smith's wire, 429 -
Stromeyer's, for ankylosis, 471
Thomas's hip, 465
Splinters of bone. (See Sequestrum.)
Spondylitis, 451
Sprain-fracture, 325
Sprains of joints, 474
Spring apparatus for spinal curvature,
733
clamps for intestinal operations, 599
Square, Broca's, 188
Stab wounds of abdomen, 571
Staff, lithotomy, 688
Staffordshire knot, 612
Staphylococcus pyogenes albus, 50
aureus, 50
Staphylorrhaphy, 554
Steatoma. (See Tumors, fatty.)
Sterilization, 135
of instruments, 128
Sterno-mastoid muscle, section of, in
torticollis, 730
Sternum, dislocations of, 491
fractures of, 371
trephining of, for mediastinal ab-
scess, 547
Sthenic fever, 44
Stimulants in inflammation, 47
Sting, of insects. (See Wounds, poi-
soned.)
Stomach, diseases and injuries of, 578
exploration of 578
foreign bodies in, 579
lavage of, 570
operations upon, 579
pump, 569
introduction of, 569
rupture of, 579
stricture of orifices of, 584
suturing of, 582
tumors of, 578, 583
washing out of, 570
before operations, 579
wounds of, 579
Stomatitis, 559
Stone in the bladder, 676
in the kidney, 661
Strangulated hernia, 620
Strangulation of intestines, 589
Strangury, in gonorrhoea, 698
Strapping of testicle, 716
Streptococcus pyogenes, 50
Stretching of nerves, 208
in tetanus, 212
of sphincter ani, 648
Stricture of gastric orifices, 584
of intestine, 589
of oesophagus, 567
of pylorus, 584
of rectum, 649
of urethra, 700
causes of, 701
dilatation of, 702
continuous, 703
forcible, 704
immediate, 704
intermittent, 702
rapid, 704
exploration of, 701
organic or true, 700
pathology of, 701
symptoms and diagnosis of,
701
treatment of, 702
permanent. (See Stricture of
urethra, organic.)
Stromeyer's ankylosis splint, 471
forceps, 491
Struma. (See Bronchocele.)
Stumps, amputation, diseases and inju-
ries of, 749
drainage of, 747
dressing of, 747
conical, 749
Styptics in hemorrhage, 230
Subclavian artery. (See Arlery.)
Subclavicular dislocation of humerus, 495
Subcoracoid dislocation of humerus, 495
Subcutaneous hemorrhage, 221
Subglenoid dislocation of humerus, 493
Subspinous dislocation of humer is, 495
Sulcus of Rolando, 186
Sunburn, 161
Supination in fracture of forearm, 404
Suppression of urine, 682
I N DEX.
795
Suppuration, 39, 50 (See also Abscess;
pus; inflammation.)
acute, 39
diffused, 52
microërganisms of, 50
Suppurative fever. (See Pyemia.)
inflammation, 39
nephritis, 658
Surgeon's knot, 138
Surgery abdominal, 572
orthopedic, 729
plastic, 146
Surgical fever. (See Pvemia.)
Suspension apparatus, 457
chair, 459
in spinal inflammation, 202
Suture, buried, 140
contin uous, 137
continuous, of intestine, 600
cranial, separation of, in fracture, 357
harelip, 137
interrupted, 137
Lembert's, 586
of heart, 220
of intestinal wounds, 586
of nerves, 206
of pericardium, 220
of veins, 240
pin, 137
quilt, 600
removal of, 138
tongue and groove, 147
twisted, 137
Sutures, 136
Suturing of stomach, 582
Swelling, inflammatory, 43
in fractures, 331
Oedematous, 43 -
white. (See Arthritis, tubercular.)
Syme's amputation, 757
Symphysis pubis, absence of in exstrophy,
669
aspiration above.
piration of.)
diastasis at, 378
Symptomatic fever, 44 .
Synostosis, 470
Synovial membrane, inflammation of, 447
Synovitis, 447
purulent, 448
septic, 448
Syphilides, 77
Syphilis, 74
alopecia in, 77
arterial changes in, 78
arthritis in, 467
caries of bone in, 313
causes of 74
clinical history of, 75
congenital, 79
definition of, 74
diagnosis of, 79
fibroid degenerations in, 78
gummy deposits in, 78
hereditary, 78
(See Bladder, as-
Syphilis, hereditary, treatment of, 82
heredity of, 74
incubation stage of, 75
inoculation of 74
iritis in, 77
marriage during, 75
mucous patches in, 77
of tongue, 559
of vulva, 725
primary stage of, 75
quarternary stage of, 78
secondary stage of, 77
symptoms of, 75
synovitis in. (See Synovitis.)
teeth in, 78
tertiary stage of, 77
treatment of, 79
Syphilitic alopecia, 77
arthritis, 467
bubo, 76
chancre, 75
iritis, 77
periostitis, 303
Syphiloderms, 77
Syringe, Tait's, 574
urethral, 700
TArts cholelithotomy forceps, 606
ovariotomy trocar, 611
syringe, 574
Talipes, 735
calcaneo-valgus, 738
calcaneus, 739
equino-valgus, 738
equino-varus, 737
equinus, 738
plano-varus, 738
planus, 739
treatment of, operative, 737
universal shoe for, 737
varus, 737
Tampon, for plugging nares, 528
Tapping, 144
of abdomen, 576
of hydrocele, 712
of hydrocephalus, 183
of joints, 515
of kidney, 665
of ovarian cysts, 610
of perieardium, 220
Tarsal bones, dislocation of, 512
excision of, in club-foot, 737
fracture of, 444
Tarsus, dislocations of, 512
fractures of, 444
Taxis, in hernia, 620
Taylor's osteoclast, 351
Teale's method of amputation, 748
Teeth, abscess of, 557
in syphilis, 78
Temperature in inflammation, 43
in tetanus, 210
Temporo-maxillary joint, excision of,
519
796
I N D E X.
Tenaculum, 127
Tendon of Achilles, tenotomy of, in
fracture, 430
in leg fracture, 441
quadriceps, rupture of, 435
Tendons, contraction of.
pedic surgery.)
dislocation of, 170
division of, 173
in fractures, 174
inflammation of, 170
rupture of, 169
suture of, 140
suturing of, 169
wounds of, 169
Tenosuture, 169
Tenosynovitis, 170
deformity from, 171
Tenotome, 173
Tenotomy, 173
correction of deformity aftſ r, 174
for muscular spasm, 174
in club-foot, 736
in luxation of muscles and tendons,
170
of sterno-mastoid, in torticollis, 730
Terminations of inflammation, 45
Test for pus, 51
sall va, 563
Senn's hydrogen, 571
Testicle, abnormalities of, 715
excision of, 717
inflammation of, 715
injuries of, 717
malposition of, 715, 720
strapping of, 716
tuberculosis of, 715
undescended, 715
Tetanus, 209
diagnosis of, 211
from ligation of umbilical cord, 210
hyperpyrexia in, 210
opisthotonos in, 210
prognosis of, 211
sardonic grin of, 211
symptoms of, 210
treatment of, 211
Theca, inflammation of, 170, 179
Thecal cyst, 176
Thecitis, 170
crepitation in, 179
Thermo-cautery, 143
Thigh, amputation of, 757
bone. (See Femur.)
dislocations of, 505
Thomas's hip splint, 465
Thoracentesis, 545
Thorax. (See Chest.)
diseases of, 542
Thornton's T-shaped forceps, 611
Thrombosis in phlebitis, 245
Thrombus, 67
venous, 66
Thrill in aneurism, 268
Thumb, amputation of, 753
(See Ortho-
Thumb, dislocations of, 504
Thyroid body or gland, diseases of, 548
excision of, 550
hypertrophy of, 549
tumors of, 549
dislocations of the ſemur, 508
Thyrotomy, 537
Tibia, deformities of, 742
dislocations of, 511
fractures of, 436
Tip-tilted nose, 531
Tissues in inflammation, 42
Toe-nail, ingrowing, 167
Toilet of peritoneum, 573
Tongue, abscess of, 559
biting of, in tetanus, 210
diseases of, 559
epithelioma of, 560
tracheotomy in, 561
Oesophagotomy in, 56.1
excision of, 560
foreign bodies in, 560
gumma of, 560
ichthyosis of, 560
incision of, 559
inflammation of, 559
leucoma of, 560
psoriasis of, 560
syphilis oſ, 559
-tie, 559
tumors of, 560
Tonics in inflammation, 48
Tonsillitis, 562
Tonsillotome, 562
Tonsillotomy, 562
Tonsils, abscess of, 562
bleeding from, after excision, 562
diseases of, 562
excision of, 562
hypertrophy of, 562
tuberculosis of, 562
Torsion of arteries, 234
Tortl Collis, 729
Tourniquet, Esmarch's, 745
Signorini’s, 277
Trachea dilator, 539
foreign bodies in, 534
fractures of, 534
tube, 539, 541
tumors of, 536
Tracheotomy, 538
in fracture of larynx, 370
in lingual cancer, 56.1
in tetanus, 212
in wounds of neck, 547
Transfusion, 228
direct, 228
indirect, 228
of milk, 229
of saline solutions, 229
Transplantation of nerve, 200
Transportation of the injured, 337
Transudate of serum, 41
Traumatic aneurism, 255
inflammation, 34
IN DE X.
Traumatic peritonitis, 575
Trephine, 362
Roberts's aseptic, 362
segmented, 363
Trephining, bone-grafting after, 364
for bone abscess, 317
for brain lesions, 189
for brain tumors, 198
for compression of brain, 197
for epilepsy, 363
hemorrhage during, 364
in brain inflammation, 186
in cranial fracture, 360
in ostitis, 307
in spinal fracture, 356
incision of dura mater in, 364
metallic plate after, 364
of spine in spondylitis, 459
of sternum for mediastinal abscess,
547
of vertebrae in spinal inflammation,
203
operation of, 362
Trismus, 209
Trocar, aspiration, 145
for tapping hydrocele, 712
pericardial aspirating, 221
Tait's ovariotomy, 611
Trusses for hernia, 617
application of, 618
Tube, stomach, 569
introduction of, 569
tracheal, 539, 541
tracheotomy, 539
Tubes, drainage, for abdomen, 573
glass, 573
Fallopian, diseases of, 612
Tubercle of joints, 450
painful subcutaneous, 96
Tubercular abscess, 53
arthritis, 450
ulcers, treatment of, 59
Tuberculosis, bacillus of, 71
causes of, 72
definition of 71
general consideration of, 71
miliary, 71
of bladder, 674
of cervical glands, 548
of glands, 250
of hip-joint, 461
of kidney, 660
of larynx, 536
of lip. (See Lupus.)
of mammary glands, 764
of sacro-iliac articulation, 460
of testicle, 716
of tonsils, 562
of vertebral articulations, 451
of vulva, 725
pathology of 71
symptoms of, 72
treatment of, 78
Tuberculous lymphadenitis, 250
ulceration of bone, 313
Tuſnell's arterial truss, 278
Tumors, 86
adenomatous, 101
bony, 93
bursal, 178
cancerous, 106
carcinomatous, 105
cartilaginous, 91
cauliflower, 100
causes of, 86
causes of death from, 89
circumscribed, 87
classification of, 88
clinical history of, 89
colloid, 108
changes in, 108
congenital, of men’nges, 182
cystic, 110
varieties of, 111
definition of 86
diffuse, 87
encephaloid, 108
epitheliomatous, 106, 108
fatty, 90
fibrous, 90
glandular, 101
leio-myomatous, 95
lymphomatous, 94
malignant, 87
metastatic, 87
mucous, 93
muscular, 95
myomatous, 95
nasal, 529
nervous, 96
non-malignant, 87
of bladder, 675
of bone, 320
of brain, 198
of intestine, 591
of jaw, 557
of joints, 448
of kidney, 663
of larynx, 536
of liver, 604
of mammary glands, 766
of mediastinum, 547
of mouth, 556
of Oesophagus, 566
of omentum, 591
of ovary, 608
of penis, 722
of stomach, 578, 583
of stumps, 749
of synovial membranes of joint-, 448
of testicle, 717
of trachea, 536
of tongue, 560
of urethra, 706
of vagina, 728
of vulva, 725
papillomatous, 100
pathology of 86
recurrent fibroid, 105
rhabdo-myomatous, 95
798
IN DE X.
Tumors, sarcomatous, 102
alveolar, 104
giant-cell, 105
melanotic, 105
myeloid, 105
round celled, 103
spindle-celled, 104
scirrhus, 107
secondary, 87
treatment of, 89
vascular, 96
Tunica vaginalis, hematocele of, 713
hydrocele of, 711
excision of, 713
incision and drainage of, 713
loose bodies in, 711
tapping of, 712
Turned-up nose, 531
Typhlitis, 594
Typhoid condition, 44
fever, rupture or perforation of in-
testines in, 585
LCER, atheromatous, 262
callous, 57
chronic, 57
closed, 53
duodenal, from burns, 163
fungous, 57
indolent, 57
mucous, 59
rupial, 78 \
syphilitic, 78
treatment of, 57
skin-grafting in, 57
varicose, 57
Ulceration, 39, 45, 55
gangrenous, 63
of stumps, 749
of vulva, 725
tuberculous, of bone, 313
Ulcers, definition of, 56
general consideration of, 56
of vulva, destructive and hyper-
trophic, 725
sloughing, 57
treatment of, plastic operations in, 58
pressure in, 59
tubercular, treatment of, 59
varieties of, 56
Ulna, dislocations of, 499, 502
fracture of, 405
Ulnar artery. (See Artery.)
Umbilical hernia, 630
|Union by first intention, 117
by secondary intention, 117
of apposed granulating surfaces, 164
of divided nerves, 205
of fractures, deformed or vicious, 350
delayed, 347
Ununited fractures, 347
Urachus, calculi in, 571, 670
patulous, 571
pervious, 670
Uranoplasty, 555
Ureters, calculi in, 705
catheterization of, 655, 668, 707
compression of, 655
diseases and defects oſ, 668
Urethra, Boutonnière operation upon.
(See External urethrotomy.)
caruncle of, 706
catheterization of, in female, 708
dilatation of, 702
in female, 709
incontinence after, 709
exploration of, 701
fistulae of, 705
foreign bodies in, 705
hemorrhoids of, 706
inflammation of, 698
injuries of, 706
laceration of, in pelvic fractures, 378
normal calibre of, 702
operations upon, 707
rupture of, 706
stricture of, 700
organic or true, 700
tumors of, 706
fibro-vascular, of female, 706
wounds of, 706
Urethral fever, 704
fistulae, 705
forceps, 705
injection syringe, 700
Urethritis, 698
chronic specific, 699
gonorrhoeal, 698
non-specific, 698
simple, 698
specific, 698
Urethrocele, 698
operation for, 698
|Urethrotome, 708
Jrethrotomy, external, 709
in stricture, 704
internal, 708
in stricture, 704
Urethro-vaginal fistula, 727
Urinal for vesical exstrophy, 669
Urine, air in, 683
blood in, 682
chyle in, 688
incontinence of, 682
after dilatation of female ure-
thra, 709
in spinal inflammation, 201
in vesical calculus, 678
true, 682
false, 682
retention of, 680
in fractures, 343
in spinal fracture, 354
in spinal inflammation, 201
suppression of, 682
Uterus, excision of, 608
injuries of, 607
tumors of, 607
fibro-myomatous, 607
IN DE X.
799
AGINA, chancre and chancroid of,
727
congenital abnormalities of, 726
cystocele of, 671
fistulae of, 727
repair of, 728
inflammation of, 727
Vaginal hysterectomy, 608
Vaginitis, 727
Valgus. (See Talipes valgus.)
Van Wagenen's fracture dressing, 344
Varicocele, 714
Varicose aneurism, 256
arteries, 300
lymphatic vessels, 251
ulcer, 57
veins, 244
in aneurism, 267
ligation of, 246
treatment of, 245
Varix, 244
aneurismal, 256
aneurismoid, 257
arterial, 300
of scrotum, 710
of spermatic veins, 714
of stumps, 749
of vulva, 723
Varus. (See Talipes varus.)
Vegetations. (See Warts; papilloma;
adenom a ; polypus.)
Weins, air in, 241
prevention of, 241
symptoms of, 241
treatment of, 241
coagulation in. (See Phlebitis.)
concretions in, 245
diseases of, 242
hypertrophy of, 244
inflammation of, 242
ligation of 240
occlusion of, in aneurism, 267
of vulva, varix of, 723
rupture of, subcutaneous, 239
spermatic, varix of, 714
suture of, 240
varicose, in aneurism, 267
varicosity of, 244
wounds of, 239
Vein-stones. (See Phleboliths.)
Welpeau's clavicle bandage, 385
Wenesection, 144. (See Bleeding; blood-
letting.)
in inflammation, 48
Ventricles, puncture
cephalus, 183
Verruca, 100, 158. (See Warts.)
Vermiform appendix, excision of, 595
foreign bodies in, 594
inflammation of, 594
perforation of 595
Vertebrae, dislocations of, 487
cervical, 487
dorsal, 488
fractures of, 352
of, in by dro-
Vertebrae, fractures of, paralysis in, 353
pathology of, 353
symptoms of, 353
trephining of, in spinal inflamma-
tion, 203
tuberculosis of, 451
diagnosis of, 454
symptoms of, 451
treatment of, 456
Vertical extension in femoral fractures,
429
Vesical fistulae, 674
Vesico-vaginal fistula, 727
Viscera. (See Individual organs.)
abdominal. (See Abdominal organs.)
Volvulus, 589
Vomiting in hernia, 617
in spinal fractures, 354
Vulva, abscess of, 724
adhesion of lips of, 723
chancre of, 725
chancroid of, 725
elephantiasis of, 725
epithelioma of, 725
hematoma of, 724
imperforate, 723
inflammation of, 724
follicular, 724
lupus of, 725
phagedena of 725
syphilis of, 725
tuberculosis of, 725
tumors of, 725
ulcers of, 725
varix of, 723
wounds of, 725
Vulvitis, 724
Wulvo-vaginal glands, inflammation of,
724
ARDIROPS method of ligation, 281
Warts, 100, 153
Washing out of joints, 515
of stomach, 570
Water-bed in fractures, 337
Watson's arterial compressor, 276
Weak ankles, 739
Webbed fingers, 734
penis, 718
Wens. (See Cysts, sebaceous.)
Whalebone bougies, 704
White swelling. (See Arthritis, tuber-
culous.)
Wilson's cyrtometer, 190
Windlass, Spanish. (See Tourniquet.)
Windpipe. (See Trachea; larynx.)
Wiring of patella, 435
Wounds, 113
arterio-venous, 256
aseptic, fever in, 65
definition of, 113
dissection, 122
dressing of, 141
gunshot, 123
800
IN DEX.
Wounds of abdomen, 57.1
gunshot, 57.1
stab, 57.1
of arteries, 222, 252
of bladder, 680
of brain, 192
of chest, 543
of gall-bladder, 604
of heart, 219
of intestines, 584
of joints, 474
of kidney, 664
of liver, 603
of lung, 543
of lymphatics, 247, 252
of nerves, 205
of Oesophagus, 564
of pancreas, 607
of pericardium, 219
suture of, 220
of pleura, 543
of scalp, 191
of spinal cord, 203
of spleen, 607
of stomach, 579
of urethra, 706
of uterus, 607
Wounds of vagina, 728
of veins, 239
of vulva, 725
poisoned, 120
repair of, 117
septic, 69
treatment of, 119
shock in, 113
suture of, 137, 147
symptoms of 113
treatment of, 118
constitutional, 118
varieties oſ, 113
Wrist-joint, amputation through, 752
dislocations of, 502
excision of, 520
fractures near, 406
Wry-neck, 729
-LIGAMENT. (See Ligament, ileo-
femoral.)
/Yaowa fracture of, 366
f UNIV, of MłCH}QAM,
SEP 16 1914
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THE MEDICAL NEWS PHYSICIANS” LEDG ER.
Containing 400 pages of fine linen “ledger” paper, ruled so that all the accounts of a
large practice may be conveniently kept in it, either by single or double entry, for a long
period. Strongly bound in leather, with cloth sides, and with a patent flexible back,
which permits it to lie perfectly flat, when opened at any place. Price, $5.00. Also,
a small special lot of same Ledger, with 300 pages. Price, $4.00.
HARTSHORNE, HENRY, A. M., M. D., L.L. D.,
Lately Professor of Hygiene in the University of Pennsylvania.
A Conspectus of the Medical Sciences; Containing Handbooks on Anatomy,
Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics.
Second edition, thoroughly revised and greatly improved. In one large royal 12mo.
volume of 1028 pages, with 477 illustrations. Cloth, $4.25; leather, $5.00.
The object of this manual is to afford a conven-
ient work of reference to students during the brief
moments at their command while in attendance
industry and .#y of its able editor.—Bostoºs
Medical and Surgical Journal, Sept. 3, 1874.
We can say with the strictest truth that it is the
upon medical lectures. It is a favorable sign that
it has been found necessary, in a short space of
time, to issue a new and carefully revised edition.
The illustrations are very numerous and unusu-
ally clear, and each part seems to have received
its due share of attention. We can conceive such
a work to be useful, not only to students, but to
practitioners as well. It reflects credit upon the
best work of the kind with which we are ac-
quainted. It embodies in a condensed form a}}
recent contributions to practical medicine, and is
therefore useful to every busy practitioner through-
out our country, besides being admirably adapted
to the use of students of medicine. The book is:
faithfully and ably executed.—Charleston Medica?
Journal, April, 1875.
NEILL, JOHN, M. D., and SMITH, F. G., M. D.,
Late Swrgeon to the Penna. Hospital.
Prof. of the Institutes of Med. in the Univ. of Penna:
An Analytical Compendium of the Various Branches of Medical
Science, for the use and examination of Students. A new edition, revised and improved.
