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rslOTTE^S 
 
 ON 
 
 Frinciflbs of Surgbry, 
 
 BY 
 
 BLANTON L. HILLSMAN, 
 
 CLASS 1898, 
 
 UNIVERSITY COLLEGE OF MEDICINE, 
 
 FROM LECTURES BY 
 
 Professor of Principles of Surgery, University 
 College of Medicine, Richmond, Va.; Surgeon to 
 St. LUKE'S Home and Virginia Hospital. 
 
 Richmond, Virginia: 
 
 james e. goode printing company. 
 1897. 
 
 A 
 

PREFACE. 
 
 The following " ISTotes ou Principles of Surgery" won the prize 
 offered by Dr. Stuart McGuire for the best report of his lectures 
 for the session '96-'97. They are published at the suggestion of 
 several friends, and appear almost exactly as taken in the classroom. 
 
 I realize that they do not do full justice to my teacher, nor re- 
 flect great credit on myself, but trust that they may prove of ser- 
 vice to my fellow students. 
 
 BLANTOlSr L. HILLSMAK 
 
 Richmond, Ya., 
 
 September 15, 1897. 
 
CONTENTS. 
 
 The Germ Theory op Disease 
 
 Surgical Bacteriology .. 
 
 " " Continued 
 Inflammation , 
 
 ^' Continued 
 
 Process op Repair 
 
 Regeneration op Special Tissues. 
 
 Continued. 
 
 SUPPLTRATION. 
 
 Continued (Clinical Forms). 
 
 Ulceration 
 
 Fistula 
 
 Sinus 
 
 Gangrene 
 
 " Continued (Clinical Forms) 
 
 Shock — 
 
 Septicemia 
 
 Pyemia 
 
 Erysipelas 
 
 Tetanus 
 
 Scurvy 
 
 Wounds in General 
 
 Special Wounds 
 
 " " Continued 
 
 Influence of Constitutional Conditions Upon Injuries 
 
 Anthrax 
 
 Hydrophobia 
 
 Glanders 
 
 Actinomycosis 
 
 Tuberculosis 
 
 Continued XXXIII 
 
 LECTURE. 
 
 page. 
 
 I. 
 
 1 
 
 II. 
 
 10 
 
 III. 
 
 14 
 
 IV. 
 
 19 
 
 V. 
 
 23 
 
 VI. 
 
 26 
 
 VII. 
 
 28 
 
 VIII. 
 
 33 
 
 IX. 
 
 37 
 
 X. 
 
 41 
 
 XI. 
 
 45 
 
 XII. 
 
 50 
 
 XIII. 
 
 54 
 
 XIV. 
 
 58 
 
 XV. 
 
 64 
 
 XVI. 
 
 70 
 
 XVII. 
 
 73 
 
 XVIII. 
 
 73 
 
 XVIIl. 
 
 73 
 
 XVIII. 
 
 76 
 
 XIX. 
 
 80 
 
 XX. 
 
 84 
 
 XXI. 
 
 88 
 
 XXII. 
 
 92 
 
 XXIII. 
 
 95 
 
 XXIV. 
 
 101 
 
 XXIV. 
 
 101 
 
 XXV. 
 
 107 
 
 XXVI. 
 
 112 
 
 XXVII. 
 
 119 
 
 XXVIII. 
 
 125 
 
 XXIX. 
 
 130 
 
 XXX. 
 
 136 
 
 XXX. 
 
 136 
 
 XXXI. 
 
 141 
 
 XXXI. 
 
 141 
 
 XXXII. 
 
 144 
 
 XXXIII. 
 
 149 
 
VI CONTENTS. 
 
 LECTURE. PAGE. 
 
 Clinical Forms op Surgical Tuberculosis XXXIV. 153 
 
 Continued XXXV. 157 
 
 " " " " " XXXVI. 161 
 
 XXXVII. 166 
 
 Rickets , XXXVIII. 170 
 
 Hemophilia XXXVIII. 170 
 
 Hysteria XXXVIII. 170 
 
 Syphilis XXXIX. 175 
 
 " Continued.., XL. 181 
 
 XLI. 185 
 
 XLII. 190 
 
 Tumors XLIII. 196 
 
 " (Benign) XLIV. 200 
 
 " (Malignant) XLV. 204 
 
 Retention Cysts XLVI. 208 
 
 Aseptic and Antiseptic Surgery XLVII. 212 
 
N o "r e: s 
 
 ON 
 
 Frinciplbs of Surgery. 
 
 LKCTURE I. 
 