In one large royal 12mo, volume of 974 pages, with 374 woodcuts. Cloth, $4; leather, $4.75,
LUDLOW, J. L., M. D.,
Consulting Physician to the Philadelphia Hospital, etc.
A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which
is added a Medical Formulary. Third edition, thoroughly revised, and greatly enlarged. Irs,
one 12mo, volume of 816 pages, with 370 illustrations. Cloth, $3.25; leather, $3.75.
The arrangement of this volume in the form of question and answer renders it espe-
cially suitable for the office examination of students, and for those preparing for graduation.
HOBLYN, RICHARD D., M. D.
A Dictionary of the Terms Used in Medicine and the Collateral
Sciences. Revised, with numerous additions, by IsAAC HAYs, M. D., late editor of
The American Journal of the Medical Sciences. In one large royal 12mo, volume of 520
double-columned pages. Cloth, $1.50; leather, $2.00.
It is the best book of definitions We have, and ought always to be upon the student's table.—Sowińern
Medical and Surgical Journal, ... ºr “º ºus
LEA BROTHERS & Co.'s PUBLICATIONs—Dictionaries.
JUST READY.
DATIODAL I))CDICAL DICTIODARY
| N C LU D | NG
English, French, German, /talian and Latin Technical Terms used in Medicine and
the Collateral Sciences, and a Series of Tables of Useful Data.
Jºhn S. Billings, M.D., LL.D., Eli, and Hary, D.C.L., DxO).
Member of the National Academy of Sciences, Surgeon U. S. A., etc.
WITH THE COLLABORATION OF
WASHINGTON MATTHEWS, M.D.,
C. S. MINOT, M.D.
H. C. YARROW, M. D.,
PROF. W. O. ATWATER,
FRANK BAKER, M. D.,
S. M. BURNETT, M. D
W. T. COUNCILMAN,
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WILLIAM LEE, M.D.,
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The publishers have great pleasure in presenting to the profession a new practical
working d; embracing in one alphabet all current terms used in every depart-
ment of medicine in the five great languages constituting modern medical literature.
For the vast and complex labor involved in such an undertaking no one better quali-
fied than Dr. Billings could have been selected. He has planned the work, chosen the
most accomplished men to assist him in special departments, and personally supervised
and combined their work into a consistent and uniform whole.
Special care has been taken to render the definitions clear, sharp and concise.
Pronunciation has been indicated by a simple phonetic spelling and by accents wherever
necessary. The definitions are given in English, with synonyms in French, German
and Italian of the more important words in English and Latin.
Regarded as a dictionary, therefore, this coming standard supplies the physician,
surgeon and specialist with all information concerning medical words, simple and com-
pound, found in English, giving correct spelling, clear, sharp definitions and proper
pronunciation, and furthermore it enables him to consult foreign works and to understand
the large and increasing number of foreign words used in medical English. It is especi-
ally full in phrases comprising two, three or more words used in special senses in the
various departments of medicine.
The work is, however, far more than a dictionary, and partakes of the nature of an
encyclopædia, as it gives in its body a large amount of valuable therapeutical and chemi-
cal information, and groups in its tables, in a condensed and convenient form, a vast
amount of important data which will be consulted daily by all in active practice.
The completeness of the work is made evident by the fact that it defines 84,844
separate words and phrases.
The type has been most carefully selected for boldness and clearness, and everything
has been done to secure ease and rapidity in use.
Its scope is one which will at once satisfy the
student and meet all the requirements of the med-
ical practitioner. , Clear and comprehensive defi-
nitions of words should form the prime feature of
any dictionary, and in this one the chief aim
seems to be to give the exact signification and the
different meanings of terms in use in medicine
and the collateral sciences in language as terse as
is compatible with lucidity. The utmost brevity
and conciseness have been kept in view. The work
is remarkable, too, for its fulness. The enumera-
tions and subdivisions under each word heading
are strikingly complete, as regards alike the Eng
lish tongue and the languages chiefly employed
by ancient and modern science. It is impossible
to do justice to the dictionary by any casual illus
tº ration. . . It presents to the English reader a
t horoughly scientific mode of acquiring a rich
vocabulary and offers an accurate and ready means
of reference in consulting works in any of the
three modern continental lan *. which are
richest in medical literature. No add to its use-
fulness as a work of reference some valuable
tables are given. Another feature of the work is
the accuracy of its definitions, all of which have
been checked by comparison with many other
standard works in the different languages it deals
with. Apart from the boundless stores of informa:
tion which may be gained by the study of a good
dictionary, one is enabled by the work under notice
to read intelligently any technical treatise in any
of the four chief modern languages. . There can-
not be two opinions as to the great value and use-
fulness of this dictionary as a book of ready refer-
ence for all sorts and conditions of medical men.
So far as we have been able to see, no subject has
been omitted, and in respect of completeness it will
be found distinctly superior to any medical lexigon
yet published.—The London Lancet, April 5, 1890.
LEA BROTHERS & Co.'s PUBLICATIONS-Anatomy.
Lecturer on Anatomy at St. George's Hospital, London.
Anatomy, Descriptive and Surgical. Edited by T. PICKERING PICK,
F. R. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London,
Examiner in Anatomy, Royal College of Surgeons of England. A new American from
the eleventh enlarged and improved London edition, thoroughly revised and re-edited
by WILLIAM W. KEEN, M. D., Professor of Surgery in the Jefferson Medical College of
Philadelphia. To which is added the second American from the latest English edition of
LANDMARKS, MEDICAL AND SURGICAL, by LUTHER Hold EN, F. R. C. S. In one imperial
octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of
edition in black: Cloth, $6; leather, $7; half Russia, $7.50. Price of edition in colors
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This work covers a more extended range of subjects than is customary in the ordinary
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those details to the practice of medicine and surgery. It thus forms both a guide for the
learner and an admirable work of reference for the active practitioner. The engravings
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original, and having the names of the various parts printed on the body of the cut, in
Fº of figures of reference with descriptions at the foot. In this edition a new departure
as been taken by the issue of the work with the arteries, veins and nerves distinguished
by different colors. The engravings thus form a complete and splendid series, which will
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh
the memory of those who may find in the exigencies of practice the necessity of recall-
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy,
the work will be found of great service to all physicians who receive students in their
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a
thorough medical education.
For the convenience of those who prefer not to pay the slight increase in cost necessi-
tated by the use of colors, the volume is published also in black alone, and maintained
in this style at the price of former editions, notwithstanding its largeſy increased size.
Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden,
has been appended to the present edition as it was to the previous one. This work gives
in a clear, condensed and systematic way all the information by which the practitioner can
determine from the external surface of the body the position of internal parts. Thus
complete, the work will furnish all the assistance that can be rendered by type and
illustration in anatomical study.
The most popular work on anatomy ever written.
books. The work is published with black and
It is sufficient to say of it that this edition, thanks
colored plates. It is a marvel of book-making.—
to its American editor, surpasses all other edi-
tions —Jour, of the Amer. Med. Ass'n, Dec. 31, 1887.
A work, which for more than twenty years has
had the lead of all other text-books on anatomy
throughout the civilized world comes to hand in
Such beauty of execution and accuracy of text
and illustration as more than to make good the
large promise of the prospectus. It would be in-
deed difficult to name a feature wherein the pres-
ent American edition of Gray could be mended
or bettered, and it needs no prophet to see that
the royal work is destined for many years to come
to hold the first place among anatomical text-
American Practitioner and News, Jan. 21, 1888.
Gray's Anatomy is the most magnificent work
upon anatomy which has ever been published in
the English or any other language.—Cincinnati
Medical News, Nov. 1887.
As the book now goes to the purchaser he is re-
ceiving the best work on anatomy that is published
in any language.—Virginia Med. Monthly, Dec. 1887.
Gray's standard Anatomy has been and will be
for years the text-book for students. The book
needs only to be examined to be perfectly under-
stood.—Medical Press of Western New York, Jan.
1888.
ALSO FOR SALE SEPARATE–
EIOLDEN, LUTHER, F. R. C. S.,
Surgeon to St. Bartholomew's and the Foundling Hospitals, London.
Landmarks, Medical and Surgical. Second American from the latest revised
English edition, with additions by W. W. KEEN, M. D., Professor of Artistic Anatomy in
the Penn. Academy of Fine Arts.
In one 12mo, volume of 148 pages.
Cloth, $1.00
I) UNGLISON, ROBLEY, M. D.,
Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia.
MEDICAL LEXICON. ; A Dictionary of Medical Science: Containing

a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol-
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris-
rudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal,
mpirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms,
and the French and other Synonymes, so as to constitute a French as well as an English
Medical Lexicon. Edited by RICHARD J. DUNGLISON, M.D. . In one very large and
handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50;
very handsome half Russia, raised bands, $8.
It has the rare merit that it certainly has no rival in the English language for accuracy
and extent of references.—London Medical Gazette,
6 LEA BROTHERS & Co.'s PUBLICATIONS-Anatomy.
A LLEN, HARRISON, M. D.,
Professor of Physiology in the University of Pennsylvania.
A System of Human Anatomy, Including Its Medical and Surgical
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the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380
illustrations on 109 full page lithographic plates, many of which are in colors, and 241
engravings in the text. In six Sections, each in a portfolio. Section I. HISTOLOGY.
Section II. Bon ES AND JoſNTs. Section III. MUSCLES AND FASCIAE. Section IV.
ARTERIES, VEINS AND LYMPHATICS. Section V. NERVous SYSTEM. Section VI.
ORGANS OF SENSE, OF DIGESTION AND GENITO-URINARY ORGANS, EMBRYOLOGY,
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For sale by subscription only.
It is to be considered a study of applied anatomy
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practice of medicine as well as of surgery. Our
author is concise, accurate and practical in his
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ground is travelled over by one thoroughly famil-
iar with it. The illustrations are made with great
Apply to the Publishers.
care, and are simply superb. There is as much
of practical application of anatomical points to
the every-day wants of the medical clinician as
to those of the operating surgeon. In fact, few
; practitioners will read the work without a
eeling of surprised gratification that so many
points, concerning which they may never have
thought before are so well presented for their con-
sideration. It is a work which is destlined to be
the best of its kind in any language.—Medical
Record, Nov. 25, 1882.
CLARKE, W. B., F.R.C.S. de LOCKWOOD, C. B., F.R.C.S.
Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London.
The Dissector’s Manual.
49 illustrations.
Messrs. Clarke and Lockwood have written a book
that can hardly be rivalled as a practical aid to the
dissector. Their purpose, which is “how to de-
scribe the best way to display the anatomical
structure,” has been fully attained. They excel in
a lucidity of demonstration and graphic terseness
of expression, which only a long training and
In one pocket-size 12mo, volume of 396 pages, with
Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 31.
intimate association with students could have
#y. With such a guide as this, accompanied
y so attractive a commentary as Treves' Surgical
#. Anatomy (same series), no student could
fail to be deeply and absorbingly interested in the
study of anatomy.—New Orleans Medical and Sūr-
gical Jowrmal, April, 1884.
TREVES, FREDERICK, F. R. C. S.,
Senior Demonstrator of Anatomy and Assistant Swrgeon at the London Hospital.
Surgical Applied Anatomy. In one pocket-size 12mo, volume of 540 pages,
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals,
page 31. *
He has produced a work which will command a
larger circle of readers than the class for which it
was written. This union of a thorough, practical
acquaintance with these fundamental branches,
uickened by daily use as a teacher and practi.
#. has enabled our author to prepare a Work
which it would be a most difficult tas
The American Practitioner, Feb. 1884.
to excel.—
This number of the “Manuals for Students” is
most excellent, giving just such practical knowl-
edge as will be required for application in relieving
the injuries to which the living body is liable,
The book is intended mainly for students, but it
will also be of great use to practitioners. The illus-
trations are well executed and fully elucidate the
text.—Southern Practitioner, Feb. 1884.
BELLA MY, ED WAR D, F. R. C. S.,
Senior Assistant-Surgeon to the Charing-Cross Hospital, London.
The Student’s Guide to Surgical Anatomy: Being a Description of the
most Important Surgical Regions of the Human Body, and intended as an Introduction to
operative Surgery. In one 12mo, volume of 300 pages, with 50 illustrations. Cloth, $2.25.
WILSON, ERASMUS, F. R. S.
A System of Human Anatomy, General and Special. Edited by W. H.
GoBRECHT, M.D., Professor of General and Surgical Anatomy in the Medical College of
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations.
Cloth, $4.00; leather, $5.00.
CLELAND, JOHN, M. D., F. R. S.,
Professor of Anatomy and Physiology in Queen's College, Galway.
A Directory for the Dissection of the Human Body.
volume of 178 pages. Cloth, $1.25.
In one 12mo,
HARTSHORNE'S HANDBOOK OF ANATOMY
AND PHYSIOLOGY. Second edition, revised.
In one royal 12mo, volume of 310 pages, with 220
woodcuts. Cloth, $1.75.
HORNER's SPECIAL ANATOMY AND HISTOL:
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LEA BROTHERS & Co. S PUBLICATIONS-Physics, Physiol., Anat. 7
D R A PER, JOHN C., M. D., L.L. D.,
Professor of Chemistry in the University of the City of New York.
Medical Physics. A Text-book for Students and Practitioners of Medicine. In
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4.
FROM THE PREFACE.
The fact that a knowledge of Physics is indispensable to a thorough understanding of
Medicine has not been as fully realized in this country as in Europe, where the admirable
works of Desplats and Gariel, of Robertson and of numerous German writers constitute a
branch of educational literature to which we can show no parallel. A full appreciation
of this the author trusts will be sufficient justification for placing in book form the sub-
stance of his lectures on this department of science, delivered during many years at the
University of the City of New York.
Broadly speaking, this work aims to impart a knowledge of the relations existing
between Physics and Medicine in their latest state of development, and to embody in the
pursuit of this object whatever experience the author has gained during a long period of
teaching this special branch of applied science.
This elegant and useful work bears ample testi-
mony to the learning and good judgment of the
author. He has fitted his work admirably to the
exigencies of the situation by presenting the
reader with brief, clear and simple statements of
such propositions as he is by necessity required to
master. The subject matter is well º
liberally illustrated and carefully indexed. Tha
it will take rank at once among the text-books is
certain, and it is to be hoped that it will find a
place upon the shelf of the practical physician
where, as a book of reference, it will be foun
useful and agreeable.—Louisville Medical News,
September 26, 1885.
ertainly we have no text-book as full as the ex-
cellent one he has prepared. It begins with a
statement of the properties of matter and energy.
After these the special departments of physics are
explaimed, acoustics, optics, heat, electricity and
magnetism, closing with a section on electro-
bioſogy. The applications of all these to physiolo
and medicine are kept constantly in view. The
text is amply illustrated and the many difficult
points of the subject are brought forward with re-
markable clearness and ability.—Medical and Surg-
ical Reporter, July 18, 1885.
That this work will greatly facilitate the study
of medical physics is apparent upon even a mere
cursory examination. It is marked by that scien-
tific accuracy which always characterizes Dr.
Draper's writings. Its peculiar value lies in the
fact that it is written from the standpoint of the
medical man. Hence much is omitted that ap-
pears in a mere treatise on physical science, while
much is inserted ofº. value to the physi-
cian.—Medical Record, August 22, 1885.
ROBERTSON, J. McG REGOR, M. A., M. B.,
Muirhead Demonstrator of Physiology, University of Glasgow.
Physiological Physics.
In one 12mo. volume of 537 pages, with 219 illustra-
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 31.
The title of this work sufficiently explains the ments.
nature of its contents. It is designed as a man-
ual for the student of medicine, an auxiliary to
his text-book in physiology, and it would be particu-
larly useful as a guide to his laboratory experi-
It will be found of great value to the
practitioner. It is a carefully prepared book of
reference, concise and accurate, and as such we
heartily recommend it.—Journal of the American
Medical Association, Dec. 6, 1884.
DALTON, JOHN C., M. D.,
Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York.
Doctrines of the Circulation of the Blood. A History of Physiological
Opinion and Discovery in regard to the Circulation of the Blood.
12mo. volume of 293 pages. Cloth, $2.
Dr. Dalton’s work is the fruit of the deep research
of a cultured mind, and to the busy practitioner it
cannot fail to be a source of instruction. It will
inspire him with a feeling of gratitude and admir-
ation for those plodding workers of olden times,
In one handsome
revolutionized the theories of teachers, than the
discovery of the circulation of the blood. This
explains the extraordinary interest it has to all
medical historians. The volume before us is one
of three or four which have been written within a
who laid the foundation of the magnificent templé few years by American physicians. It is in several
of medical science as it now stands.--New Orleans
Medical and Surgical Journal, Aug. 1885.
In the progress of physiological study no fact
was of greater moment, none more completely
º: the most complete. The volume, though
ST(18,
tributions from an American pen to medical history
that has appeared.—Med. &
in size, is one of the most creditable con-
urg. Rep., Dec. 6, 1884.
B.E.L.L., F. JEFFE EY, M. A.,
Professor of Comparative Anatomy at King's College, London.
Comparative Physiology and Anatomy. In one 12mo, volume of 561 pages,
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 31.
The manual is prečminently a student's book—
clear and simple in language and arrangement.
It is well and abundantly illustrated, and is read-
able and interesting. On the whole we consider
it the best work in existence in the English
language to place in the hands of the medical
student.—Bristol Medico-Chirurgical Jowrnal, Mar.
1886.
ELLIS, GEORGE VINER,
Emeritus Professor of Anatomy in University College, London.
Demonstrations of Anatomy. Being a Guide to the Knowledge of the
Human Body by Dissection. From the eighth and revised London edition. In one very
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25; leather, $5.25.
ROBERTS, JOHN B., A. M., M. D., *
Prof. of Applied Anat, and Oper. Swrg. in Phila. Polyclinic and Coll. or Graduates in Medicine.
The Compend of Anatomy. For use in the dissecting-room and in preparing
In one 16mo, volume of 196 pages.
for examinations.
Limp cloth, 75 cents.
8
LEA BROTHERS & Co.'s PUBLICATIONS-Physiology, Chemistry.
CHAPMAN, HENRY C., M. D.,
Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia,
A Treatise on Human Physiology.
Cloth, $5.50; leather, $6.50.
925 pages, with 605 fine engravings.
It represents very fully the existing state of
Fº The present work has a special value
the student and practitioner as devoted more
to the practical application of well-known truths
which the advance of science has given to the
profession in this department, which may be con-
sidered the foundation of rational medicine.—Buf-
falo Medical and Surgical Journal, Dec. 1887.
Matters which have a practical bearing on the
practice of medicine are lucidly expressed; tech-
nical matters are given in minute detail; elabo-
rate directions are stated for the guidance of stu-
dents in the laboratory. In every respect the
work fulfils its promise, whether as a complete
treatise for the student or for the physician; for
the former it is so complete that he need look no
In one handsome octavo volume of
farther, and the latter will find entertainment and
instruction in an admirable book of reference,—
North Carolina Medical Journal, Nov. 1887.
The work certainly commends itself to both
student and practitioner. What is most demanded
by the progressive physician of to-day is an adap-
tation of physiology to practical therapeutics, and
this work is a decided improvement in this respect
over other works in the market. . It will certainly
take place among the most valuable text-books.-
Medical Age, Nov. 25, 1887.
It is the production of an author delighted with
his work, and able to inspire students with an en-
thusiasm akim to his own.—American Practitioner
and News, Nov. 12, 1887.
DALTON, JOHN C., M. D.,
Professor of Physiology in the College of Physicians and Surgeons, New York, etc.
A Treatise on Human Physiology. Designed for the use of Students and
Practitioners of Medicine.
Seventh edition, thoroughly revised and rewritten.
In one
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth,
$5.00; leather, $6.00.
From the first appearance of the book it has
been a favorite, owing as well to the author's
renown as an oral teacher as to the charm of
simplicity with which, as a writer, he always
succeeds in º: even intricate subjects.
It must be gratifying to him to observe the fre-
quency with which his work, written for students
and practitioners, is quoted by other writers on
physiology. This fact attests its value, and, in
great measure, its originality. It now needs no
such seal of approbation, however, for the thou-
sands who have studied it in its various editions
have never been in any doubt as to its sterling
worth.-N. Y. Medical Journal, Oct. 1882.
Professor Dalton's well-known and deservedly-
appreciated work has long passed the stage at
which it could be reviewed in the ordinary sense.
The work is eminently one for the medical prac-
titioner, since it treats most fully of those branches
of physiology which have a direct bearing on the
diagnosis and treatment of disease. The work is
one which we can highly recommend to all our
readers.--Dublin Journal of Medical Science, Feb.'83.
FOSTER, MICHAEL, M. D., F. R. S.,
Prelector in Physiology and Fellow of Trinity College, Cambridge, England.
Text-Book of Physiology. New (fourth), and enlarged American from the
fifth and revised English edition, with notes and additions,
Preparing.
A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED.
It is delightful to meet a book which deserves
only unqualified praise. Such a book is now before
us. It is in all respects an ideal text-book. With a
complete, accurate and detailed knowledge of his
subject, the author has succeeded in giving a
thoroughly consecutive and philosophic account
of the science. A student's attention is kept
throughout fixed on the great and salient ques-
tions, and his energies are mot frittered away and
degenerated on petty and trivial details. Review-
ing this volume as a whole we are Justified in Say-
ing that it is the only tºº. good text-book
of physiology in the English language, and that it
is probably the best text-book in any language.
—Edinburgh Medical Journal, December 1889.
POWER, HENRY, M. B., F. R. C. S.,
Eacaminer in Physiology, Royal College of Surgeons of England.
Human Physiology. Second edition. In one handsome pocket-size 12mo, Vol-
ume of 396 pp., with 47 illustrations. Cloth,
$1.50. See Students' Series of Manuals, p. 31.
SIMON, W., Ph. D., M. D.,
Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and
Professor of Chemistry whithe Maryland College of Pharmacy.
Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine.
New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates
illustrating 56 of the most important chemical tests.
In this book the author has endeavored to meet
the wants of the student of medicine or pharmacy
in regard to his chemical studies, and he has suc-
ceeded in presenting his subject so clearly that no
one who really wishes to acquire a fair knowledge
of chemistry can fail to do so with the help of this
work. The largest section of the book is naturally
that devoted to the consideration of the carbon
compounds, or organic chemistry. An excellent
Cloth, $3.25.
feature is the introduction of a number of plates
showing the various colors of the most important
chemical reactions of the metallic salts, of Some
of the alkaloids, and of the urinary tests. In the
part treating of Fº chemistry the section
on analysis of the urine will be found very, practiº
cal, and well suited to the needs of the practitioner
of medicine.—The Medical Record, May 25, 1889.
Wöhler's Outlines of Organic Chemistry. Edited by FITTIG. Translated
by IRA REMSEN, M.D., Ph
. D. In one 12mo, volume of 550 pages.
Cloth, $3.
LEHMANN'S MANUAL OF CHEMICAL PHYS- |CARPENTER'SPRIZE ESSAY ON THE USE AND .
IOLOGY. In one octavo volume of 327 pages,
with 41 illustrations. Cloth, $2.25.
CARPENTER'S HUMAN PHYSIOLOGY. Edited
by HENRY PowRR. In one octavo volume.
ABUSE of ALCOHOLIC LIQUORS IN HEALTH AND Dis-
EASE. With explanations of scientific words. Small
12mo. 178 pages. Cloth, 60 cents.
LEA BROTHERS & Co.'s PUBLICATIONS—Chemistry.
9
FRANKLAND, E., D. C. L., F. R.S., & JAPP, F. R., F.I. C.,
Professor of Chemistry in the Normal School
of Science, London.
Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51
woodcuts and 2 plates.
This work should supersede other works of its
class in the medical colleges. It is certainly better
adapted than any work upon chemistry, with which
we are acquainted, to impart that clear and full
knowledge of the science which students of med-
icine should have. Physicians who feel that their
chemical knowledge is behind the times, would
do well to devote some of their leisure time to the
study of this work. The descriptions and demon-
strations are made so plain that there is no diffi-
culty in understanding them.—Cincinnati Medical
New8, January, 1886.
Cloth, $3.75; leather, $4.75.
FOWNES, GEORGE, Ph. D.
A Manual of Elementary Chemistry;
bodying WATTS' Physical Inorganic Chemistry. New American, from the twelfth English
edition. In one large royal 12mo, volume of 1061 pages, with 168 illustrations on wood
and a colored plate.
Fownes' Chemistry has been a standard text-
book upon chemistry for many years. Its merits
3ré ". fully known by chemists and physicians
everywhere in this country and in England. As
the science has advanced by the making of new
discoveries, the work has been revised so as to
keep it abreast of the times. . . It has steadily
maintained its position as a text-book with medi-
cal students. In this work are treated fully: Heat,
Light and Electricity, includin É Magnetism. The
influence exerted by these forces in chemical
action upon health and disease, etc., is of the most
important kind, and should be familiar to every
medical practitioner. We can commend the
work as one of the very best text-books upon
Cloth, $2.75; leather,
ATTFIELD, JOHN, Ph. D.,
Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc.
Chemistry, General, Medical and Pharmaceutical; Including the Chem-
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science,
and their Application to Medicine and Pharmacy. A new American, from the twelfth
English edition, specially revised by the Author for America. In one handsome royal
12mo, volume of 782 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. Just ready.
Attfield’s Chemistry is the most popular book
among students of medicine and phal macy. This
popularity has a good, substantial basis. It rests
upon real merits. Attfield's work combines in the
happiest manner a clear exposition of the theory
of chemistry with the practical application of this
knowledge to the everyday dealings of the phy-
sician and pharmacist. His discernment is shown
not only in what he puts into his work, but also in
what he leaves out. His book is precisely what
the title claims for it. The admirable arrangement
of the text enables a reader to get a good idea of
chemistry without the aid of experiments, and
BLOXAM, CHARLES L.,
Professor of Chemistry in King's College, London.
Chemistry, Inorganic and Organic.
don edition, thoroughly revised and much improved. In one very handsome octavo
volume of 727 pages, with 292 illustrations.
Comment from us on this standard work is al-
most superfluous. It differs widely in scope and
aim from that of Attfield, and in its way is equally
beyond criticism. It adopts the most direct meth-
ods in stating the principles, hypotheses and facts
of the science. Its º is so terse and lucid,
and its arrangement of matter so logical in se-
quence that the student never has occasion to
complaim that chemistry is a hard study. . Much
attention is paid to experimental illustrations of
chemical principles and phenomena, and the
mode of conducting these experiments. The book
maintains the position it has always held as one of
Cloth, $2.00; leather, $3.00.
GREENE, WILLIAM H., M. D.,
Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania.
A Manual of Medical Chemistry. For the use of Students. Based upon Bow-
man's Medical Chemistry. In one 12mo, volume of 310 pages, with 74 illus. Cloth, $1.75.
Assist. Prof. of Chemistry in the Normal
School of Science, London.
This excellent treatise will not fail to take its
place as one of the very best on the subject of
which it treats. We have been much pleased
with the comprehensive and lucid manner in
which the difficulties of chemical notation and
momenclature have been cleared up by the writers.
It shows on every page that, the problem of
rendering the obscurities of this science easy
of comprehension has long and successfully
engaged the attention of the authors.-Medical
Q, urgical Reporter, October 31, 1885.
Theoretical and Practical. Em-
$3.25.
chemistry extant.—Cincinnati Medical News, Oc-
tober, 1885. -
Of all the works on chemistry intended for the
use of medical students, Fownes' Chemistry is
E.;; the most widely used. Its Pºłº, is
ased upon its excellence. This last edition con-
tains all of the material found in the Preyjºis;
and it is also enriched by the addition of Watts
Physical and Inorganic Chemistry. All of the mat-
ter is brought to the present standpoint of chemi-
cal knowledge. We may safely predict for this
work a continuance of the fame and favor it enjoys
among medical students.-New Orleans Medical
and Surgical Journal, March, 1886.
again it is a good laboratory guide, and finally it
contains such a mass of well-arranged information
that it will always serve as a handy book of refer-
ence. He does not allow any unutilizable knowl-
edge to slip into his book; his long years of
experience have produced a work which is both
scientific and practical, and which shuts out
everything in the nature of a superfluity, and
therein lies the secret of its success. This last,
edition shows the marks of the latest progress
made in chemistry and chemical teaching.—New
Orleans Medical and Surgical Journal, Nov. 1889.
New American from the fifth Lon-
the best manuals of general chemistry in the Eng-
lish language.—Detroit Lancet, Feb. 1884,
We know of no treatise on chemistry which
contains so much practical information in the
same number of pages. The book can be readily
adapted not only to the needs of those who desire
a tolerably º: course of chemistry, but also
to the needs of those who desire only a general
knowledge of the subject. . We take pleasure in
recommending this work both as a satisfactory
text-book, and as a useful book of reference.—Bos-
ton Medical and Swrgical Journal, June 19, 1884.
It is a concise manual of three hundred pages,
giving an excellent summary of the best methods
the recognition of compounds due to pathological
conditions. The detection of poisons is treated
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of the stu-
for the estimation of their normal constituent and
dent or practitioner.—Boston Jl. of Chem. June,’80.
10
LEA BROTHERS & Co.'s PUBLICATIONs—Chemistry.
IEEMSEN, IRA, M. D., Ph. D.,
Professor of Chemistry in the Johns Hopkins University, Baltimore.
Principles of Theoretical Chemistry, with special reference to the Constitu-
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand-
Some royal 12mo, volume of 316 pages.
This work of Dr. Remsen is the very text-book
needed, and the medical student who has it at
his fingers' ends, so to speak, can, if he chooses,
make himself familiar with any branch of chem-
istry which he may desire to pursue. It would be
difficult indeed to find a more lucid, full, and at
the same time compact explication of the philos-
ophy of chemistry, than the book before us, and
we recommend it to the careful and impartial
Cloth, $2.00
examination of college faculties as the text-book of
chemical instruction.—St. Lowis Medical and Sur-
gical Journal, January, 1888.
It is a healthful sign when we see a demand for
a third edition of such a book as this. This edi-
tion is larger than the last by about seventy-five
ages, and much of it has been rewritten, thus
ringing it fully abreast of the latest investiga-
tions.—N. Y. Medical Jowrmal, Dec. 31, 1887.
CHARLES, T. CRANSTOUN, M. D., F. C. S., M. S.,
Formerly Asst. Prof. and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast.
The Elements of Physiological and Pathological Chemistry. A
Handbook for Medical Students and Practitioners.
Containing a general account of
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and
Excretions of the Body in Health and in Disease. Together with the methods for pre-
paring or separating their chief constituents, as also for their examination in detail, and
an outline syllabus of a practical course of instruction for students. In one handsome octavo
volume of 463 pages, with 38 woodcuts and 1
Dr. Charles is fully º With the import-
ance and practical reach of his subject, and he
has treated it in a competent and instructive man-
ner. We cannot recommend a better book than
the present. In fact, it fills a gap in medical text-
books, and that is a thing which can rarely be said
colored plate. Cloth, $3.50.
nowadays. , Dr. Charles, has devoted much space
to the elucidation of urinary mysteries. He does
this with much detail, and yet in a practical and
intelligible manner. In fact, the author has filled
his book with many practical hints.-Medical Rec-
ord, December 20, 1884.
HOFFMA NN, F., A.M., Ph.D., & POWER F.B., Ph.D.,
Public Analyst to the State of New York.
Prof. of Anal. Chem. in the Phil. Coll. of Pharmacy.
A Manual of Chemical Analysis, as applied to the Examination of Medicinal
Chemicals and their Preparations. Being a Guide for the Determination of their Identity
and Quality, and for the Detection of Impurities and Adulterations.
For the use of
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and
Medical Students.
Third edition, entirely rewritten and much enlarged.
In one very
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25.
We congratulate the author on the appearance
of the third edition of this work, published for the
first time in this country also. It is admirable and
the information it undertakes to i. is both
extensive and trustworthy. The selection of pro-
cesses for determining the purity of the substan-
ces of which it treats is excellent and the descrip-
tion of them singularly explicit. Moreover, it is
exceptionally free from typographical errors. We
have no hesitation in recommending it to those
who are engaged either in the manufacture or the
testing of medicinal chemicals.-London Pharma-
cewtical Journal and Transactions, 1883.
CLOWES, FRA NEC, D. Sc., London,
Senior Science-Master at the High School, Newcastle-under-Lyme, etc.
An Elementary Treatise on Practical Chemistry and Qualitative
Inorganic Analysis.
Colleges and by Beginners.
In one very handsome royal 12mo, volume
$2.50.
This work has long been a favorite with labora-
tory instructors on account of its systematic plan,
carrying the student step by step from the simplest
º of chemical analysis, to the more recon-
ite problems. Features quite as commendable
are the regularity and system demanded of the
Specially adapted for use in the Laboratories of Schools and
Third American from the fourth and revised English edition.
of 387 pages, with 55 illustrations. Cloth,
student in the performance of each analysis,
These characteristics are preserved in the present
edition, which we can heartily recommend as a sat-
isfactory guide for the student of inorganic chem-
ical analysis.--New York Medical Journal, Oct. 9,
1886
RAL FE, CHARLES H., M.
Assistant Physician at the London Hospital.
D., F. R. C. P.,
Clinical Chemistry. In one pocket-size 12mo, volume of 314 pages, with 16
illustrations. Limp cloth, red edges, $1.50.
This is one of the most instructive little works
that we have met with in a long time. The author
is a physician and Fº as well as a chem-
ist, consequently the book is unqualifiedly prac-
tical, telling the #..." just what he ought to
know, of the applications of chemistry in medi-
See Students' Series of Manuals, page 31.
cine. Dr. Ralfe is thoroughly acquainted with the
latest contributions to his science, and it is quite
refreshing to find the subject dealt with so clearly
and simply, yet in such evident harmony with the
modern scientific methods and spirit.—Medical
Record, February 2, 1884.
CLASSEN, ALEXANDER,
Professor in the Royal Polytechnic School, Aia:-la-Chapelle.
Elementary Quantitative Analysis. Translated, with notes and additions, by
EDGAR F. SMITH, Ph.D., Assistant Professor
TJniversity of Penna.
In one 12mo, volume of 324 pages, with 36 illus.
of Chemistry in the Towne Scientific School,
Cloth, $2.00.
It is probably the best manual of an elementary and then advancing to the analysis of minerals and
nature extant, insomuch as its methods are the such products as are met with in applied chemis-
best. It teaches by examples, commencing with try. It is an indispensable book for students in
single determinations, followed by separations,
f
chemistry.—Boston Journal of Chemistry, Oct. 1878.
LEA BROTHERs & Co.'s PUBLICATIONS-Pharm., Mat. Med., Therap. 11
BRUNTON, T. LAUDER, M.D., D.Sc., F.R.S., F.R.C.P.,
Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc.
A Text-book of Pharmacology, Therapeutics and Materia Medica;
Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs.
Third edition.
No words of praise are needed for this work, for
it has already spoken for itself in former editions.
It was by unanimous consent placed among the
foremost books on the subject ever published in
any language, and the better it is known and studied
the more highly it is appreciated. The present
edition contains much new matter, the insertion
of which has been necessitated by the advances
made in various directions in the art of therapeu-
tics, and it now stands unrivalled in its thoroughly
scientific presentation of the modes of drug action.
No one who wishes to be fully up to the times in
this science can afford to neglect the study of Dr.
Brunton’s work. The indexes are excellent, and
add not a little to the practical value of the book.
—Medical Record, May 25, 1889.
Nothing so original andso complete on the action
of drugs on the body generally and on its various
Octavo, 1305 pages, 230 illustrations.
Cloth, $5.50; leather, $6.50.
parts, has appeared during the life of the present
generation. This is strong language, but it is the
truth. The great merit of this work is that the
author has been able so well to coordinate facts
into an intelligible and rational system of pharma-
cology, and henceforth no treatise on therapeutics
will be considered complete which does not in
some measure adopt this method. The busy
physician will approach this book to learn some-
thing that will better fit him for his work, and on
every page he will find something that will reward
him for the time spent in its perusal. We com-
mend this book as one which every physician
should own and study. It is a work which if once
owned will be likely to be read and consulted till
the covers fall off from much use.—Boston Medical
and Surgical Journal, Dec. 20, 1888.
FIA RE, HOBART AMORY, B. Sc., M. D.,
Demonstrator of Therapeutics and Clinical Professor of Diseases of Children in the University of
Pennsylvania ; Secretary of the Convention for the Revision of the United States Pharmacopoeia of
1890.
A Text-Book of Practical Therapeutics; With Especial Reference to the
Application of Remedial Measures to Disease and their Employment upon a Rational
Basis.
With special chapters by DRs. G. E. DE SCHWEINITz, EDWARD MARTIN,
J. HowARD REEVES and BARTON. C. HIRST. In one handsome octavo volume of about
700 pages. Shortly.
The publishers take great pleasure in announcing the early appearance of a new work
on Therapeutics, planned on lines which will secure for it a leading position as a text-book
and work of reference.
The author's large experience in experimental, didactic and
clinical work, has peculiarly fitted him to produce a volume containing all that is latest
and best in the application of remedial measures, and to present this material in a way
which will not only impress it into the mind of the student firmly, because rationally,
but which will also render it of daily service to practitioners by reason of its definite
instructions as to the choice of various agents which may be employed.
MA. ISC H., JOHN M., Phar. D.,
Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
A Manual of Organic Materia Medica; Being a Guide to Materia Medica of
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists
and Physicians. New (4th) edition, thoroughly revised. In one handsome royal 12mo.
volume of 529 pages, with 258 illustrations.
For everyone interested in materia medica,
Maisch's Manual, first published in 1882, and now
in its fourth edition, is an indis ensable book.
For the American pharmaceutical student it is
the work which will give him the necessary knowl-
edge in the easiest way, #. because the text is
brief, concise, and free from unnecessary matter,
Cloth, $3. Just ready.
fore his eyes. That it answers its purposes in this
jº the rapid succession of editions is the best
evidence. It is the favorite book of the American
student even outside of Maisch’s several hundred
personal students. The arrangement of its con-
tents shows the practical tendency of the book.
Maisch's system of classification is easy and com-
and partly because of the numerous illustrations,
which bring facts worth knowing immediately be:
PARE IS H., ED WA R D,
Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy.
. A Treatise on Pharmacy: designed as a Text-book for the Student, and as a
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions.
Fifth edition, thoroughly revised, by THOMAS S. WIEGAND, Ph. G. In one handsome
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5; leather, $6.
No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to
himself of so useful a guide to practice, and no leave this work out of the list of their works Of
physician who properly estimates the value of an reference. The country practitioner, who must
accurate knowledge of the remedial agents em- always be in a measure his own pharmacist, will
ployed by him in daily practice, so far as their find it indispensable.—Louisville Medical News,
miscibility, compatibility and most effective meth- March 29, 1884.
HERMANN, Dr. L.,
Professor of Physiology in the University of Zurich. *
Experimental Pharmacology. A Handbook of Methods for Determining the
Physiological. Actions of Drugs. Translated, with the Author's permission, and with
extensive additions, by RoBERT MEADE SMITH, M. D., Demonstrator of Physiólogy in the
University of Pennsylvania. 12mo, 199 pages, with 32 illustrations. Cloth, $1.50.
STILLE, A LIFRED, M. D., L.L. D.,
Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
Therapeutics and Materia Medica. A Systematic Treatise on the Action and
Uses of Medicinal Agents, including their Description and History. Fourth edition,
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages.
Cloth, $10,00; leather, $12.00.
prehensive.—Pharmaceutische Zeitung, Germany,
1890.
12 LEA BROTHERS & Co.'s PUBLICATIONS—Mat. Med., Therap.
STILLE, A., M.D., L.L. D., & MAISCH, J. M., Phar. D.,
Prof. of Mat. Med, and Botany in Phila.
College of ...} Sec'y to the Ameri-
can Pharmaceutical Association.
Professor Emeritus of the Theory and Prac-
tice of Medicine and of Clinical Medicine
in the University of Pennsylvania.
The National Dispensatory.
CONTAINING THE MATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF
MED/CIMES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPGE/AS OF THE
UNITED STATES, GREAT BRITAIN AND GERMANY, WITH MUMEROUS
REFERENCES TO THE FREWCH CODEX.
Fourth edition revised, and covering the new British Pharmacopoeia. In one mag-
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings, Price
in cloth, $7.25; leather, raised bands, $8.00. *x*This work will be furnished with Patent
Ready Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding.
In this new edition of THE NATIONAL DISPENSATORY, ºf important changes in the
recent British Pharmacopoeia have been incorporated throughout the volume, while in
the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical
novelties which have been established in professional favor since the publication of the
third edition two years ago. Since its first publication, THE NATIONAL DISPENSATORY
has been the most accurate work of its kind, and in this edition, as always before, it may
be said to be the representative of the most recent state of American, English, German
and French Fº Therapeutics and Materia Medica.
It is with much pleasure that the fourth edition
of this magnificent work is received. The authors
and publishers have reason to feel proud of this,
the most comprehensive, elaborate and accurate
work of the kind ever printed in this country. It
is no wonder that it has become the standard au-
thority for both the medical and pharmaceutical
profession, and that four editions have been re-
uired to supply the constant and increasing
iºd since its first appearance in 1879. The
entire field has been gone over and the various
articles revised in accordance with the latest
developments º: g the attributes and thera-
peutical action of drugs. The remedies of recent
discovery have received due attention.—Kansas
oº: Medical Index, Nov. 1887.
e think it a matter for congratulation that the
profession of medicine and that of pharmacy have
shown such appreciation of this great work as to call
for four editions within the comparatively brief
period of eight years. The matters with which it
deals are of so practical a nature that neither the
hysician nor the pharmacist can do without the
atest text-books on them, especially those that are
so accurate and comprehensive as this one. The
book is in ‘. way creditable both to the authors
and to the publishers.--New York Medical Journal,
May 21, 1887.
IFA RQUEIA RSON, ROBERT, M. D., F. R. C. P., L.L. D.,
Lecturer on Materia Medica at St. Mary's Hospital Medical School, London.
A Guide to Therapeutics and Materia Medica.
Enlarged and adapted to the U. S. Pharmacopoeia. By
from the fourth English edition.
New (fourth) American,
FRANK WooDBURY, M. D., Professor of Materia Medica and Therapeutics and Clinical
Medicine in the Medico-Chirurgical College of Philadelphia.
volume of 581 pages. Cloth, $2.50.
It may correctly be regarded as the most modern
work of its kind. It is concise, yet complete.
Containing an account of all remedies that have
a place in the British and United States Pharma-
copoeias, as well as considering all non-official but
important new drugs, it becomes in fact a miniature
dispensatory.—Pacific Medical Journal, June, 1889.
An especially attractive feature is an arrange-
ment by which the physiological and therapeutical
In one handsome 12mo,
actions of various remedies are shown in parallel
columns. This aids greatly in fixing attention and
facilitates study. The American editor has en-
larged the work so as to make it include all the
remedies and preparations in the U. S. Pharma-
copoeia. The book is a most valuable addition to
the list of treatises on this most important subject.
—American Practitioner and News, Nov. 9th, 1889.
IEDES, ROBERT T., M. D.,
Jackson Professor of Clinical Medicine in Harvard University, Medical Department.
A Text-Book of Therapeutics and Materia Medica.