 THE GERM THEORY OF DISEASE. 
 
 Ever since the fall of man from his perfect state he has been 
 liable to disease, and being a selfish as Avell as an intelligent ani- 
 mal, he bas demoted much study to its cause, in order that ha 
 might avert its effects. His earliest conceptions of disease, while 
 amusing, -were so clouded by ignorance and superstition that they 
 scarcely deserve mention. The great Hippocrates, the father of 
 medicine, for instance, maintaining that the body was composed 
 of four humors — blood, phlegm, black bile andj'-ellow bile — a right 
 proportion and mixture of which constituting health, an improper 
 proportion or irregualr distribution constituting disease; and it 
 was not until the Phlogistic theory was advanced that we have 
 evidence of anything like scientific reasoning. The Phlogistic 
 Theokt was based on a supposed analogy between combustion 
 and disease. Physicians saw pestilence strike a community like a 
 spark strikes among straw and kindling, attack person after per- 
 son in society, as fire would leap from house to house in a city. 
 Stahl had taught, and his views were generally accepted by chem- 
 ists, that combustion was due to the liberation of a fluid or essence 
 called phlogiston^ which was inherent in all matter, and it was 
 therefore inferred that if this be true there must be some substance 
 in man himself which, once put in motion, acted similarly to fire 
 and spread with deadly effect. This theory was long held, and 
 
2 PRINCIPLES OF SURGERY. 
 
 evea to this day remedies which are directed against inflauimation 
 or iniiammatory conditions are called anti-jphlogistics. 
 
 The next hypothesis of importance was called the Zymotic Theory, 
 and was based on the similarity between the processes of fermen- 
 tation and disease. It was known that vihen yeast was added to 
 certain solutions containing sugar certain changes occurred. It 
 was observed that a very small quantity of yeast \\ as necessary 
 to inaugurate these changes; that the quantity cf j^east was large- 
 ly increased by the changes, and that the new 3^east thus formed 
 would again produce fermentation if added to fresh solutions. It 
 was claimed that infectious disease presented similar characteris- 
 tics; that disease was started by the introduction into the body 
 of a substance similar to yeast; that the quantity of the substance 
 was increased by the process, and that the substance was after- 
 wards convej'^ed from the sick person to healthy individuals, thus 
 repro'lucing the disease and rapidly diffusing it through a com- 
 munity. Confidence in the ' '"zymotic theory'''' of disease was greatly 
 strengthened when Jenner, in 1798, began the use of vaccine virus 
 as a preventive of small pox. Here the physician had a substance 
 which he could carry about as he could yeast. He could intro- 
 duce it into tne skin of a healthy person, and after a certain time 
 a disease would manifest itself, just as he could iotroduce yeast into 
 a solution of sugar, and after a certain time find changes of fer- 
 mentation. A small amount of either was sufficient, and in each 
 case a certain period of rest was observed before the characteristic 
 changes were seen. Nor did the likeaess stop here. It was found 
 that intense heat destroyed the power of yeast, and the same was 
 found to be true of vaccine virus. It was also known that when 
 a solution of sugar had once undergone the process of fermentation, 
 further change would rot be produced by adding fresh yeast to it, 
 and an analogy was found in vaccination, for a person onr.e vacci- 
 nated is rendered insusceptible to further inoculation by the virus, 
 at least for some years. All these facts furnished the strongest 
 possible proof of the identity of the two processes, at least in mode 
 of operation, however wide the difference in results, and the 
 theory was generally accepted. 
 
 With the advance of knowledge during the present century the 
 subjects of fermentation and putrefaction were earnestly studied. 
 
PRINCIPLES OF SURGERY. 6 
 
 Learned men in all parts of the world devoted their liv^es to their 
 investigation; but it remained for the great scientist Pasteur to 
 announce to the world, in 1858, their real nature. It had pre- 
 viously been supposed that they were due to the action of oxygen, 
 and were a purely chemical process. Pasteur proved, by a series 
 of experiments, whose ingenuity and originality have rarely been 
 equalled, that they were due to the action of a living micro- 
 organism, and hence were a vital process. 
 