Octavo,
TJse of Students and Practitioners,
The present work seems destined to take a prom-
inent place as a text-book on the Subjects of which
it treats. It possesses all the essentials which we
expect in a book of its kind, such as conciseness,
clearness, a judicious classification, and a reason-
able degree of dogmatism. All the newest drugs
of promise are treated of. The clinical index at
the end will be found very useful. We heartily
Intended for the
544 pages. Cloth, $3.50; leather, $4.50.
commend the book and congratulate the author
on having produced so good a one.—N. Y. Medical
Jowº mal, Feb. 18, 1888.
Dr. Edes' book represents better than any older
book the practical therapeutics of the present
day. The book is a thoroughly practical one. The
classification of remedies has reference to their
therapeutic action.— Pharmaceutical Era, Jam. 1888.
B EUCE, J. MITCHELL, M. D., F. R. C. P.,
Physician and Lecturer on Materwa Medica and Therapeutics qt Charing Cross Hospital, London.
Materia Medica and Therapeutics.
An Introduction to Rational Treatment.
Fourth edition. 12mo, 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 31.
GRIFFITH, ROBERT EGLESFIELD, M. D.
A Universal Formulary, containing the Methods of Preparing and Adminis-
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut-
ists. Third edition, thoroughly revised, with numerous additions, by JoHN M. MAISCH,
Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
In one octavo volume of 775 pages, with 38 illustrations, Cloth, $4.50; leather, $5.50.
LEA BROTHERs & Co.'s PUBLICATIons—Pathol. , Histol.
13
GREEN, T. HENRY, M. D.,
Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London.
Pathology and Morbid Anatomy.
Phwith 167 engravings. Cloth, $2.75.
O r
revised English edition. Octavo, 539
The º and Morbid Anatomy -
Green is too well known by members of the medi-
cal profession to need any commendation. There
is scarcely an intelligent º anywhere who
has not the work in his library, for it is almost an
essential. In fact it is better adapted to the wants
of general practitioners than any work cf the kind
with which we are acquainted. The works of
German authors upon pathology, which have been
New (sixth) American from the seventh
Just ready.
translated into English, are too abstruse for the
physician. Dr. Green’s work precisely meets his
wishes. The cuts exhibit the appearances of
pathological structures just as they are seen
through the microscope. The fact that it is so
generally employed as a text-book by medical stu-
dents is evidence that we have not spoken too
much in its favor.—Cincinnati Medical New8, Oct.
1889.
PAYNE, JOSEPH F., M. D., F. R. C. P.,
Senior Assistant Physician and Lecture, on Pathological Anatomy, St. Thomas' Hospital, London.
A Manual of General Pathology. Designed as an Introduction to the Prac-
tice of Medicine.
Knowing, as a teacher and examiner, the exact
needs of medical students, the author has in the
work before us prepared for their especial use
Octavo of 524 pages, with 152 illus. and a colored plate.
Cloth, $3.50.
cal factors in those diseases now with reasonable
certainty ascribed to pathogenetic microbes. In
this department he has been very full and explicit,
not only in a descriptive manner, but in the tech-
nique of investigation. The Appendix, giving
amined. ... A departure which our author has methods of research, is alone worth the price of the
taken is the greater attention paid to the causa- book, several times over, to every student of,
tion of disease, and more especially to the etiologi- pathology.—St. Louis Med. and Surg. Jowr., Jan.’89.
SENN, NICHOLAS, M.D., Ph.D.,
Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago.
Surgical Bacteriology. In one handsome octavo of 259 pages, with 13 plates,.
of which 9 are colored. Cloth, $1.75.
COATS, JOSEPH, M. D., F. F. P. S.,
Pathologist to the Glasgow Western Infirmary.
... A Treatise on Pathology. In one very handsome octavo volume of 829 pages, -
with 339 beautiful illustrations. Cloth, $5.50; leather, $6.50.
Medical students, as well as physicians, who manner, the changes from a normal tº º
desire a work for study or reference, that 'treats effected' in †: by disease, and º:
the subjects in the various departments in a very the characteristics of various morbid’ agencies
thorough manner. but without prolixity, will cer- so that they can be easily recognized. §ut, not
tainly give this one the preference to any with limited to morbid anatomy, it explains fully how
which we are acquainted. It sets forth the most the functions of organs are disturbed by abnormal
recent discoveries, exhibits, in an interesting conditions.—Cincinnati Medical News, Oct. 1883.
WOOD HEAD, G. SIMS, M. D., F. R. C. P. E.,
Demonstrator of Pathology in the University of Edinburgh.
... , Practical Pathology. A Manual for Students and Practitioners. In one beau-
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00.
It forms a real,guide for the student and practi- themselves with this manual. The numerous
tioner who is thoroughly in earnest in his en- | drawings are not fancied pictures, or merely
§eavor to see for himself and do for himself. To schematic diagrams, but they represent faithfully
the laboratory student, it will be a helpful.com- the actual images seen under the microscope.
#. and all those who may wish to familiarize | The author merits all praise for having produced
hemselves with modern methods of examining | a valuable work.-Medical Record, May 31, 1884.
morbid tissues are strongly urged to provide 3.
IF. R. S.,
SCHAFER, EDWARD A.,
Jodrell Professor of Physiology in University College, London.
The Essentials of Histology. In one octavo volume of 246 pages, wi
º e º with
281 illustrations. Cloth, $2.25. pag
This admirable work was greatly needed. It |cially adapted for laboratory work, at th
has been written, with the object of supplying time it * intended to º 8S in ºne:
the student with directions for the microscopical | text-book of histology, comprising all the essen-
examination of the tissues, which are given in a tial facts of the je.*}. Physician and Sur-
clear and understandable way. Although espe- |geon, July, 1887.
ICLEIN, E., M. D., F. R. S.,
jºint Lecturer on Général 4"at, and Phys. in the Med. School of St. Bartholomew's Hosp., London.
..., Elements of Histology. Fourth edition. In one 12mo, volume of 376 pages,
with 194 illus. Limp cloth, $1.75. See Students' Series of Manuals, page 31.
Çonsidered With regard to its, contents, it can index affords a ready reference to the histology of
only be looked on as a large and comprehensive every tissue and organ, and presents, at the same
volume. . New and original illustrations have been time, a complete glossary of the scientific terms.
added, with the help of which the structure of each Provincial Medical Journal, May 1, 1889.
tissue becomes clear to the reader. A copious º
PEPPER, A. J., M. B., M. S., F. R. C. S.,
Surgeon and Lecturer at St. Mary’s Hospital, London.
Surgical, Pathology. In one pocket-size 12mo, volume of 511 pages, with 81
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 31.
Its form is practical, its language is clear, and in it nothing that is unnecessary. The list of
the information, set forth is well-arranged, well: subjects covers the whole range o Surgery.—New
indexed and well-illustrated. The student will find | York Medical Journal, May 31, 1884.
what we do not hesitate to say is the best introduc-
tion to general pathology that we have yet ex-
34
LEA BROTHERS & Co.'s PUBLICATIONS-Practice of Med.
FLINT, AUSTIN, M. D., L.L. D.
Prof. of the Principles and Practice of Med, and of Clin. Med. in Bellevue Hospital Medical College, N. Y.
A Treatise on the Principles and Practice of Medicine.
the use of Students and Practitioners of Medicine.
Designed for
New (sixth) edition, thoroughly re-
vised and rewritten by the Author, assisted by WILLIAM. H. WELCH, M.D., Professor of
. Pathology, Johns Hopkins University, Baltimore, and AUSTIN FLINT, J.R., M.D., LL. D.,
3Professor of Physiology, Bellevue Hospital Medical College, N. Y.
In one very handsome
Yoctavo volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50.
A new edition of a work of such established rep-
tºtation as Flint's Medicine, needs but few words to
commend it to notice. It may in truth be said to
•eymbody the fruit of his labors in clinical medicine,
Sripened by the experience of a long life devoted to
fits pursuit. America may well be proud of havin
produced a man whose indefatigable industry an
general approval by medical students and practi-
tioners as the work of Professor Flint. In all the
medical colleges of the United States it is the fa-
vorite work upon Practice; and, as we have stated
before in alluding to it, there is no other medical
work that can be so Hºlly found in the libra-
ries of physicians. In every state, and territory
gifts of genius have done so much to advance med-
\i cine; and all English-reading students must be
rateful for the work which he has left behind him.
it has few equals, either in point of literary excel-
lence, or of scientific learning, and no one can
-study its pages without being struck by the lu-
ºscidity and accuracy which characterize them. . It
is qualities such as these which render it so valu-
.ab{e for its purpose, and give it a foremost place
among the text-books of this generation.—The
London Lancet, March 12, 1887.
* No text-book on the principles and practice of
ºnedicine has ever met in this country with such
of this vast country the book that will be most likely
to be found in the office of a medical man, whether
in city, town, Village, or at Some cross-roads, is
Fljnt's Practice. e make this statement to a
considerable extent from personal observation, and
it is the testimony also of others. An examina-
tion shows that very considerable changes have
been made in the sixth edition. The work may un-
doubtedly be regarded as fairly representing the
present state of the science of medicine, and as
reflecting the views of those who exemplify in
their practice the present stage of progress of med-
ical art.—Cincinnati Medical News, Oct. 1886. g
JHARTSHORNE, HENRY, M. D., L.L. D.,
Lately Professor of Hygiene in the University of Pennsylvania.
Essentials of the Principles and Practice of . Medicine. A Handbook
{for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one
aroyal 12mo, volume of 669 pages, with 144 illustrations. Cloth, $2.75; half bound, $3.00.
* Within the compass of 600 pages it, treats of the this one; and probably not one writer in our day
History of medicine, general pathology, general had a better º than Dr. Hartshorne for
symptomatology, and physical diagnosis (including condensing all the views of eminent practitioners
Taryngoscope, &phtha moscope, etc.), general ther- into a 12mo. The numerous illustrations will be
sapeutics, nosology, and special pathology and prac- very useful to students º: These essen-
tice. There is a wonderful amount of information | tials, as the name suggests, are not intended to
contained in this work, and it is one of the best sº the text-books of Flint and Bartholow,
-of its kind that we have seen.—Glasgow Medical but they are the most valuable in affording the
-Josºrnal, Nov. 1882. means to see at a glance the whole literature of any
An indispensable book. No work ever exhibited disease, and the most valuable treatment.—Chicago
za better average of actual practical treatment than Medical Journal and Easaminer, April, 1882.
EEYNOLDS, J. R. USSELL, M. D.,
Professor of the Principles and Practice of Medicine in University College, London.
A System of Medicine. With notes and additions by HENRY HARTSHORNE,
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. . In three large
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra-
tions. Price per volume, cloth, $5.00; sheep, $6.00; very handsome half Russia, raised bands,
$6.50. Per set, cloth, $15; leather, $18. Sold only by subscription.
Really too much praise can scarcely be given to of reference it is invaluable. . It is up with the
this noble book. It is a cyclopædia of medicine times. It is clear and concentrated in style, and
written by some of the best men of Europe. It is its form is worthy of its famous publisher.-
ºfaull of useful information, such as one finds fre- || Lowisville Medical News, Jan. 31, 1880.
quent need of in one's daily work. As a book
STILLE, ALFRED, M. D., LL.D.,
Professor Emeritus of the Théory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat-
gment. In one handsome 12mo, volume of 163 pages, with a chart. Cloth, $1.25.
WATSON, SIR THOMAS, M. D.,
Late Physician in Ordinary to the Queen.
Lectures on the Principles and Practice of Physic. A new American
from the fifth English edition. Edited, with additions, and 190 illustrations, by HENRY
JHARTSHORNE, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania.
Wºm two large octavo volumes of 1840 pages. Cloth, $9.00; leather, $11.00.
tº, ECTURES ON THE STUDY OF FEVER. By
A. HuDSON, M. D., M. R. I. A. In one octavo
<!olume of 308 pages. Cloth, $2.50.
a TREATISE ON FEVER. By Robert D. Lyons,
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25.
BRISTOWE'S PRACTICE OF MEDICINE. In
one octavo volume.
LA ROCHE ON YELLOW FEVER, considered in
its Historical, Pathological, Etiological and
Therapeutical Relations. In two large and hand-
some octavo volumes of 1468 pp. Cloth, $7.00.
LEA BROTHERs & Co.'s PUBLICATION5–System of Med. 15
For Sale by Subscription. Only.
A System of Practical Medicine.
i RY AMERICAN AUTHORS.
EDITED BY WILLIAM PEPPER, M. D., LL.D.,
!
| PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA,
Assisted by Louis STARR, M.D., Clinical Professor of the Diseases of Children in the
Hospital of the University of Pennsylvania.
The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready-
Price per volume, cloth, $5; leather, $6; half Russia, raised bands and open back, $7.
In this great work American medicine is for the first time reflected by its worthiest,
teachers, .# presented in the full development of the practical utility which is its pre-
&minent characteristic. The most able men—from the East and the West, from the
North and the South, from all the prominent centres of education, and from all the
hospitals which afford special opportunities for study and practice—have united] in
generöus rivalry to bring together this vast aggregate of specialized experience. 2 :#
The distinguished editor has so apportioned the work that to each author has been
assigned the subject which he is peculiarly fitted to discuss, and in which his views
will be accepted as the latest expression of scientific and practical knowledge. The
practitioner will therefore find these volumes a complete, authoritative and unfailing work
of reference, to which he may at all times turn with full certainty of finding what he needs
in its most recent aspect, whether he seeks information on the general principles of medi-
cine, or minute guidance in the treatment of special disease. So wide is the scope of the
work that, with the exception of midwifery and matters strictly surgical, it embraces the
whole domain of medicine, including the departments for which the physician is accustomed
to rely on special treatises, such as diseases of women and children, of the genito-urinary
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology
and otology. Moreover, authors have inserted the formulas which they have found most
efficient in the treatment of the various affections. It may thus be truly regarded as a
CoMPLETE LIBRARY OF PRACTICAL MEDICINE, and the general practitioner possessing it.
may feel secure that he will require little else in the daily round of professional duties.
In spite of every effort to condense the vast amount of practical information fur-
nished, it has been impossible to present it in less than 5 large octavo volumes, containing
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary
octavos. Illustrations are introduced wherever requisite to elucidate the text.
A detailed prospectus will be sent to any address on application to the publishers.
These two volumes bring this admirable work
to a close, and fully sustain the high standard
reached by the earlier volumes; we have only
therefore to echo the eulogium pronounced upon
them. ... We would warmly congratulate the editor
and his collaborators at the conclusion of their
laborious task on the admirable manner in which
from first to last, they have performed their several
duties. . . They have succeeded in producing a
work which will long remain a standard work of
reference, to which practitioners will look for
uidance, and authors will resort for facts.
rom a literary point of view, the work is without
any serious blemish, and in respect of production,
it has the beautiful finish that Americans always
#. their works,—Edinburgh Medical Journal, Jan.
887.
* * The greatest distinctively American work on
the practice of medicine, and, indeed, the super-
lative adjective would not be inappropriate were
even all other productions placed in comparison.
An examination of the five volumes is sufficient
to convince one of the magnitude of the enter-
rise, and of the success which has attended its
lfilment.—The Medical Age, July 26, 1886.
This huge volume forms a fitting close to the
reat system of medicine which in so short a time
as won so high a place in medical literature, and
has done such credit to the profession in this
country. Among the twenty-three contributors
are the names of the leading neurologists in
America, and most of the work in the Volume is of
the highest order.—Boston Medical and Surgical
Journal, July 21, 1887.
We consider it one of the grandest works on
Practical Medicine in the English language. It is
a work of which the profession of this country can
feel proud. Written exclusively by American
physicians who are acquainted with all the varie-
ties of climate in the United States, the character
of the soil, the manners and customs of the peo—
ple, etc., it is peculiarly adapted to the wants
of American practitioners of medicine, and it
seems to us that every one of them would desire
to have it. It has been truly called a “Complete
Library of Practical Medicine,” and the general
practitioner will require little else in his round
of professional duties.—Cincinnati Medical News,
March, 1886. º
Each of the volumes is provided with a most
tºº. index, and the work altogether promises
to be one which will add much to the medical
literature of the present century, and reflect great
credit upon the scholarship and practical acumen
of its authors.--The London Lancet, Oct. 3, 1885.
The feeling of proud satisfaction with which the
American profession sees this, its representative
system of practical medicine issued to the medi-
cal world, is fully justified by the character of the
work. The entire caste of the system is in jºr
ing with the best thoughts of the leaders and fo
lowers of our home school of medicine, and the
combination of the scientific study of disease and
the practical application of exact and experimen-
tal knowledge to the treatment of human mal-
adies, makes every one of us share in the pride
that has welcomed Dr. Pepper's labors. Sheared.
of the prolixity that wearies the readers of the
German school, the articles glean these same
fields for all that is valuable. It is the outcome
of American brains, and is marked throughout
by much of the sturdy independence of thought
and originality that is a mational characteristic-
Yet, nowhere is there lack of study of the most
advanced views of the day,+North Carolina Medi-
cal Journal, Sept. 1886.
16
LEA BROTHERS & Co.'s PUBLICATIONS-Clinical Med., etc.
FOTHERGILL, J.M., M. D., Edin, M. R. C. P., Loma,
Physician to the City of London Hospital for Diseases of the Chest. f
The Practitioner's Handbook of Treatment; Or, The Principles of Thera-
peutics. New (third) edition. In one 8vo, vol. of 661 pages. Cloth, $3.75; Teather, $4.75.
To have a description of the normal physiologi-
cal processes of an organ and of the methods of
treatment of its morbid conditions brought
together in a single chapter, and the relations
§. the two clearly stated, cannot fail to prove
a great convenience to many thoughtful but busy
physicians. The practical value of the volume is
greatly increased by the introduction of many
rescriptions. That the profession appreciates
#. the author has undertaken an important work
and has accomplished it is shown by the demand
for this third edition.—N. Y. Med. Jowr., June 11,'87.
This is a wonderful book. If there be such a
thing as “medicine made easy,” this is the work to
accomplish this result.— Va. Med. Month., June,’87.
It is an excellent, practical work on therapeutics,
Well arranged and clearly expressed, useful to the
student and young practitioner, perhaps even to
* old,—Dublin Journal of Medical Science, March,
888. |
We do not know a more readable, practical and
useful work on the treatment of disease thanithe
one we have now before us.-Pacific Medical and
Surgical Jowrmal, October, 1887. !
WAUG HAN, VICTOR. C., Ph. D., M. D.,
Prof. of Phys, and Path. Chem. and Assoc. Prof. of Therap. and Mat.
Med. in the Univ. of Mich.
and NOVY, FREDERICR. G., M. D,
Instructor in Hygiene and Phys. Chem. in the Univ. of Mich.
Ptomaines and Leucomaines, or Putrefactive and Physiological
Alkaloids.
This book is what has been wanted for some
years by the medical profession. The subject of
ptomaines and leucomaines, so far as their disease-
producing relations are concerned, has been under
special study scarcely more than a decade, but
within that period facts have been discovered
upon which theories of permanent standing have
been built, until now the practitioner is far be-
hind the times if he does not appreciate the
importance of ptomaines. This is the first attempt
made to collect into book form the results of
In one handsome 12mo, volume of 311 pages.
Just ready. Cloth, $1.75.
observers and experimenters on micro-organisms
and to trace the relationship of cause and effe
of the putrefactive alkaloids. . We congratulate
the authors upon the successful presentation of
the current views on the subject in such manner
as to make them easily comprehensible, while to
the practitioner, after he has carefully read the
book, it will serve, also, as a frequent reference
Work, because of the technical information it gives.
Va. Medical Monthly, Sept. 1888.
JFINLAYSON, JAMES, M. D., Editor,
Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc.
Clinical Manual for the Study of Medical Cases.
With Chapters
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of
the Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis;
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case-
taking, Family History and Symptoms of Disorder in the Various Systems. New edition.
In one 12mo, volume of 682 pages, with 158 illustrations. Cloth, $2.50.
The profession cannot but welcome the second
edition of this very valuable work of Finlayson
and his collaborators. The size of the book has
been increased and the number of illustrations
nearly doubled. The manner in which the subject
is treated is a most practical one. Symptoms
alone and their diagnostic indications form the
basis of discussion. The text explains clearly and
fully the methods of examinations and the con-
clusions to be drawn from the physical signs.—
The Medical News, April 23, 1887. e $ tº
We are pleased to see a second edition of this
admirable book. It is essentially a practical
treatise on medical diagnosis, in which every sign
and Symptom of disease is carefully analyzed, and
their relative significance in the different affec-
tions in which they occur pointed out. From their
§º. the student can accurately determine
the disease with which he has to deal. The book
has no competitor, nor is it likely to have as long
as future editions maintain its present standard of
excellence. The general practitioner will find
many practical hints in its pages, while a careful
study of the work will save him from many pitfalls
in diagnosis.—Liverpool Medico-Chirurgical Jour-
nal, January, 1887.
FEN WICE, SAMUEL, M. D.,
Assistant Physician to the London Hospital.
The Student’s Guide to Medical Diagnosis.
From the third revised and
enlarged English edition. In one very handsome royal 12mo, volume of 328 pages, with
87 illustrations on wood. Cloth, $2.25.
IHABERSHON, S. O., M. D.
9
Senior Physician to and late Lect, on Principles and Practice of Med. at Guy's Hospital, London.
On the Diseases of the Abdomen;
other parts of the Alimentary Canal, CEsophagus, Caecum, Intestines and Peritoneum. Second
American from third enlarged and revise
volume of 554 pages, with illustrations.
This valuable treatise on diseases of the stomach
and abdomen will be found a cyclopædia of infor:
mation, systematically arranged, on all diseases of
the alimentary tract, from the mouth to the
rectum, . A fair proportion of each chapter is
devoted to symptoms, path º and therapeutics.
The present edition is fuller than former ones in
many particulars, and has been thoroughly revised
and amended by the author.
§ ers have been added, bringing the work fully up
Cloth, $3.50.
Several new chap- || April, 1879.
TANNER, THOMAS HAWKES, M. D.
A Manual of Clinical Medicine and Physical Diagnosis. Third American
rom the second London edition.
Revised and enlarged
Comprising those of the Stomach, and
English edition. In one handsome octavo
to the times, and making it a volume of interest to
the practitioner in every field of medicine and
surgery. Perverted nutrition is in some form
associated with all diseases we have to combat,
and we need all the light that can be obtained on
a subject so broad and general. Dr. Habershon's
work is one that every practitioner should read
and study for himself—N. Y. Medical Journal,
by TILBURY Fox, M. D.
In one small 12mo, volume of 362 pages, with illustrations. Cloth, $1.50.
k
LEA BROTHERS & Co.'s PUBLICATIONS-Hygiene, Electr., Pract.
17
BARTHOLOW, ROBERTS, A. M., M. D., L.L. D.,
Prof. of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila, etc.
|
i
to Medicine and Surgery. New (third) edition.
Cloth, $2.50.
308 pages, with 110 illustrations.
The fact that this work has reached its third edi-
tion in six years, and that it has been kept, fully
abreast, with the increasing use and knowledge of
electricity, demonstrates its claim to be considered
a practical treatise of tried value to the profession.
#}. matter added to the present edition embraces
the most recent advances in electrical treatment.
The illustrations are abundant and clear, and the
work constitutes a full, clear and concise manual
well adapted to the needs of both student and
practitioner.— The Medical News, May 14, 1887.
This “practical treatise on the º Of
electricity to medicine and surgery” has grown to
be so important a work that every practitioner
Medical Electricity. A Practical Treatise on the Applications of Electricity
YEO, I. BUIRNEY, M. I.)., F. R. C. P.,
Professor of Clinical Therapeutics in King's College, London, and Physician to King's College
Elospital.
Food in Health and Disease. In one 12mo, volume of 590 pages. Cloth, $2.
Just ready.
Dr. Yeo is fully master of his subject and he
supplies in a compact form nearly all that the
º: requires to know on the subject of
iet. The work is divided into two parts—food in
health and food in disease. Dr. Yeo has gathered
together from all quarters an immense amount of
useful information within a comparatively small
See Series of Clinical Manuals, page 31.
RICHARDSON, B. W., M.D., LL.D., F.R.S.,
Fellow of the Royal College of Physicians, London.
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5.
Dr. Richardson has succeeded in producing a
work which is elevated in conception, comprehen-
sive in scope, scientific in character, systematic in
arrangement, and which is written in a clear, con-
cise and pleasant manner. He evinces the happy
faculty of extracting the pith of what is known on
the subject, and of presenting it in a most simple,
intelligent and practical form. There is perhaps
no similar work written for the jº public
that contains such a complete, reliable and instruc-
tive collection of data upon the diseases common
to the race, their origins, causes, and the measures
for their prevention. The descriptions of diseases
are clear, chaste and scholarly; the discussion of
THE YEAR-BOOK OF TEEATMENT FOR 1890.
A Comprehensive and Critical Review for Practitioners of Medi-
cine.
In one 12mo, volume of 329 pages. Cloth, $1.25.
*** For special commutations with periodicals see page 2.
In the present issue of the Year-Book of Treat-
ment we find the usual clear, concise, complete
and accurate epitome of the chief advances made
in the treatment of disease during the year end
ing Sept. 1st. The different subjects are arranged
in sections under the heads of the principal sys-
tems of the body. The serial medical literature
of England, America and of the Continent has
been laid under contribution, with the result that
THE YEAR-BOOKS of TREATMENT for 1886–87-89.
Similar to above.
12mo, 320–341 pages.
SCHREIB.E.R., JOSEPH, M. D.
A Manual Of Treatment by Massage and Methodical Muscle Ex-
Translated by WALTER MENDELson, M.D., of New York.
In one very handsome octavo volume of
should read it, especially when it is recalled what
possibilities lie in the path of the further study of
the therapeutics of electricity. Dr. Bartholow has
here E. the profession with a concise work
that, beginning with elementary descriptions and
principles, graduall rows, page by page, into a
magnificently practical treatise, describing opera-
tions in detail, and giving records of successes
that prove electricity to be marvellous as a curative
agent in many forms of disease. The doctor can-
not now do better than to possess himself of Dr.
Bartholow's treatise, just as it is.- Virginia Medi-
cal Monthly, June, 1887.
compass, and he has arranged and digested his
materials with skill for the use of the practitioner.
We have seldom seen a book which more thor-
oughly realizes the object for which it was written
than this little work of Dr. Yeo.—British Medical
Journal, Feb. 8, 1890.
the question of disease is comprehensive, master!
and fully abreast with the latest and best knowl-
edge on the subject, and the preventive measures
advised are accurate, explicit and reliable. — The
American Journal of the Medical Sciences, April, 1884.
This is a book that will surely find a place on the
table of every progressive physician. To the medi-
cal profession, whose duty is quite as much to
prevent as to cure disease, the book will be a boon.
—Boston Medical and Surgical Journal, March 6, ’84.
The treatise contains a vast amount of solid, val-
uable hygienic information.—Medical and Surgical
Reporter, Feb. 23, 1884.
Just ready.
a large mass of information, valuable to the prac-
titioner, is presented for his immediate reference.
Brief notices of the most important new books on
each subject add greatly to the value of the annual
retrospect. Such a book, produced as it is in an
elegant and convenient form and at a very low
price, ought to be in the hands of every member
of the profession.—The Practitioner, Feb. 1890.
Limp cloth, $1.25 each.
ercise.
In one handsome
octavo volume of 274 pages, with 117 fine engravings. Cloth, $2.75.
STURGES INTRODUCTION TO THE STUDY
OF CLINICAL MEDICINE. Being a Guide to
the Investigation of Disease. In one handsome
12mo, volume of 127 pages. Cloth, $1.25.
DAVIS' CLINICAL LECTURES ON VARIOUS
IMPORTANT DISEASES. By N. S. DAvis
M. D. Edited by FRANK H. DAVIs, M. D. Second
edition. 12mo, 287 pages. Cloth, $1.75. '
TODD’S CLINICAL LECTURES ON CERTAIN
ACUTE DISEASES. In one octavo Volume of
820 pages. Cloth, $2.50.
PAVY'S TREATISE ON TEIE FUNCTION OF DI-
GESTION; its Disorders and their Treatment.
From the second London edition. In one octavo
volume of 238 pages. Cloth, $2.00.
BAR.LOW'S MANUAL OF THE PRACTICE OF
MEDICINE. With additions by D. F. CoNDIE,
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50.
CHAMBERS MANU'Af, ÖFIDIETANſ) REGIMEN
IN HEALTH AND SICKNESS. In One hand-
some octavo volume of 302 pp. Cloth, $2.75,
HOLLAND’S MEDICAL NOTES AND REFLEC-
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50.
18 LEA BROTHERS & Co.'s PUBLICATIONS—Throat, Lungs, Heart.
FLINT, AUSTIN, M. D., L.L. D.,
Professor of the Principles and Practice of Medicine whibellevue Hospital Medical College, N. Y.
A Manual of Auscultation and Percussion; Of the Physical Diagnosis of
Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition.
Edited by James C. Wilson, M. D., Jefferson Medical College, Philadelphia. In one
handsome royal 12mo, volume of about 300 pages, with 14 illustrations. Preparing.
A notice of the previous edition is appended.
The original work done by Dr. Flint in the devel- passed through four editions attests its popularity.
opment of the art of physical diagnosis will always | There, is a tendency among physical diagnosti-
make this manual an authority on this subject. cians to make altogether too many varieties of
Among all the works issued on this topic during morbid chest sounds, and especially of rales. The
the last few years, none exceeds this one in sim- | conciseness of Dr. finţ's Māmuā is one of its chief
plicity and completeness. The fact that it has advantages —Medical Record, June 16, 1888.
BY THE SAME AUTHOR.
A Practical Treatise on the Physical Exploration of the Chest and
the Diagnosis of Diseases Affecting the Respiratory. Organs. Second and
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50.
Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and
Complications, Fatality and Progriosis, Treatment and Physical Diag-
nosis; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50.
A Practical Treatise on the Diagnosis, Pathology and Treatment of
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume
of 550 pages, with a plate. Cloth, $4.
Essays on Conservative Medicine and Kindred Topics. In one very hand-
some royal 12mo. volume of 210 pages. Cloth, $1.38.
BROWNE, LENNOX, F. R. C. S., E.,
Senior Physician to the Central London Throat and Ear Hospital.
A Practical Guide to Diseases of the Throat and Nose, including
Associated Affections of the Ear. With 120 illustrations in color, and 235 en-
gravings on wood. New (third) and enlarged edition. In one imperial octavo volume
of 714 pages. Cloth, $6.50. Just ready.
SEIL ER, CA. R. L., M. D.,
Lecturer on Laryngoscopy in the University of Pennsylvania.
A Handbook of Diagnosis and Treatment of Diseases of the Throat,
Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo.
volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25.
Few medical writers surpass this author in of topics and methods. The book deserves a large
ability to make his meaning perfectly clear in a sale, especially among general practitioners—Chi-
few words, and in discrimination in selection, both cago Medical Journal and Easaminer, April, 1889.
COHEN, J. SOLIS, M. D.,
Lecturer on Laryngoscopy and Diseases of the Throat and Chest wn the Jefferson Medical College.
Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and
Treatment of Affections of the Pharynx, OEsophagus, Trachea, Larynx and Nares. Third
edition, thoroughly revised and rewritten, with a large number of new illustrations. In
one very handsome octavo volume. Preparing.

GROSS, S. D., M.D., LL.D., JD. C.L. O3Com., LL.D. Cantab.
A Practical Treatise on Foreign Bodies in the Air-passages. In one
octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. º
BROAD BENT, W. H., M. D., F. R. C. P.,
Physician to and Lecturer on Medicine at St. Mary's Hospital, London.
The Pulse. In one 12mo, volume of 312 pages. Cloth, $1.75. Just ready. See
Series of Clinical Manuals, page 31,
FULLER ON DISEASES OF THE LUNGS AND | valence in various Countries. Second and revised
AIR-PASSAGES. Their Pathology, Physical Di- edition. In one 12mo, vol., Fº: 158. Cloth, $1.25.
agnosis, Symptoms and Treatment. From the SMITH ON CONSUMPTION; ſts Early and Reme-
second and revised English edition. In one diable Stages. 1 vol. 8vo.,Nº. 253. Cloth, $2.25.
octavo volume of 475 pages. Cloth, $3.50. LA ROCHE ON PNEUMONIA. I vol. 8vo. of 490
WALSHE ON THE DISEASES OF THE HEART ages. Cloth, $3.00.
ANi GrºßAT VEssfīš. Third American edi. wifi.i.am's ON. Fiji,MONARY CONSUMPTION:
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. its Nature, Varieties and Treatment. With an
8LADE ON DIPHTHERIA ; its Nature and Treat- analysis of one thousand cases to º it's
ment, with an account of the History of its Pre- duration. In one 8vo, vol. of 303 pp. Cloth, $2.50
LEA BROTHERS & Co.'s PUBLICATIONS-Nerv. and Ment. Dis., etc.
19
ROSS, JAMES, M.D., F. B. C. P., L.L. D.,
Senior Assistant Physician to the Manchester Royal Infirmary.
A Handbook on Diseases of the Nervous System.
volume of 725 pages, with 184 illustrations.
This admirable work is intended for students of
medicine and for such medical men as have no time
for lengthy treatises.
In the present instance the
In one octavo
Cloth, $4.50; leather, $5.50.
the department of medicine of which it treats.
Dr. Ross holds such a high scientific position that
any writings which bear his name are naturally
duty of arranging the vast störe of material at the expected to have the impress of a powerful intel-
disposal of the author, and of abridging the de- lect.
In every part this handbook merits the
scription of the different aspects of nervous dis. | highest praise, and will no doubt be found of the
eases, has been performed with singular skill, and greatest value to the student as well as to the prac-
the résult is a concise and philosophical guide to i titioner.— Fºlinburgh Medical Journal, Jan. 1887.
MITCHELL, S. WEIR, M. D.,
Physician to Orthopaedic Hospital and the Infirmary for Dweases of the Nervous Sustem, Phala., etc.
Lectures on Diseases of the Nervous System; Especially in Women.
Second edition.
No work in our language develops or displays
more features of that many-sided affection, hyS-
teria, or gives clearer directions for its differen-
tiation, or sounder suggestions relative to its
eneral management and treatment. The book
s particularly valuable in that it represents, in
the main the author's own clinical studies, which
have been so extensive and fruitful as to give his
In one 12mo, volume of 288 pages. Cloth, $1.75.
º the stamp of authority all over the
realm of medicine. The work, although written
by a specialist, has no exclusive character, and
the general practitioner above all others wifſ find
its perusal profitable, since it deals with diseases
which he frequently encounters and must essay
to treat.—American Practitioner, August, 1885.
FIAMILTON, ALLA N McLA NE, M. D.,
Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell'8 Island, N. Y.
Nervous Diseases; Their Description and Treatment. Second edition, thoroughly
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4.
When the first edition of this good book appeared characterized this book as the best of its kind in
we gave it our emphatic endorsement, and the any language, which is a handsome endorsement
É. edition enhances our appreciation of the
ook and its author as a safe guide to students of
clinical neurology. One of the best and most
om an exalted source. The improvements in the
w edition, and the additions to it, will justify its
urchase even by those who possess the old.—
critical of English neurological journals, Brain, has Alienist and Neurologist, April, 1882.
TUKE, DANIEL HACK, M. D.,
.*
Joint Author of The Manual of Psychological Medicine, etc.
Illustrations of the Influence of the Mind upon the Body in Health
and Disease. Desi
ed to elucidate the Action of the Imagination.
New edition.
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3.
It is impossible to peruse these interesting chap-
ters without being convinced of the author's per-
fect sincerity, impartiality, and thorough mental
grasp. Dr. Tuke has exhibited the requisite
amount of scientific address on all occasions, and
the more intricate the phenomena the more firmly
has he adhered to a physiological and rational
method of interpretation., Guided by an enlight-
ened deduction, , the author has réclaimed for
science a most interesting domain in psychology,
preyiously abandoned to gharlatans and empirićs.
This book, well conceived and well written, must
commend itself to every thoughtful understand-
ing.—New York Medical Journal, September 6, 1884.
CLOUSTON, THOMAS S., M. D., F. R. C. P., L. R. C. S.,
Lecturer on Mental Diseases in the University of Edinburgh. w
Clinical Lectures on Mental Diseases. With an Appendix, containing an
Abstract of the Statutes of the United States and of the Several States and Territories re-
lating to the Custody of the Insane.
tº By CHARLES F. FOLSOM, M.D., Assistant Professor
of Mental Diseases, Med. Dep. of Harvard Univ.
In one handsome octavo volume of 541
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4.
The practitioner as well as the student will ac-
cept the plain, practical teaching of the author as a
forward step in the literature of insanity. It is
refreshing to find a physician of Dr. Clouston’s
experience and high º giving the bed-
side notes upon which his experience has been
founded and his mature judgment established.
Such clinical observations cannot but be useful to
the general practitioner in guiding him to a diag-
nosis and indicating the treatment, especially in
many obscure and doubtful cases of mental dis-
ease. To the American reader Dr. Folsom's Ap-
pendia, adds, greatly to the value of the work, and
will m lºse it a desirable addition to every library.
—American Psychological Journal, July, 1884.
Bº Dr. Folsom's Abstract may also be obtained separately in one octavo volume of
108 pages, Cloth, $1.50.
w
S.A. VAGE, GEORGE H., M. D.,
Lecturer on Mental Diseases at Guy's Hospital, London.
Insanity and Allied Neuroses,
Practical and Clinical. In one 12mo, vol.
of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 31.
PLAYFAIR, W. S., M. D., F. R. C. P.
The Systematic Treatment of Nerve Prostration and Hysteria.
one handsome small 12mo, volume of 97 pages.
I
Cloth, $1.00. In
Blandford on Insanity, and its Treatment: Lectures on the Treatment,
Medical and Legal, of Insane Patients.
In One very handsome octavo volume.
Jones’ Clinical Observations on Functional Nervous Disorders.
Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25.
20
LEA BROTHERS & Co.'s PUBLICATIONs—Surgery.
ASHHURST, JOHN, Jr., M. D.,
Barton Prof. of Surgery and Clin. Surgery in Univ. of Penna, Surgeon to the Penna. Hosp, etc.
The Principles and Practice of Surgery. New (fifth), edition, enlarged
and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with
642 illustrations.
A complete and most excellent Work on surgery.
It is only necessary to examine it to see at once
its excellence and real merit either as text-book
for the student or a guide for the general practi;
tioner. It fully considers in detail every surgical
injury and disease to which the body is liable, and
every advance in surgery worth noting is to be
found in its proper place. It is unquestionably the
best and most complete single volume on surgery,
in the English language, and cannot but receive
that continued appreciation which its merits justly
demand.—Southern Practitioner, Feb. 1890.
Cloth, $6; leather, $7. Just ready.
DRUITT, ROBERT, M. R. C. S., etc.
Manual of Modern Surgery. Twelfth edition, thoroughly revised by STAN-
LEY BOYD, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illustra-
tions. Cloth, $4; leather, $5.
It is essentially a new book, rewritten from be-
ginning to end. The editor has brought his work
W. to the latest date, and nearly every subject on
which the student and practitioner would desire
to consult a surgical volume, has found its place
here. The volume closes with about twenty pages
of formulae covering a broad range of practical
therapeutics. . The student will find that the new
Druitt is to this generation what the old one was
to the former, and no higher raise need be
accorded to any volume.—North Carolina Medical
Journal, October, 1887.
GANT, FREDERICE JAMES, F. R. C. S.,
Senior Surgeon to the Royal Free EIospital.
The Student’s Surgery. A Multum in Parvo.
Cloth, $3.75.
of 848 pages, with 159 engravings.
The claims of this volume to be a multwm in
parvo are certainly substantiated. The author
covers the whole field of clinical and operative
surgery in about eight hundred pages of very Com-
pactly printed matter. For a student's manual it
appears to us in every way excellent, containing
almost everything necessary to equip the student
with sound, matter-of-fact knowledge on surgical
ROBIERTS, J. B., M. D.,
Professor of Anatomy and Surgery in the Philadelphia Polyclinic.
oman's Medical College of Pennsylvania.
Practice of Swrgery in the
The Principles and Practice of Modern Surgery. For the use of Students
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of about
850 pages, with about 425 illustrations. In press.
In this volume, as its title indicates, the author has endeavored to give a thorough
exposition of the best surgical practice of the present time.
large experience, he has consulted the latest literature of all kinds bearing on his spec-
ialty, and has gleaned therefrom the opinions of the best authorities, and the methods of
the most practical Surgeons.
but history, theories and untried innovations are rigidly excluded.
In the selection of matter and in the consideration of the vast number of
illustrated.
The well-established facts of the science are clearly stated,
questions involved, the author has used his most critical judgment in the endeavor to
render the work of the greatest practical advantage to both practitioners and students.
GEOSS,
Cantab.,
S. L., M. ID., LL. D., I). C. L. Oacom., LL. IX.
Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia.
A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative.
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully-
rinted imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings:
Strongly bound in leather, raised bands, $15.
B.A. L.L., CHAIR LES B., M. Ch., Dwb., F. R. C. S., E.,
Surgeon and Teacher at Sir P. Dun's Hospital, Dublin.
Liseases of the Rectum and Anus.
This is one of the most popular and useful of
the many well-known treatises on general Surgery.
It furnishes in a concise manner a clear” and
comprehensive description of the modes of prac.
tice now generally º in the treatment of
surgical affections, with a plain exposition of the
pºpº on which those modes of practice are
ased. The entire work has been carefully revised
and a number of new illustrations introduced
that greatly enhance the value of the book.--
Cincinnati Lancet-Clinic, Dec. 14, 1889.
Druitt's Surgery has been an exceedingly popu-
lar work in the profession. It is stated that 50,000
copies, have been sold in England, while in the
United States, ever since its first issue, it has been
used as a text-book to a Very large extent. Dur-
ing the late war in this country it was so highly
appreciated that a copy was issued by the Govern.
ment to each surgeon. The present edition, while
it has the same features peculiar to the work at
first, embodies all recent discoveries in surgery
and is fully up to the times. Cincinnati Miśācāī
News, September, 1887.
In one Square octavo volume
subjects. The volume is a condensation of the
author’s well-known º Works on surgery,
notably his “Science and Practice of Surgery".
Students, requiring , the essentials of surgery
in a handy and condensed form, and those who
cannot devote time, to theoretical or speculative
pathology will find this volume exceedingly ser-
viceable.—The Physician and Surgeon, April, 1890
Professor of the Principles and
Not relying on his own
The work is richly
In one 12mo, volume of 417 pages,
with 54 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical
Manuals, page 31.
GIB NEX, W, P., M.D.,
Surgeon to the Orthopaedic Hospital, New York, etc.
Orthopaedic Surgery. For the use of Practitioners and Students. In one hand-
some octavo volume, profusely illustrated. Preparing.
LEA BROTHERS & Co.'s PUBLICATIONS–Surgery.
21
IEEICHSEN, JOHN E., F. R. S., F. R. C. S.,
Professor of Surgery in University College, London, etc. e º & e º
The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Dis-
eases and Operations.
beautiful octavo volumes of 2316 pages,
Cloth, $9; leather, raised bands, $11.
We have always regarded “The Science , and
Art of Surgery” as one of the best Surgical text-
books in the English language, and this eighth
edition only confirms our previous opinion. ...We
take great pleasure in cordially commending it to
our readers.—The Medical New8, April 11, 1885.