 There lived at this period in Glasgotv, Scotland, a surgeon named 
 Joseph Listf^r, a man who, despite the demands of an active prac- 
 tice, found time for theoretical study. He read \\ith interest the 
 demonstrations of Pasteur and his fellow-workers, and at once con- 
 cluded that the discovery was of great practical value. 12 fermen- 
 tation and putrefaction could be prevented by exclusion of germs 
 from a test tube, why could not disease, such as suppuration, be 
 prevented by exclusion of germs from a wound? On this premise, 
 as a basis, he began a series of experiments, and soon found that a 
 wound made through clean skin, by a clean hand, with a clean 
 knife, and protected by a clean dressing would heal without in- 
 fiamination and without the formation of pus. The results were 
 elaborated and published jn 1865, and were the origin of "The 
 Germ Theory of Disease" — a theory ^ivhich was destined to revo- 
 lutionize the practice of medicine and surgery. 
 
 The application of the principles of the germ theor}^ to the prac- 
 tice of medicine and surgery has been of untold benefit to man- 
 kind. In surgery, suffering is lessened, convalescence is shortened, 
 and lives of patients are saved. Regions of the body are now 
 safely invaded which were hitherto believed to be inaccessible, and 
 operations are now successfully performed which, if suggested be- 
 fore, would have been considered the outcome of a diseased brain, 
 or the freak of a disordered imagination. It is difficult for you 
 who visit the hospitals of to-day and see the comfortable patients 
 in their clean and airy v^ards, their wounds covered with artistic 
 dressings and their faces free from evidences of pain or fever, to 
 realize the dangers which beset a patient before the antiseptic era, 
 or to have any conception of the horrors of a metropolitan hospital 
 of the olden time. I recently read a description by a French writer 
 of the Hotel Dieu, of Paris, a hospital whose wards were immedi- 
 
4 PRINCIPLES OF SURGERY. 
 
 ately over the dead house, and whose atmosphere reeked with the 
 odors of putrefaction. A hospital whose only heat emanated from 
 the bodies of its tv retched inmates, and whose only ventilation was 
 derived from the accidental defects of its structure. A hospital 
 whose walls "weie soiled by expectorations from patients, and whose 
 floors were covered with blood and pus from wounds. Into this 
 pest house patients were packed four and sii^ in a bed, and, in 
 emergencies, were placed in tiers one over the other, so that some 
 were reached only by the use of ladders. It is not surprising that 
 gangrene and erysipelas were rife, and that one out of every four 
 patients died. Lister is the magician who has wrought the change; 
 the germ theory the agent he employed. 
 
 Id medicine, too, the results accomplished have been marvelous. 
 Plagues are prevented, epidemics are arrested, and contagious 
 diseases are cured. One of the drst great discoveries in this de- 
 partment was Pasteur's treatment of hydrophobia by inoculation. 
 This great scientist, in order to study the disease, produced it arti- 
 ficially in a rabbit by injecting under its skin some virus taken 
 from the mouth of a rabid dog. When the rabbit finally died, he 
 took some of its blood and injected it into a fresh animal, and 
 hydrophobia again developed. He noticed that the second case 
 was more severe than the first, and further experiments proved 
 that the disease became ncore intense each time it was reproduced. 
 Pasteur concluded that if the germ became more virulent under cer- 
 tain circumstances, that there must be other conditions which 
 would render it milder. Investigation at length resulted in the 
 discovery of these conditions, and. in the production of germs which 
 were so attenuated that they could not produce the aisease in an 
 animal, but would protect it from an attack of the disease. A 
 patient who has been bitten by a rabid animal can now be pro- 
 tected from the disease b}'" being inoculated with weakened germs, 
 and hydrophobia, formerly the most horrible and hopeless of ali 
 diseases, has been robbed of its terrors. 
 
 The civilized world was startled not many years ago by the an- 
 nouncement that Koch, of Berlin, had discovered a remedy for 
 tubsrculosis, the dread disease which causes the death of one out 
 of every seven people who die. It was a well known fact that no 
 animal could live in its own excreta; and by injecting the products 
 
PRINCIPLES OF SURGERY. 5 
 
 of the bacillus tuberculosis into the body of a patient suffering from 
 consuiT. ption, it was belie'^ecl the disease could be cured. The 
 treatrcent was published preraaturely, published before its value 
 was determined by experiments, published without the consent of 
 its originator. Koch's lymph or tuberculin has proven of little 
 ■value, but it was an advance. Other investigators are now work- 
 ing on the same lines, and we may look forward to the result of 
 the future with hope and with confidence. 
 
 Cancer, the terror of its victim, the- "J^fe noir''^ of the surgeon, 
 is by some believed to be due to a germ. It has been observed 
 that its advance is frequently checked, and in eome instances the 
 disease is absolutely cured, by accidental attacks of erysipelas. In- 
 vestigation has shown that there is an antagonism between the 
 microbe, which is know^n to cause erysipelas, and on the principle 
 of fighting fire with fire, erysipelas is used to fight cancer. The 
 cancerous growth is inoculated with erysipelas, and sometimes the 
 cancer is conquered. It is a desperate remedy, but it is used in 
 desperate cases. Statistics certainly justify further investigation 
 of the subject. The future only can determine its value. 
 