For many years this classic work has been
made by preference of teachers the principal
text-book on surgery, for medical students, while
through translations into the leading continental
languages it may be said to guide the surgical
teachings of the civilized world. , No excellence
of the former edition has been dropped and no
discovery, device or improvement which has
From the eighth and enlarged English edition.
In two large and
illustrated with 984 engravings on wood.
marked the progress of jºy during the last
decade has been omitted. The illustrations are
many and executed in the highest style of art.
—Louisville Medical News, Feb. 14, 1885.
We cannot speak too highly of this excellent
work. It represents the most advanced and settled
views in regard to the science of surgery, and will
ever be found a faithful guide and counsellor in
practice.—Canada, Lancet, May, 1885.
It appears simultaneously in England, America,
Spain and Italy, and is too well known as a safe
guide and familiar friend to need further com.
ment.—New York Medical Journal, March 28, 1885.
BRYA NT, THOMAS, F. R.
C. S.,
Surgeon and Lecturer on Surgery at Guy's Hospital, London.
The Practice of Surgery. Fourth American from the fourth and revised Eng-
lish edition.
727 illustrations.
The fourth edition of this work is fully abreast
of the times. The author handles his subjects
with that degree of judgment and skill which is
attained by years of patient toil and varied ex-
perience. The present edition is a thorough re-
vision of those which preceded it, with much new
matter added. His diction is so graceful and
logical, and his explanations are So lucid, as to
face the work among the highest order of text-
É. for the medical student. Almost every
topic in surgery is presented in such a form as to
In one large and very handsome imperial octavo volume of 1040 pages, with
Cloth, $6.50; leather, $7.50.
enable the busy practitioner to review any subject
in every-day practice in a short time. No time is
lost with useless theories or superfluous verbiage.
In short, the work is eminently clear, logical and
practical.—Chicago Medical Journal and Examiner,
April, 1886.
This book is essentially what it purports to be,
viz.: a manual for the practice of surgery. It is
peculiarly well fitted for the student or busy general
practitioner.—The Medical News, August 15, 1885.
TREVES, FREDERICK, F. R. C. S.,
Hunterian Professor at the Royal College of Surgeons of England.
A Manual of Surgery.
Students' Series of Manuals, page 31.
We have here the opinions of thirty-three
authors, in an encyclopædic form for easy and
ready reference. The three volumes embrace
every variety of surgical affections likely to be
met with, the paragraphs are short and pithy, and
In Treatises by Various Authors.
volumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2.
In three 12mo.
See
the Salient points and the beginnings of new sub-
jects are always printed in extra-heavy type, so
that a person may find whatever information he
may be in need of at a moment's glance.—Cin-
cunnati Lancet-Clinic, August 21, 1886.
MARSH, HO WAR D, F. R. C. S.,
Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London.
Diseases of the Joints.
In one 12mo, volume of 468 pages, with 64 woodcuts
and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 31.
BUTLIN, HENRY T., F. R. C. S.,
Assistant Surgeon to St. Bartholomew's Hospital, London.
Diseases of the Tongue.
In one 12mo, volume of 456 pages, with 8 colored
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 31.
The language of the text is clear and concise. venient
The author has aimed to state facts rather than to
express opinions, and has compressed within the
compass of this small volume the pathology, etiol-
ogy, etc., of diseases of the tongue that are incon-
# scattered through general works on sur-
.gery and the practice of medicine. The physician
and Surgeon will appreciate its value as an aid and
guide.— Physician and Surgeon, Sept. 1886.
TREVES, FREDERICE, F. R. C. S.,
Surgeon to and Lecturer on Surg
Intestinal Obstruction.
illustrations. Limp cloth, blue edges, $2.00.
A standard work on a subject that has not been
so comprehensively treated by any contemporary
Its completeness renders a full
review difficult, since every chapter deserves mi-
mute attention, and it is impossible to do thorough
Friglish writer.
at the London Hospital.
n one pocket-size 12mo, volume of 522 pages, with 60
See Series of Clinical Manuals, page 31.
justice to the author in a few paragraphs. Intes-
timal Obstruction is a work that will prove of
equal, value to the practitioner, the student, the
pathologist, the physician and the operating sur-
geon.—British Medical Journal, Jam. 31, 1885.
GOULD, A. P.E.A.R.C.E., M. S., M. B., F. R. C. S.,
In one pocket-size 12mo, volume of 589
Assistant Surgeon to Middlesea: Hospital.
Elements of Surgical Diagnosis.
Cloth, $2.00. See Students' Series of Manuals, page 31.
pages.
PIRRIE’S PRINCIPLES AND PRACTICE OF
SURGE
RY, Edited by JoBN NEILI., M. D. I
one 8vo. vol. of 784 pp. with 316 illus. Cloth,
MILLER'S PRINCIPLES OF SURGERY. Fourth
American from the third Edinburgh edition. In
Il
$3.75.
one 8vo. Vol. of 638 pages, with 340 illustrations.
Cloth, $3.75.
MILLER'S PRACTICE OF SURGERY. Fourth
and revised American edition. In one large 8vo.
Wol, of 682 pp., with 364 illustrations. Cloth, $3.75.
y
22
LEA BROTHERS & Co.'s PUBLICATIONS-Surgery, Frac., Disloc.
SMITH, STEPHEN, M. D.,
Professor of Clinical Surgery in the University of the City of New York.
The Principles and Practice of Operative Surgery. New (second) and
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with
1005 illustrations.
This excellent and very valuable book is one of
the most satisfactory works on modern operative
surgery yet published. Its author and publisher
have spared no pains to make it as far as possible
an ideal, and their efforts have given it a position
prominent among the recent works in this depart-
ment of surgery. The book is a compendium for
the modern surgeon. The present, the only revised
edition since 1879, presents many changes from
the original manual. The volume is much em.
larged, and the text has been thoroughly revised,
so as to give the most improved methods in asep-
Cloth, $400; leather, $5.00.
tic Surgery, and the latest instruments known for
Operative work. It can be truly said that as a hand-
book for the student, a compañion for the surgeon,
and even as a book of reference for the physician
not especially engaged in the practice :Fº
this volume will long, hold a most conspicuous
place, and seldom will its readers, no matter how
unusual the Subject, consult its pages in vain. Its
Compact form, excellent print, numerous illustra-
tions, and especially its decidedly practical char-
acter, all combine to commend it.—Boston Medical
and Surgical Journal, May 10, 1888.
FIOLMES, TIMOTHY, M. A.,
Swrgeon and Lecturer on Swrqery at St. George's Hospital, London.
A Treatise On Surgery : Its Principles and Practice.
New American
from the fifth English edition, edited by T. PICKERING PICK, F. R. C. S., Surgeon and
Lecturer on Surgery at St. George's Hospital, London,
Cloth, $6; leather, $7.
pages, with 428 illustrations.
To the younger members of the profession and
to others not acquainted, with the book and its
merits, we take pleasure in recommending it as a
surgery complete, thorough, well-written, full
illustrated, modern, a Work º volumi-
nous for the surgeon specialist, adequately concise
In one octavo volume of 997
Just ready.
for the general practitioner, teaching those things
that are necessary to be known for the successful
pro ecution of the physician's career, imparting
nothing that in our present knowledge is consid-
ered unsafe, unscientific or inexpedient.—Pacific
Medical Jowrmal, July, 1889.
HOLMES, TIMOTHY, M. A.,
Surgeon and Lecturer on Surgery at St. George's Hospital, London.
A System of Surgery; Theoretical and Practical. IN TREATISES BY
VARIOUS AUTHORS, AMERICAN EDITION, THOROUGHLY REVISED AND RE-EDITED
by John H. PACKARD, M. D., Surgeon to the Episcopal and St. Joseph’s Hospitals,
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons.
In three large imperial octavo volumes containing 3137 double-columned pages, with
979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per
set, cloth, $18.00; leather, $21.00. Sold only by subscription.
STIMSON, LEWIS A., B. A., M. D.,
Surgeon to the Presbyterian and Bellevue º JProfessor of Clunical §§ in the Medical
Faculty of Univ. of City of N. Y., Correspon
A Manual of Operative Surgery.
some royal 12mo, volume of 503 pages, with 342 illustrations.
There is always room for a good book, so that
while many works on operative surgery must be
considered superfluous, that of Dr. Stimson has
held its own. The author knows the difficult art
of condensation.
work of reference, and at the same time as a
handy guide. It teaches, what, it professes, the
steps of operations. In this edition Dr. Stimson
has sought to indicate the changes that have been
Thus the manual serves as a
ing Member of the Societe de Chirwrgie of Paris.
ew (second) edition. In one very hand-
Cloth, $2.50.
effected in operative methods and procedures by
the antiseptic system, and has added an account
of many new operations and variations in the
steps of older operations. We do not desire to
extol this manual above many excellent standard
British publications of the same class, still we be-
lieve that it contains much that is worthy of imi-
tation.—British Medical Journal, Jan. 22, 1887.
By the same Author.
A Treatise on Fractures and Dislocations.
Vol. I., FRACTURES, 582 pages, 360 beautiful illustrations.
Complete work, cloth, $5.50; leather, $7.50.
UIDO €S.
TIONs, 540 pages, with 163 illustrations.
In two handsome octavo wol-
Vol. II., DISLoCA-
Either volume separately, cloth, $3.00; leather, $4.00,
The appearance of the second volume marks the
completion of the author's original plan of prepar.
ing a work which should present in the fullest
manner all that is known on the cognate subjects
of Fractures and Dislocations. The volume on
Fractures assumed at once the position of authority
on the subject, and its companion on Dislocations
will no doubt be similarly received. The closing
volume of Dr. Stimson's work exhibits the surgery
of Dislocations as it is taught and practised by the
most eminent surgeons of the present time. Com-
taining the results of such extended researches it
must for a long time be regarded as an authority
on all subjects pertaining to dislocations. Every
º of surgery, will feel it incumbent on
im to have it for constant reference.—Cincinnati
Medical News, May, 1888.
HAMILTON, FRA NEC H., M. D., L.L. D.,
Surgeon to Bellevue Hospital, New York.
A Practical Treatise on Fractures and Dislocations.
Seventh edition
thoroughly revised and much improved. In one very handsome octavo volume of 998
pages, with 379 illustrations.
Cloth, $5.50:
leather, $6.50.
This book is without a rival in any language. It fully given. The book is so well known that it does
is essentially a practical treatise, and it gathers | not require any lengthened review. We can only
within its covers almost everything valuable that say that it is still una.
has been written about fractures and dislocations.
The principles and methods of treatment are very
roached as a treatise.-
The Dublin Journal of Medical Science, Feb. 1886.
PICK, T. PICECE RING, F. R. C. S.,
Surgeon to and Lecturer on Surgery at St. George's Hospital, London.
Fractures and Dislocations.
illustrations.
In one 12mo, volume of 530 pages, with 93
Limp cloth, $2.00. See Series of Clinical Manuals, page 31.
LEA BROTHERs & Co.'s PUBLICATIONS-Otol., Ophthal.
23
BURNETT, CHARLES H.,
A. M., M. D.,
Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society.
The Ear, Its Anatomy, Physiology and Diseases.
for the use of Medical Students and Practitioners.
A Practical Treatise
Second edition. In one handsome
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00; leather, $5.00.
We note with pleasure the appearance of a second
edition of this valuable work. When it first came
out it was accepted by the profession as one of
the standard works on modern aural surgery in
the English language; and in his second edition
Dr. Burnett has fully maintained his reputation,
for the book is replete with valuable information
and suggestions. The revision has been carefully
carried out, and much new matter added. Dr.
Burnett's work must be regarded as a very valua-
ble contribution to aural surgery, not only on
account of its comprehensiveness, but because it
contains the results of the careful personal observa-
tion and experience of this eminentaural surgeon.
—London Lancet, Feb. 21, 1885.
POLITZER, ADAM,
Imperial-Royal Prof. of Awral Therap. in the Univ. of Vienna.
A Text-Book of the Ear and its Diseases. Translated, at the Author’s re-
quest, by JAMES PATTERSON CASSELLs, M. D.,
ume of 800 pages, with 257 original illustrations.
The whole work can be recommended as a reli-
able guide to the student, and an efficient aid to
M. R. C. S. In one handsome octavo vol-
Cloth, $5.50.
the practitioner in his treatment.—Boston Medical
and Surgical Journal, June 7, 1883.
IBERRY, GEORGE A., M. B., F. R. C. S., Ed.,
Ophthalmic Surgeon, Edinburgh Royal Infirmary.
Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In
one octavo volume of 683 pages, with 144 illustrations, 62 of which are beautifully
colored. Cloth, $7.50.
This newest candidate for favor among ophthal-
mological students is designed to be i. clinical
in character and the plan is well adhered to. We
have been forcibly struck by the rare good taste
in the selection of what is essential which per-
vades the book. The author seems to have the
uncommon faculty of viewing his subject as a
whole and seizing the salient points and not con-
fusing his reader—presumably a student and a
novice—with a mass of details with no key to their
unravelling. It is apparent that the literature of
each subject has been gone over in a very thor-
ough manner. The fact that he was writing a
clinical treatise for beginners and not an encyclo-
adia has always been present with the author.
he number and excellence of the colored illus-
trations in the text deserve more than a passing
notice.—Archives of Ophthalmology, Sept. 1889.
JULER, HENRY E., F. R.
C. S.,
Senior Ass’t Surgeon, Royal Westminster Ophthalmic Hosp.; late Clinical Ass’t, Moorfields, London.
A Handbook of Ophthalmic Science and Practice. Handsome 8vo. vol-
ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of
Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50; leather, $5.50.
It presents to the student concise descriptions
and typical illustrations of all important eye affec:
tions, placed in juxtaposition, so as to be grasped
at a glance Beyond a doubt it is the best illus-
taleã handbook of ophthalmic science which has
ever appeared. Then, what is still better, these
illustrations are nearly all original. We have ex-
amined this entire work with great care, and it
represents the commonly accepted views of ad-
vanced ophthalmologists. We can most heartily
commend this book to all medical students, prad-
titioners and specialists.-Detroit Lancet, Ján. '85.
NETTLESHIP, EDWARD,
IF. IR. C. S.,
Ophthalmic Surg. and Lect. on Ophth. Surg. at St. Thomas' Hospital, London.
The Student’s Guide to Diseases of the Eye. New
oughly revised. With a chapter on the Detection of Color-Blin
THOMson, M.D., Professor of Ophthalmology in the Jefferson Medical College.
º edition, thor-
ness, by WILLIAM
In one
12mo, volume of 479 pages, with 164 illust, test-types and formulae. Cloth, $2.
The extent of the sale of this now accepted
authority has conclusively shown that its claim for
favor was not an imaginary one. The introductory
chapter on optical outlines is a wonderfully clear
statement of the principles involved. The writer’s
in the chapter devoted to operations. A very
important part of the work to general practitioners
is that, embraced in the consideration of eye dis-
eases in relation to general diseases and condi-
tions. The arrangement of the remedies employed
decision of character has fully impressed his pro- into a formulary is adopted, and it contains much
duction, and this is nowhere more apparent than | useful knowledge.—South. Practitioner, Dec. 1887.
INO RRIS, WM. F., M. D., and OLIVER, CHAS. A., M. D.
Clin. Prof. of Ophthalmology in Univ. of Pa.
A Text-Book of Ophthalmology. In one octavo volume of about 500 pages,
with illustrations. Preparing.
CARTER, R. B.R.U.D.E.NELL, & FROST, W. A. DAMS,
I'. R. C. S.,
Ophthalmic Surgeon to and Lect, on Ophthal-
ondon.
mic Surgery at St. George's Hospital,
F. R. C. S.,
Ass’t Ophthalmic Surgeon and Joint Lect.
on Oph. Sur., St. George's Hosp., London.
Ophthalmic Surgery. In one 12mo, volume of 559 pages, with 91 woodcuts,
color blindness test, test-types and dots and appendix of formulae.
Series of Clinical Manuals, page 31.
Cloth, $2.25. See
WELLS ON THE EYE. In one octavo volume.
LAURENCE AND MOON'S HANDY BOOK OF
OPHTHALMIC SURGERY, for the use of Prag-
In one octavo Wol-
titioners. Second edition.
ume of 227 pages, with 65 illus. Cloth, $2.75.
LAWSON ON INJURIES TO THE EYE, ORBIT
AND EYELIDS: Their Immediate and Remote
Effects. In one octavo volume of 404 pages, with
92 illustrations. Cloth, $3.50.
24 LEA BROTHERS & Co.'s PUBLICATIONS-Urin. Dis., Dentistry, etc.
IEO BEIRTS, WILLIAM, M. D.,
Lecturer on Medicine in the Manchester School of Medicine, etc. . . *
A Practical Treatise on Urinary and Renal Diseases, including Uri-
nary Deposits.
some octavo volume of 609 pages, with 81 illustrations,
It may be said to be the best book in print on the
subject of which it treats.-The American Journal
of }. Medical Sciences, Jan. 1886.
The peculiar value and finish of the book are in
a measure derived from its resolute maintenance
of a clinical and practical character. It is an un-
rivalled exposition of everything which relates
directly or indirectly to the diagnosis, prognosis
and treatment of urinary diseases, and possesses
a completeness not found elsewhere in our lan-
Fourth American from the fourth Londom edition.
In one hand-
Cloth, $3.50.
§ºgº in its account of the different affections.—
The Manchester Medical Chronicle, July, 1885.
The value of this treatise as a guide book to the
physician in daily practice can hardly be over-
estimated. That it is fully up to the level of our
present knowledge is a fact reflecting great credit
upon Dr. Roberts, who has a wide reputation as a
; practitioner.—The Medical Record; July 31,
86.
PUR DY, CHARLES W., M. D., Chicago.
IBright's Disease and Allied Aº of the Kidneys.
oth, $2.
volume of 288 pages, with illustrations.
The object of this work is to “furnish a system-
atic, practical and concise description of the
athology and treatment of the chief organic
#. of the kidney associated with albuminu-
ria, which shall represent the most recent ad-
wańces in our knowledge on these subjects; ” and
this definition of the object is a fair description of
the book. The work is a useful one, giving in a
In one octavo
short space the theories, facts and treatments, and
going more fully into their later developments.
On treatment the writer, is particularly strong,
steering clear of generalities, and seldom omi
ting, what text-books usually do, the unimportant
items which are all important to the #. prac-
titioner.—The Manchester Medical Chronicle, Oct.
1886.
MORRIS, HENRY, M. B., F. R. C. S.,
Surgeon to and Lecturer on Surgery at Middlesea: Hospital, London.
Surgical Diseases of the Kidney.
In one 12mo, volume of 554 pages, with 40
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31.
In this manual we have a distinct addition to
surgical literature, which gives information not
elsewhere to be met with in a single work. Such
a book was distinctly required, and Mr. Morris
has very diligently and ably performed the task
he took in hand. It is a full and trustworthy
book of reference, both for students and prac-
titioners in search of guidance. The illustrations
in the text and the chromo-lithographs are beau-
tifully executed.— The London Lancet, Feb. 26, 1886.
LUCAS, CLEMENT, M. B.,
Senior Assistant Surgeon to Guy's Hospital, London.
In one 12mo, volume.
T)iseases of the Urethra.
of Clinical Manuals, page 4.
E. S., F. R. C. S.,
Preparing. See Series
THOMPSON, SIR HENRY,
Surgeon and Professor of Clinical Surgery to University College Hospital, London.
Lectures on Diseases of the Urinary Organs.
Second American from the
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25.
By the Same Author.
On the Pathology and Treatment of Stricture of the Urethra and
Urinary Fistulae.
From the third English edition. In one octavo volume of 359
pages, with 47 cuts and 3 plates. Cloth, $3.50.
TEIE AMERICAN SYSTEM OF DENTISTRY.
In Treatises by Various Authors.
Edited by WILBUR. F. LITCH, M. D.,
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con-
taining 3160 pages, with 1863 illustrations and 9 full page plates, Per volume, cloth, $6;
leather, $7; half Morocco, gilt top, $8. The complete work is now ready. For sale by
subscription only.
As an encyclopædia of Dentistry it has no Su-
erior. It should form a part of every dentist's
ibrary, as the information it contains is of the
reatest value to all engaged in the practice of
š., "... Jour. Dent. Sci., Sept. 1886.
A grand system, big enough and good enough
and handsome enough for a monument (which
doubtless it is), to mark an epoch in the history of
dentistry. Déntists will be satisfied with it and
proud of it—they must. It is sure to be precisely
what the student needs to º him and keep him
in the right track, while, the profession at large
will receive incalculable benefit from it.—Odonto-
graphic Journal, Jan. 1887.
COLEMAN, A., L. Ič. C. IP.,
F. Ič. C. S., JEaca/m. L. ID. S.,
Senior Dent. Surg, and Lect, on Dent. Surg. at St. Bartholomew's Hosp, and the Dent. Hosp., London;
A Manual of Dental Surgery and Pathology. Thoroughly revised and
adapted to the use of American Students
by THOMAS C. STELLWAGEN, M.A.,
M. D.,
D. D. S., Prof. of Physiology in the fhiladelphia Dental College. In one handsome octavo
volume of 412 pages, with 331 illustrations.
It should be in the possession of every practi-
tioner in this country. The part devoted to first
and second dentition and irregularities in the per-
manent teeth is fully worth the price. In fact,
price should not be considered in purchasing such
a work. If the money put into some of our so-
called standard text-books could be converted into
such publications as this, much good would result.
—Southern Dental Journal, May, 1882.
Cloth, $3.25. *
The author brings to his task a large experience
acquired under the most favorable circumstances,
There have been added to the volume a hundred
pages by the American editor, embodying the
views of the leading home teachers in dental Sur-
gery. The work, therefore, may be regarded, as
strictly abreast of the times, and as a very high
authority on the subjects of which it treats.-
American Practitioner, July, 1882.
BASHAM ON RENAL DISEASES: A Clinical
Guide to their Diagnosis and Treatment. In
one 12mo, vol. of 304 pages, with 21 illustrations.
Cloth, $2.00.
LEA BROTHERS & Co.'s PUBLICATIONS-Venereal, Impotence. 25
GROSS, SAMUEL W., A. M., M. D., L.L. D.,
Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila.
A Practical Treatise on Impotence, Sterility, and Allied Disorders
of the Male Sexual Organs.
New (4th) edition, thoroughly revised by F. R.
STURGIs, M.D., Prof. of Diseases of the Genito-Urinary Organs and of Venereal Diseases,
N. Y. Post Grad. Med. School.
pages, with about 20 illustrations.
In one very handsome octavo volume of about 175
Preparing.
A few notices of the previous edition are appended.
It must be gratifying to both author and pub-
lishers that large first and second editions of this
little work were so soon exhausted, while the fact
that it has been translated into Russian may indi-
cate that it filled a void even in foreign literature.
His is a careful and physiological study of the
sexual act, so far as concerns the male, and all
his conclusions are scientifically reached. The
book has a place by itself in our literature, and
furnishes a large fund of information concerning
important matters that are too often passed over
in silence.—The Medical Press, June, 1887.
TAYLOR, R. W., A. M., M. D.,
Surgeon to Charity Hospital, New York, Prof. of Venereal and Skin Diseases in the University of
Vermont, Pres. of the Am. Dermatological Ass’n.
The Pathology and Treatment of Venereal Diseases.
results of recent investigations upon the subject. Being the sixth edition of Bumstead
and Taylor.
Entirely rewritten by Dr. Taylor.
with about 150 engravings, as well as numerous chromo-lithographs.
A few notices of the previous edition are appended.
It is a splendid record of honest labor, wide
research, just comparison, careful scrutiny and
original experience, which will always be held, as
a high credit to American medical literature. This
is not only the best work in the English language
§§ the subjects of which it treats, but also one
which has no equal in other tongues for its clear,
comprehensive and practical handling of its
themes.—Am. Jowr. of the Med. Sciences, Jam, 1884.
It is certainly the best single treatise on vene-
real in our own, and probably the best in any lan-
guage.—Boston Med. and Surg. Journal, April 3, 1884.
The character of this standard work is so well
CORNIL, V.,
Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital.
Syphilis, its Morbid Anatomy, Diagnosis and Treatment.
by the Author, and translated with notes and additions by J. HENRY C. SIMEs,
revise
M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. WILLIAM
WHITE, M. D., Lecturer on Venereal Diseases, Univ. of Pa.
volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75.
The anatomy, the histology, the pathology and
the clinical features of syphilis are represented in
this work in their best, most practical and most
instructive form, and no one will rise from its
EIUTCHINSON, JONATHA N, F. R. S., F. R. C. S.,
Consulting Surgeon to the London Hospital.
Syphilis.
In one 12mo, volume of 542 pages, with 8 chromo-lithographs.
$2.25. See Series of Clinical Manuals, page 31.
Those who have seen most of the disease and
those who have felt the real difficulties of diagno-
sis and treatment will most highly appreciate the
facts and suggestions which abound in these
* It is a worthy and valuable record, not
only of Mr. Hutchinson's very large experience
GIROSS, S. D., M. D., L.L. D., D. C. L., etc.
A Practical Treatise on the Diseases, Injuries and Malformations
of the Urinary Bladder, the Prostate Gland and the Urethra.
edition, thoroughly revised by SAMUEL W. GROSS, M. D. In one octavo volume of 574
pages, with 170 illustrations. Cloth, $4.50.
CULLERIER, A., & BUIMSTEAD, F. J., M.D., LL.D.,
Surgeon to the Hôpital du Midi.
An Atlas of Venereal Diseases.
Late Professor#. Venereal Diseases in the College of Physicians
and Swrgeons, New
STEAD, M. D. In one imperial 4to, volume of 328 pages, double-columns, with 26 plates,
containing about 150 figures, beautifully colored, many of them the size of life.
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts.
HILL ON SYPHILIS AND LOCAL CONTAGIOUS
DISORDERS. In one 8wo vol. of 479 p. Cloth, $3.25.
LEF's LECTURESTON'SYPHiffs' AND 3.5M;
This now classical work on the subject of ::::::::
tence and sterility in the male needs no extended
review, for it is already well known to the pro-
fession. Dr. Gross has by his tireless labor done
more towards clearing up the diagnosis and treat-
ment of these obscure cases than any other Ameri-
can physician. The fact that this book has rapidly
run through two large editions, and that the author
is now forced to issue a third, is good and sufficient
evidence of its excellence.—Atlanta Medical and
Surgical Journal, April, 1888. -
Including the
Large 8vo. volume, about 900 pages,
Preparing.
known that it would be superfluous here to pass in
review its general or special points of excellence.
The verdict of the profession has been passed; it
has been accepted as the most thorough and com-
plete º of the pathology and treatment of
venereal diseases in the language. Admirable as a
model of clear description, an exponent of Sound
pathological doctrine, and a guide for rational and
successful treatment, it is an ornament to the medi-
cal literature of this country. The additions made
to the present edition are eminently judicious,
from the standpoint of º utility.—Journal of
Cutaneous and Venereal Diseases, Jan. 1884.
Specially
In one handsome octavo
perusal without the feeling that his gº of the
wide and important subject on which it treats is
a stronger and surer one.—The London Practi-
tioner, Jan. 1882.
Cloth,
and power of observation, but of his patience and
assiduity in taking notes, of his cases, and keep-
ing them in a form available for such excellent
use as he has put them to in this volume.—London
Medical Record, Nov. 12, 1887.
Third
York.
Translated and edited by FREEMAN J. BUM-
Strongly
FORMS OF LOCAL DISEASE AFFECTING
PRINCIPALLY THE ORGANS OF GENERA-
TION. In one 8vo. vol. of 246 pages. Cloth, $2.25.
26
LEA BROTHERs & Co.'s PUBLICATIONs—Venereal, Skin.
TAYLOR, ROBERT W., A. M., M. D.,
Surgeon to Charity Hospital, New York, and to the Department of Venereal and Skin Diseases of
the New York Hospital.
A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis,
Prognosis and Treatment.
In eight large folio parts, measuring 14 x 18 inches, and
comprising 58 beautifully-colored plates with 213 figures, and 431 pages of text with 85
engravings. Complete work just ready. Price per part, $2.50. Bound in one volume,
half Russia, $27; half Turkey Morocco, $28.
plates sent on receipt of 10 cents.
The completion of this monumental work is a
subject of congratulation, not only to the author
and publishers, but to the profession at large ;
indeed it is to the latter that it directly appeals as
a wonderfully clear exposition of a confessedly
difficult branch of medicine Good literature has
joined hands with good art with highly satisfac.
tory results for hoth. There are altogether 213
figures, many of which are life size, and represent
the highest perfection of the chromo-litho-
graphic art, and scattered throughout the text are
innumerable engravings. Quite a proportion of
these illustrations are from the author’s own
collection, while on the other hand the best
atlases of the world have been drawn upon for
the most typical and successful pictures of the
many different types of venereal and skin dis
G8 Se. We think we may say without undue
exaggeration that the reproductions, both in color
and in black and white, are almost invariably
successful. The text is practical, full of , thera-
peutical suggestions, and the clinical accounts of
disease are clear and incisive. Dr. Taylor is,
happily, an eminent authority in both departments,
and we find as a consequence that the two divis-
ions of this work possess an equal scientific and
literary merit. We have already passed the limits
A full prospectus sent to any address on application.
HYDE, J. NE WINS, A. M., M. D.,
Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago.
A Practical Treatise on Diseases of the Skin.
In one handsome octavo volume of 676 pages,
Practitioners. New (second) edition.
with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50.
We can heartily commend it, not only as an
admirable text-book for teacher and student, but
in its clear and comprehensive rules for diagnosis,
its sound and independent doctrines in pathology,
and its minute, and judicious directions for the
treatment of disease, as a most satisfactory and
complete practical guide for the physician.—Ameri-
can Journal of the Medical Sciences, July, 1888.
A useful glossary descriptive of terms is given.
The descriptive portions of this work are plain
and easily understood, and above all are very
accurate. The therapeutical part is abundantly
supplied with excellent recommendations. The
P. part is well done. The value of the work
o practitioners is great because of the excellence
of the descriptions, the suggestiveness of the
advice, and the correctness of the details and the
principles of therapeutics impressed upon the
reader.— Virginia Med. Monthly, May, 1888.
FOX, T., M. D., F.R.C. P., and FOX, T. C., B.A., M.R.C.S.,
Physician to the Department for Skin Duseases,
University College Hospital, London.
An Epitome of Skin Diseases.
With Formulae.
titioners. Third edition, revised and enlarged. In one very handsome 12mo, volume
of 238 pages. Cloth, $1.25.
The third edition of this convenient handbook
Calls for notice owing to the revision and expansion
which it has undergone. The arrangement of skin
diseases in alphabetical order, which is the method
of classification adopted in this work, becomes a
positive advantage to the student. The book is
one which we can strongly recommend, not only
to students but also to practitioners who require a
compendious summary of the present state of
dermatology.-British Medical Journal, July 2, 1883.
We cordially recommend Fox's Epitome to those
whose time is limited and who wish a handy
WILSON, ERASMUS, F. R. S.
The Student's Book of Cutaneous Medicine and Diseases of the Skin.
In one handsome small octavo volume of 535 pages.
HILLIER'S HANDBOOK OF SIKIN DISEASES;
for Students and Practitioners. Second Ameri-
For sale by subscription only. Specimen
allotted to a notice of this kind, and while we
have nothing but praise for this admirable atlas,
it must be said in justification that it is more than
warranted by the merits of the work itself.—
The Medical News, Dec. 14, 1889.
It would be hard to use words which would per-
spicuously enough convey to the reader the great
value of this Clinical Atlas. This Atlas is more
complete even than an ordinary course of clinical
lectures, for in no one college or hospital course
is it at all probable that all of the diseases herein
represented would be seen. It is also more ser-
viceable to the majority of students than attend-
ance upon clinical lectures, for most of the
students who sit on remote seats in the lecture
hall cannot see the subject as well as the office
student can examine these true to-life chromo-lith-
ographs. Comparing the text to a lecturer, it is
more satisfactory in exactness and fulness than
he would be likely to be in lecturing over a single
case. Indeed, this Atlas is invaluable to the gem-
eral practitioner, for it enables the eye of the
physician to make diagnosis of a given case of
skin manifestation by comparing the case with
the picture in the Atlas, where will be found also
the text of diagnosis, pathology, and full sections
on treatment.— Virginia Medical Monthly, Dec., 1889.
For the use of Students and
The second edition of his treatise is like his
clinical instruction, admirably arranged, attractive
in diction, and strikingly practical throughout.
The chapter on general symptomatology is a model
in its way; no clearer description of the various
º and consecutive lesions of the skin is to
e met with anywhere. Those on general diagno:
sis and therapeutics are also worthy of careful
study. Dr. Hyde has shown himself a compre-
hensive reader of the latest literature, and has in-
corporated into his book all the best of that which
the past years have brought forth. The prescrip:
tions jº. are given in both common and
metric systems. Text and illustrations are good
and colored plates of rare cases lend additiona
attractions. Altogether it is a work exactly fitted
to the needs of a general practitioner, and no Qne
will make a mistake in purchasing it.—Medical
Press of Western New York, June, 1888.
Physician for Diseases of the Skin to the
Westminster Hospital, London.
For Students and Prac-
manual to lie upon the table for instant reference.
Its alphabetical arrangement is suited to this use,
for all one has to know is the name of the disease,
and here are its description and the appropriate
treatment at hand and ready for instant appliº-
tion. The present edition has been very carefully
revised .# a number of new diseases., are de-
scribed, while most of the recent additions to
dermal therapeutics find mention, and the formº:
lary at the end of the book has been considerably
augmented.—The Medical News, December, 1883.
Cloth, $3.50.
| can edition.
In one 12mo. volume of 353 pages,
with plates. Cloth, $2.25.
LEA BROTHERS & Co.'s PUBLICATIONs—Dis. of Women. 27
The American Systems of Gynecology and Obstetrics.
Systems of Gynecology and Obstetrics, in Treatises by American
Authors. Gynecology edited by MATTHEw D. MANN, A.M., M.D., Professor of Obstetrics
and Gynecology in the Medical Department of the University of Buffalo; and Obstet-
rics edited by BARTON CookE HIRST, M. D., Associate Professor of Obstetrics in the
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con-
taining 3612 pages, 1092 engravings and 8 plates. Complete work just ready. Per vol-
ume: Cloth, $5.00 ; leather, $6.00; half Russia, $7.00. For sale by subscription only.
Address the Publishers. Full descriptive circular free on application.
LIST OF CONTRIBUTORS.
WILLIAM H. BAKER, M. D.,
ROBERT BATTEY, M. D.
SAMUEL C. BUSEY, M. D.,
jAMES C. CAMERóN. M. p
HENRY C. COE, A. M., M. D
EDWARD P. DAVIS, M. D.,
G. E. De SCHWEINITZ, M. D.,
F. C. DUDLEY, A. B., M. D.,
5. McE. EMMÉ'ſ, M.'ſ,
GEORGE J. FNGELMANN, M. D.,
HENRY J. GARRIGUES, A. M., D
WILLIAM GOODELL, A. M., M. D.
ÉGEER’ſ H. GRANDIN. A. M. M. D.
SAMUEL W. GROSS, M.D.,
ROBERT P. HARRIS, M. D.,
GEORGE T. HARRISON, M.D.,
BARTON. C. H. IRST, M. D.
STEPHEN Y. Höw'ELL, M. D.,
A. REEVES JACKSON, A. M., M. D.,
W. W. JAGGARD, M. D.,
EDWARD W. J.ENKS, M. D., L.L. D.,
HOWARD A. KELLY, M. D.,
This is volume two of The American System of
Obstetrics, completing the wonderfully full series
issued from the house of Lea Brothers & Co. dur.
ing the past two years. Two magnificent volumes
devoted to gynecology, and now two like volumes
embracing everything pertaining to obstetrics.
These volumes are the contributions of the most
eminent gentlemen of this country in these de-
partments of the profession. Each contributor
presents a monograph upon his special topic,
apparently without restriction in space, so that
everything in the way of history, theory, methods,
and results is presented to our fullest need. The
work will long remain as a monument of great in-
dustry and good judgment. As a work of general
reference, it will be found remarkably full and in-
structive in every direction of inquiry.—The Ob-
8tetric Gazette, September, 1889.
There can be but little doubt that this work will
find the same favor with the profession that has
been accorded to the “System of Medicine b
American Authors,” and the “System of Gynecol-
§ by American Authors.” One is at a loss to know
what to say of this volume, for fear that just and
merited praise may be mistaken for flattery. The
subjects of some of the papers are discussed in
various works on obstetrics, though not to the full
extent that is found in this volume. The papers
of Drs. Engelmann, Martin, Hirst, Jaggard and
Reeve are incomparably beyond anything that can
be found in obstetrical works. Certainly the Edi-
• ?
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3.
THOMAS, T. GAILLAR D, M. D., L.L. D.,
Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y...
A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly
revised and rewritten.
illustrations. Cloth, $5.00; leather, $6.00.
In one large and handsome octavo volume of 810 pages, with 266
That the previous editions of the treatise of Dr. trician and gynaecologist as a safe guide to practice.
Thomas were thought worthy of translation into
German, French, Italian and Spanish, is enough
to give it the stamp of genuine merit. At home it
has made its way into the library of every obste-
IEDIS, AIRTHUR W., M. D., Lond., F. R. C. P., M. R. C. S.,
Assist. Obstetric Physician to Middlesea: Hospital, late Physician to British Lying-in Hospital.
. The Diseases of Women.
Diagnosis and Treatment.
It is a, pleasure to read a book so thoroughly
good as this one. The special qualities which are
Conspicuous are , thoroughness in covering the
Whole ground, clearness of description and con-
eiseness of statement. Another majºed feature of
the book is the attention paid to the details of
many minor surgical operations and procedures
as, for instance, the use of tents, application of
leeches, and use of hot water injections. These
Including their Pathology, Causation, Symptoms,
A Manual for Students and Practitioners. In one handsome
octavo volume of 576 pages, with 148 illustrations.
CHARLES CARROLL LEE, M. D.,
WILLIAM T. LUSK, M. D., L.L. D.,
j. HENDRIE fióYi), M. f. ,
MATTHEW D. MANN, A. M., M. D.,
H. Niº whil, MARTIN. F. R. S., M. D.,
D.Sc., M.A.,
RICHARAE, B. MAURY, M. D.,
C. D. PALM ER, M. D.,
ROSWELL PARK, M.D.,
THEOPHILUS PARVIN, M. D., LL.D.,
R. A. F. PENROSE, M. D., LL.D.,
THADDEUS A. REAMY, A. M., M. D.,
J. C. REEVE, M. D.,
A. D. ROCKWELL, A. M., M. D.,
ALEXANDER. J. C. SKENE, M. D.,
J. LEWIS SMITH, M. D.,
STEPHEN SMITH, M. D.,
R. #A spury SUTTON, A. M., M. D.,
-1 - 12 - ?
T. GAILLARD THOMAS, M. D., L.L. D.,
ELY WAN DE WARKER, M. D.,
W. GILL WYLIE, M. I.).
tor may be congratulated for having made such a
wise selection of his contributors.—Journal of the
American Medical Association, Sept. 8, 1888.
In our notice of the “System of Practical Medi-
cine by American Authors,” we made the follow-
ing statement:—“It is a work of which the pro-
fession in this country can feel proud. Written
exclusively by American physicians who are ac-
uainted with all the varieties of climate in the
nited States, the character of the soil, the man-
ners and customs of the people, etc., it is pecul-
iarly adapted to the wants of American practition-
ers of medicine, and it seems to us that every one
of them would desire to have it.” Every word
thus expressed in regard to the “American Sys-
tem of Practical Medicine” is applicable to the
“System of Gynecology by American Authors,”
which we desire now to bring to the attention of
our readers. It, like the other, has been written
...} § American physicians who are
acquainted with all the characteristics of American
people, who are well informed in regard to the
peculiarities of American women, their manners,
customs, modes of living, etc. As every practis-
ing physician is called upon to treat diseases of
females, and as they constitute a class to which
the family physician must give attention, and
cannot pass over to a specialist, we do not know of
a work in any department of medicine that We
should so strongly recommend medical men gen-
erally purchasing.—Cincinnati Med. News, July, 1887.
No small number of additions have been made to
the present edition to make it correspond to re-
cent improvements in treatment.—Pacific Medical
and Surgical Journal, Jan. 1881.
Cloth, $3.00; leather, $4.00.
are among the more common methods of treat-
ment, and yet very little is said about them in
many of the text-books. The book is one to be
warmly recommended especially to students, and
general practitioners, who need a concise but com-
plete résumé of the whole subject. Specialists, too,
will find many useful hints in its pages,—Boston
Med, and Surg. Journ., March 2, 1882.
28
LEA BROTHERS & Co.'s PUBLICATIONs—Dis. of Women, Midwfy.
FMMET, THOMAS AID DIS, M. D., L.L. D.,
Surgeon to the Woman's Hospital, New York, etc.
The Principles and Practice of Gynaecology; For the use of Students and
Practitioners of Medicine.
New (third) edition, thoroughly revised. In one large and very
handsome octavo volume of 880 pages, with 150 illustrations.
Cloth, $5; leather, $6;
very handsome half Russia, raised bands, $6.50.
We are in doubt whether to congratulate the
the privilege thus offered them of perusing the
author more than the profession upon the appear- views and practice of the author. His earnestness
ance of the third edition of this well-known work.
Embodying, as it does, the life-long experience of
one who has conspicuously distinguished himself
as a bold and successful operator, and who has
devoted so much attention to the specialty, we
feel sure the profession will not fail to appreciate
of purpose and conscientiousness are manifest.
He gives not only his individual experience but
endeavors to represent the actual state of gynae-
cological science and art.—British Medical Jowr-
mal, May 16, 1885.
TAIT, LA WSON, F. R. C. S.,
Professor of Gymoecology in Queen's College, Birmingham ; late President of the British Gyne-
cological Society; Fellow American Gynecological Society.
Diseases of Women and Abdominal Surgery. In two very handsome
Octavo volumes.
teady. Volume II., preparing.
The plan of the work does not indicate the regu-
lar system of a text book, and yet nearly every-
thing of disease pertaining to the various organs
receives a fair consideration. The description of
diseased conditions is exceedingly clear, and the
treatment, medical or surgical, is very satisfactory.
Volume I., 554 pages, 62 engravings and 3 plates.
Cloth, $3. Just
Much of the text is abundantly illustrated with
cases, which add value in showing the results of
the suggested plans of treatment. We feel con:
fident that few gynecologists of the country will
fail to place the work in their libraries.—Thé
Obstetric Gazette, March, 1890.
DAVENPORT, F. H., M. D.,
Assistant in Gymoecology in the Medical Department of Harvard University, Boston.
Diseases of Women, a Manual of Non-Surgical Gynaecology. De-
signed especially for the Use of Students and General Practitioners.
12mo, volume of 317 pages, with 105 illustrations.
We agree with the many reviewers whose no-
tices we have read in other journals congratulating
Dr. Davenport on the success which he has
attained. He has tried to write a book for the
student and general practitioner which would
tell them just what they ought to know without
distracting their attention with a lot of compila-
tions for which they could have no possible use.
In this he has been eminently successful. There
is not even a paragraph of useless matter.
In one handsome
Cloth, $1.50. Just ready.
Everything is of the newest, freshest and most
practical, so much so that we have recommended
it to our class of gynecology students. What the
author advises in the way of treatment has all
been practically tested by himself, and each
method receives only so much commendation as he
has found that it deserves. We are sure, that
these good qualities will command for it a large
sale.—Canada Medical Record, Dec. 1889.
MAY, CHARLES H., M. D.,
Late House Surgeon to Mount Sinai Hospital, New York.
A Manual of the Diseases of Women. Being a concise and Systematic expo-
sition of the theory and practice of gynecology.
New (2d) edition, edited by L. S. Rau,
M. D., Attending Gynecologist at the Harlem Hospital, N.Y. In one 12mo, volume of
360 pages, with 31 illustrations
This is a manual of gynecology in a very con-
densed form, and the fact that a second edition
has been called for indicates that it has met with
a favorable reception. It is intended, the author
tells us, to aid the student who after having care-
fully perused larger works desires to review the
subject, and he adds that it may be useful to the
practitioner who wishes to refresh his memory
Cloth, $1.75. Just ready.
DUNCAN, J. MATTHEWS, M.D., L.L. D., F. R. S. E., etc.
Clinical Lectures on the Diseases of Women; Delivered in Saint Bar-
rapidly but has not the time to consult larger
works. We are much struck with the readiness
and convenience with which one can refer to any
subject contained in this volume. Carefully com:
piled indexes and ample illustrations also enrigh
the work. This manual will be found to fulfil its
purposes very satisfactorily.—The Physiciaſ, and
Surgeon, June, 1890.
tholomew's Hospital.
They are in every way worthy of their author;
indeed, we look upon them as among the most
valuable of his contributions. They are all upon
matters of great interest to the general practitioner.
Some of them deal with subjects that are not, as a
In one handsome octavo volume of 175 pages.
Cloth, $1.50.
rule, adequately handled in the text-books; Others
of them, while bearing upon topics that are usually
treated of at length in such works, yet bear such a
stamp of individuality that they deserve .59 be
widely read.—N. Y. Mºdical Journal, March, 1880.
HODGE ON DISEASES PECULIAR, TO WOMEN.
Including Displacements of the Uterus. Second
edition, revised and enlarged. In one beauti-
fully printed octavo volume of 519 pages, with
original illustrations. Cloth, $4.50
RAMSEof HAM's PRINöffiliš AND PRAC-
TICE OF OBSTETRIC MEDICINE AND
SURGERY. In reference to the Process of
Parturition. A new and enlarged edition, thor-
oughly revised by the Author. With additions
by W. W. KEAT.NG, M. D., Professor of Obstetrics,
etc., in the Jefferson Medical College of Philº,
delphia. In one large and handsome in erial
octavo volume of 610 pages, with 64 full page
plates and 43 woodcuts in the text, containing tº
all nearly 200 beautiful figures. Strongly bound
in leather, with raised bands, $7.
wfisi's fijófúRES ON THE DISEASES OF
WOMENT Third American from the third Lom-
don edition. In one octavo volume of 543 pages.
Cloth, $3.75; leather, $4.75,
LEA BROTHERS & Co.'s PUBLICATIONS–Midwifery.
29
PLAYFAIR, W. S., M. D., F. R. C. P.,
Professor of Obstetric Medicine in King'8 College, London, etc.
A Treatise on the Science and Practice of Midwifery.
New (fifth)
American, from the seventh English edition. Edited, with additions, by ROBERT P. HAR:
RIs, M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5
plates.
Playfair's Midwifery has for many years been a
favorite authority both among obstetric teachers
and general practitioners of the obstetric art. A
work of this kind having reached a fifth American
from the seventh English edition would seem
scarcely to require any extended notice. Of
revious American editions the matter has been
º, rewritten or remodelled, besides many
new short notes have been added. For either the
student or the old practitioner this work meets
all needs; it is full and yet condensed; it is clear
and well arranged.—Obstetric Gazette, Nov., 1889.
Truly a wonderful book; an epitome of all ob-
stetrical knowledge, full, clear and concise. In
thirteen years it has reached seven editions. It
Cloth, $4.00; leather, $5.00. Just ready.
is perhaps the most popular work of its kind ever
présented to the profession... Beginning with the
anatomy and physiology of the organs concerned,
nothing is left unwritten that the practical ac-
coucheur, should know. It seems that every
conceivable physiological or pathological condi-
tion from the moment of conception to the time
of complete involution has had the author's
patient attention. The plates and illustrations,
carefully studied, will teach the science of mid-
wifery. The reader of this book will have before
him the very latest and best of obstetric practice
and also of all the coincident troubles connecte
therewith.-Southern Practitioner, Dec., 1889.
JKING, A. F. A., M. D.,
Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer-
sity, Washington, D. C., and in the University of Vermont, etc.
A Manual of Obstetrics.
volume of 432 pages, with 140 illustrations.
Dr. King, in the preface to the first edition of
this manual, modestly states that “its purpose is
to furnish a good groundwork to the student at
the beginning of his obstetric studies.”. Its pur-
pose is attained; it will furnish a good ground-
Work to the student who carefully reads it; and
further, the busy practitioner should not scorn the
yolume because written for students, as it con-
tains much valuable obstetric knowledge, some
of which is not found in more elaborate text-
books. The chapters on the anatomy of the
female generative organs, menstruation, fecunda-
tion, the signs of pregnancy, and the diseases of
pregnancy, are all excellent and clear; but it is in
New (fourth) edition.
In one very handsome 12mo.
Cloth, $2.50. Just ready.
the description of labor, both normal and abnor-
mal, that Dr. King is at his best. Here his style
is so concise, and the illustrations are so good,
that the veriest tyro could not fail to receive a clear
conception of labor, its complications and treat-
ment. Of the 141 illustrations it may be safely
said that they all illustrate, and that the engraver’s
work is excellent. The name of the publishers
is a sufficient guarantee that the work is pre-
sented in an attractive form, and from every
standpoint we can most heartily recommend the
book both to practitioner and student.—The Medi-
cal News, Dec. 7, 1889.
BARNES, ROBERT, M. D., and FA WCOURT, M. D.,
Phys. to the General Lying-in Hosp., Lond.
Obstetric Phys. to St. Thomas' Hosp., Lond.
A System of Obstetric Medicine and Surgery, Theoretical and Clin-
ical. For the Student and the Practitioner.
In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5; leather, $6.
Marshall.
The immediate purpose of the work is to furnish
a handbook of obstetric medicine and surgery
for the use of the student and practitioner. It is
not an exaggeration to say of the book that it is
the best treatise in the English language yet
published, and this will not be a surprise to those
who are acquainted with the work of the elder
Barnes. Every practitioner who desires to have
The Section on Embryology by Prof. Milnes
the best obstetrical opinions of the time in a
readily accessible and condensed form, ought to
own a copy of the book.-Journal of the American
Medical Association, June 12, 1886.
The Authors have made a text-book which is in
every way quite worthy to take a place beside the
best treatises of the period.—New York Medical
Journal, July 2, 1887.
PAR VIN, THEOPHILUS, M. D., L.L. D.,
Prof. of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila.
The Science and Art of Obstetrics.
New (2d) edition. In one handsome
8vo. Volume of about 700 pages, with about 225 engravings and a colored plate. Shortly.
IBARKER, FOR DYCE, A. M., M. D., L.L. D. Edin.,
Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College,
New York,
Obstetrical and Clinical Essays.
onorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc.
PARRY, JOHN S., M. D.,
Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia.
IExtra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50.
WINCREL, F.
A Complete Treatise on the Pathology and Treatment of Childbed,
For Students and Practitioners. Translated, with the consent of the Author, from the
second German edition, by J. R. CHADWICK, M. D. Octavo 484 pages. Cloth, $4.00.
ASHWELL’S PRACTICAL TREATISE ON THE
DISEASES PECULIAR, TO WOMEN. Third
American from the third and revised London
edition. In one 8vo. vol., P. 520. Cloth, $3.50.
TANNER ON PREGNANCY, Octavo, 490 pages,
colored plates, 16 cuts. Cloth, $4.25,
12mo, about 300 pages. Preparing.
CHURCHILL ON THE PUERPERAL FEVER
AND OTHER DISEASES PECULIAR TO WO-
MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50.
MEIGS ON THE NATURE, SIGNS AND TREAT-
MENT OF CHILDBED FEVER. In one 8vo.
volume of 346 pages. Cloth, $2.00.
30
LEA BROTHERS & Co.'s PUBLICATIONs—Midwfy., Dis. Childn.
LEISHMAN, WILLIAM, In, D.,
Regius Professor of Midwifery in the University of Glasgow, etc.
A System of Midwifery, Including the Diseases of Pregnancy and the
Puerperal State.
Third American edition, revised by the Author, with additions by
JoHN S. PARRY, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and
Very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50; leather,
$5.50.
The author is broad in his teachings, and dis-
cusses briefly the comparative anatomy of the pel-
yis and the mobility of the pelvic articulations.
The second chapter is devoted especially to
the study of the pe. while in the third the
female organs of generation are introduced.
The structure and development of the ovum are
admirably described. Then follow chapters upon
the various subjects embraced in the study of mid-
wifery. The descriptions throughout the work are
Fº aud pleasing. It is sufficient to state that in
his, the last edition of this well-known work, every
recent advancement in this field has been brought
forward.—Physician and Surgeon, Jan. 1880.
To the American student the work before us
must prove admirably adapted. Complete in all its
arts, essentially modern in its teachings, and with
emonstrations noted for clearness and precision,
it will gain in favor and be recognized as a work
of standard merit. The work cannot fail to be
opular and is cordially recommended.—N. O.
ed. and Surg. Journ., March, 1880.
It has been well and carefully written. The
views of the author are broad and liberal, and in-
dicate a well-balanced judgment, and matured
mind. We observe no spirit of dogmatism, but
the earnest teaching of the thoughtful observer
and lover of true science. Take the volume as a
whole, and it has few equals.—Maryland Medical
Journal, Feb. 1880. .
LANDIS, HENRY G., A. M., M. D.,
Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O.
The Management of Labor, and of the Lying-in Period.
In one
handsome 12mo, volume of 334 pages, with 28 illustrations. Cloth, $1.75.
The author has designed to place in the hands
9f the young practitioner a book in which he can
find necessary information in an instant. As far
as We can see, nothing is omitted. The advice is
Sound, and the proceedures are safe and practical.
Centralblatt für Gynakologie, December 4, 1886.
This is a book we can heartily recommend.
the author goes much more practically into the
qetails of the management of labor than most cal and Surgical Journal, Mar. 1886.
text-books, and is so readable throughout as to
tempt any one who should happen to commence
the book to read it through. The author pre-
supposes a theoretical knowledge of obstetrics,
and has consistently excluded from this little
work everything that is not of practical use in the
lying-in room. "We think that if it is as widely
read as it deserves, it will do much to improve
obstetric practice in general.—New Orleans Medi-
SMITH, J. LEWIS, M. D.,
Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y.
...A Treatise, on the Diseases of Infancy and Childhood. New (sixth)
edition, thoroughly revised and rewritten. In one handsome octavo volume of 867
pages, with 40 illustrations.
For years it has stood high in the confidence.of
the profession, and with the additions and alter-
ations now made it may be said to be the best
book in the language on the subject of which it
treats... An examination of the text fully sus-
tains the claims made in the preface, that “in
Fº the sixth edition the author has revised
he text to such an extent that a considerable
part of the book may be considered new.” If the
Yºn g practitioner proposes to place in his library
ut one book on the diseases of children, we
Would unhesitatingly say, let that book be the one
which is the subject of this notice.—The American
Journal of the Medical Sciences, April, 1886. -
No better work on children's diseases could be
placed in the hands of the student, containing, as
it does, a very complete account of the symptoms
and º of the diseases of early life, and
possessing the further advantage, in which it
stands alone amongst other works on its subject,
Of º; treatment in accordance with
the most recent therapeutical views.-British and
Foreign Medico-Chirurgical Review.
Those familiar with former editions of the work
Cloth, $4.50; leather, $5.50.
will readily recognize the painstaking with which
this revision has been made. Many of the articles
have been entirely rewritten. The whole work is
enriched with a research and reasoning which
plainly show that the author has spared neither
time nor labor in bringing it to its present ap-
proach towards perfection. The extended table of
contents and the well-prepared index will enable
the busy practitioner to reach readily and º
for reference the various subjects treated of in the
body of the work, and even those who are familiar
with former editions will find the improvements
in the present richly worth the cost of the work.--
Atlantá Medical and Surgical Journal, Dee. 1886.
Dr. Smith's work has justly become the standard
all over the world as the book on children's dis-
eases The whole book is admirable, both for the
raditioner and the student. Dr. Šmith writes
rom a large experience and a close observation
of cases at the bedside. He is extremely prac-
tical, and these facts make the work what it is—
the best of all works on the diseases of children.
— Virginia Medical Monthly, June, 1886.
OWEN, EDMUND, M. B., F. R. C. S.,
Surgeon to the Children's Hospital, Great Ormond St., London.
Surgical Diseases of Children.
In one 12mo, volume of 525 pages, with 4
chromo-lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical Manuals,
page 31.
Qne is immediately struck on reading this book
With its agreeable style and the evidence it every-
where presents of the practical familiarity of its pleasantly given.—Annals of Surgery, May, 1886.
author with his subject. The book may be
WEST, CHARLES, M. D.,
Physician to the Hospital for Sick Children, London, etc.,
On Some Disorders of the Nervous System in Childhood. In one small
12mo, volume of 127 pages. Cloth, $1.00.
CONDIE'S PRACTICAL TREATISE ON THE
DISEASES OF CHILDREN. Sixth edition, re-
homestly recommended to both students and
practitioners. It is full of sound information,
vised and augmented. In one octavo volume of
779 pages. Cloth, $5.25; leather, $6.25.
lPA BROTHERS & Co.'s PUBLICATIONS-Med. Juris., Miscel. 31
TIDY, CHAIRLES MEYMOTT, M. B., F. C. S.,
Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc.
Legal Medicine. VoIUME II. Legitimacy and Paternity, Pregnancy, Abor-
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia,
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc-
tavo volume of 529 pages. Cloth, $6.00; leather, $7.00.
VoIUME I. Containing 664 imperial octavo pages, with two beautiful colored
plates. Cloth, $6.00; leather, $7.00.
The satisfaction expressed with the first portion | tables of cases appended to each division of the
of this work is in no wise lessened by a perusal of subject must have cost the author a prodigious
the second volume. We find it characterized by amount of labor and research, but they constitute
the same fulness of detail and clearness of ex- one of the most valuable features of the book,
pression which we had occasion so highly to com- especially for reference in medico-legal trials.—
mend in our former notice, and which render it so | American Journal of the Medical Sciences, April, 1884.
valuable to the medical jurist. The copious
TAYLOR, AL FRED S., M. D.,
Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London.
Poisons in Relation to Medical Jurisprudence and Medicine. Third
American, from the third and revised English edition. In one large octavo volume of 788
pages. Cloth, $5.50; leather, $6.50.
By the Same Author.
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon-
don edition, thoroughly revised and rewritten. Edited by JoHN J. REESE, M. D. In one
large octavo volume.
PEPPER, AUGUSTUS J., M. S., M. B., F. R. C. S.,
Eacaminer in Forensic Medicine at the University of London.
Forensic Medicine. In one pocket-size 12mo, volume. Preparing. See Students’
Series of Manuals, below.
STUDENTS’ SERIES OF IMA NUALS.
A Series of Fifteen Manuals, for the use of Students, and Practitioners of Medicine and Surgery,
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The following is in active preparation: Lucas on Diseases of the Urethra. For separate notices see
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LEA, HENRY C.
Chapters from the Religious History of Spain.—Censorship of the
Press.-Mystics and Illuminati.-The Endemoniadas of Queretaro.—
El Santo Nino de la Guardia.-Brianda de Bardaxi. In one 12mo, volume
of about 500 pages. In press.
In making researches for a History of the Spanish Inquisition the author has been
led to investigate various subjects deserving of treatment more elaborate than could be
accorded to them in a continuous narrative. These he has worked out in the present vol-
ume in the hope that beside the intrinsic interest of the themes themselves, they may
serve to explain some of the causes which reduced to impotence a nation that in the
Sixteenth century aspired to universal monarchy.
- By the same Author.
Superstition and Force: Essays on The Wager of Law, The Wager of
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one
handsome royal 12mo, volume of 552 pages. Cloth, $2.50.
By the Same Author.
Studies in Church. History. The Rise of the Temporal Power—Ben-
efit of Clergy—Excommunication. New edition. In one very handsome royal
octavo volume of 605 pages. Cloth, $2.50.
Of the Medical Sciences º
of Gymecolo
Of Practical Medicine.
of Dentistry * º
º t t
Of Women . :
Essays,
and Anatomy
Dictionary
of Medicine .
NoSe and Ear º .
and Therapeutics
and Therapeutics
Surgery . *
On Venereal.
of Alcohol :
and
Chem.
‘Manual
OIOleIOl
Dlotionary .
and Therapeutics
OIOleIl . te
of Anatomy
and Mat. Méd.
Organs te
S. On of Insane
of
Chemistry .
and ObstetricS
& 8
23, 31
1.
6
3
27
15
24
20
29
9
See Taylor, :
21, 31
8
21,
Juler's Ophthalmic Science and Practice
King's Manual of Obstetrics . &
Klein's Histology º tº ſº
Landis on Labor 4. & *
La Roche on Pneumonia, Malaria, etc.
La Roche on Yellow Fever . tº
Laurence and Moon's Ophthalmic Surgery
Lawson on the Eye, Orbit and Eyelid .
Lea's §§ from Religious History of Spal
Lea's Studies in Church History . ſº
Lea's Superstition and Force e
Pee Qin Syphººls., tº
Lehmann's Chemical Physiology .
Leishman's Midwifery º g
Lucas on Diseases of the Urethra .
Ludlow's Manual of Examinations
Lyons on Fever . º * e
Maisch's Organic Materia Medica .
Marsh. On the Joints
§ on Diseases of Women ,
I
I
.
Medical News .
Medical News Y; List .
Medical News Physicians' Ledger
Meigs on Childbed Fever &
Miller's Practice of Surgery .
Miller's Principles of Surgery
Mitchell's Nervous Diseases of Women
Morris on Diseases of the Kidney .
National Dispensatory & &
National Medical Dictiona
º
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tº
tº
ſº
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Pepper's Surgical º ë
Pick on Fractures and Dislocations
Pirrig's System of Surgery... g o
Playfair on Nerye Prostration and Hysteria
Playfair's Midwifery . º
Neill and Smith's Compendium of Med. Sci.
Nettleship on Diseases of the Eye . t
Norris and Oliver on the Eye º th
Owen on Diseases of Children & ſº
Parrish’s Practical Pharmacy e º
Parry on Extra-Uterine Pregnancy *
Parvin's Midwifery e º e e
Pavy on Digestion and its Disorders &
Payne's General Pathology . g º
Pepper's System of Medicine g e
Pepper's Forensic Medicine . e º
Rolitzer on the Ear and its Diseases tº
Power's Human Physiology . e • , . . "
Purdy on Bright's Disease and Allied Affections
Ralfe's Clinical Chemistry tº t
Ramsbotham on Parturition. *
Remsen's Theoretical Chemistry .
Reynolds' System of Medicine . . .
Richardson's Preventive Medicine
IRoberts on Urinary Diseases º
Roberts’ Compend of Anatomy .
bºoberts' Surgery ." * . . .
Robertson’s Physiological Physics
Ross on Nervous Diseases ... . &
§ on Insanity, including Hysteria
Schäfer's Essentials of Histology,
Schreiber on Massage . º g tº
Seiler on the Throat. Nose and Naso-Pharynx
Senn's Surgical Bacteriology g
Series of Clinical Manuals , . t * º
Simon’s Manual of Chemistry º g
Slade on Diphtheria
Smith gº on Consumption
Smith (J. Lewis) on Children
Smith's Operative Surgery .
Stillé on Cholera. ... • g e
itillé & Maisch's National Dispensatory
itillé's Therapeutics and Materia Medica
timson on Fractures and Dislocations
timson's Operative Surgery e *
Students' Series of Manuals . e *
Sturges’ Clinical Medicine . e º
Tait's Diseases of Women and Abdom. Surger
y
Tanner on Signs and Diseases of Pregnancy
Tanner's Mañual of Clinical Medicine . . º
Taylor's Atlas of Venereal and Skin DiseaseS
Taylor on Venereal Diseases º t e
Taylor on Poisons - p ſº e
Taylor's Medical Jurisprudence . e e
Thomas on Diseases Of Women . * e
Thompson on Stricture s e s tº
Thompson on Urinary Organ * & º
Tidy's Legal Medicine. º * &
Todd On Acute iiseases g o o º
Treves' Mamual of Surgery . t º ſº
Treves' Surgical A FF; Anatomy º sº
Treves On Intestinal Obstruction . o e
Tuke on the Influence of Mind on the Body.....
Vaugham & Noyy's Ptomaines and Leucomaine
Visiting List, The Medical News . g º
Walshé on the Heart . . . tº w w
Watson's Practice of Physic . te th e
Wells on the Eye wº º g º ©
West on Diseases of WOrmen º e º
West on Nervous Disorders in Childhood o
Williams on Consumption . * & *
Wiś #º º Cutaneous Medicine .
Wilson's Human Anatomy . * e º
winckei on Pathol, and Treatment of Childbed
Wöhler's Organic Chemistry e
Wöjääeñāśrºtičaj Pathology . t
Year-Books of Treatment for 1886,
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’87, '89 and ’90, 17
Yeo on Food in Health and Disease e . 17, 31
Anatomy
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Diseases
OIl WOIOleIl & o : :
Power's Chemical Analysis
otes and Reflections
and Practice of Surgery
Surgery
and Histology
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the Skin . g
On Nervous Disorders
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ones (C.
LEA BROTHERS & CO., Philadelphia.
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