 The last advance which the germ theory has accomplished is iu 
 the treatment of diph^-heria, a disease which hurries to an untimely 
 grave so many of its victims. The treatment is an endeavor to in- 
 crease the antiseptic po\;^ er of the blood, and thus destroy the germ 
 which produces the disease, and is carried out by injecting beneath 
 the skin of a patient suffering v/ith diphtheria a substance called 
 Antitoxin. Antitoxin is prepared in the following way: The 
 germ of diphtheria is placed in a test tube containing iDroth, and 
 allowed to grow for ten or twelve days. At the end of that time 
 it has saturated the broth with its specific poison, or jptomaine. 
 The contents of the tube is then boiled, the heat killing the germ, 
 but having no effect on the chemical poison it has produced. A 
 young and healthy horse is taken, and a few drops of the solution 
 injected beneath the skin. It makes him very sick; he has high 
 fever, loses flesh and refuses to eat, but usually he recovers in two 
 or three days, and at the end of a week is apparently well. He is 
 then injected with the same material — -this time twice the former 
 dose being used — and again the same symptoms come on, though 
 not so well marked. This weekly dose of poison is continued for 
 
6 , PKINCIPLES OF SURGERY, 
 
 about six months, when the horse is found to have acquired a toler- 
 ance to its action, and can take an enormous dose without any bad 
 effects being observed. To use a technical term, the horse has 
 become immune. As soon as this is accomplished, the horse's 
 neck is shaved and disenfected, one of the jugular veins opened, 
 and about two gallons of blood withdrawn. The blood is allowed 
 to cool, and the serum separated from the other constituents. The 
 serum conlains the antitoxin, and is concentrated and put in a suit- 
 able form for use. Before it is placed on the market, its power and 
 strength is tested by observing its effects on G-uinea pigs, in whom 
 diphtheria has been artificially produced. The action of this new 
 agent on diphtheria is remarkable. Used in the early stage, it alwaj^'s 
 cures, and it is only when its employment is too long delayed that it 
 fails. I have mentioned only a few of the many important results 
 which the germ theory has accomplished. Only enough to show 
 yo'j Its present practical value. Earnest men in all parts of the 
 civilized world are working night and day upon the subject and no 
 one can predict what the ultimate outcome will be. Perhaps the 
 possibilities are not exaggerated by a French writer, who says: 
 "When man learned to protect himself from wild beast, he made 
 the first step in civilization. To-day man is learning how to defend 
 himself from microbes; it is a step of equal importance. A day will 
 come when in Berlin, in London, in Paris, a man will not die of 
 diphtheria, of typhoid fever, of scarlet fever, of cholera, or of 
 tuberculosis, any more than he dies in these cities to-day of the venom 
 of snakes or the teeth of wolves,'' Candor compels me to admit 
 that, despite the facts which I have adduced, and the logical con-, 
 elusions which they bring, that the germ theory has not yet been uni- 
 versally accepted, and that there are still some men of prominence 
 who do not yield in practice to its teaching. The medical skeptics 
 are much more numerous than the surgical infidels, and this is ex- 
 plained bv the fact that medicine is yet but an art, while surgery 
 is a science. The physician treats maladies which are hidden from 
 his sense of touch and sight, and whose symptoms give but vague 
 indications of their real nature. He goes to the bedside of a pa- 
 tient, feels the pulse, examines the tongue, auscultates and percusses 
 the chest, and prescribes medicines uncertain iii their indication 
 and indefinite in their action, and then either turns a prayerful eye 
 
PRINCIPLES OP SURGERY. 7 
 
 heavenward, or calls long and loudly on mother nature for assist- 
 ance. It is natural that he should regard the germ theory w;ith 
 suspicion. The surgeon, on the other hand, meets the enemy face 
 to face, and in his bloody battle with disease for the life or death 
 of a patient, appreciates his power, and recognizes the potency of 
 his remedies. By him the germ theory is accepted. 
 
 Only one surgeon of great prominence lives who denies its va- 
 lidity, and this is "Mr. Lawson Tait, of England," a man v^ hose 
 wonderful success in abdominal work has made his name famous 
 throughout ihe civilized world, but whose love of notoriety renders 
 the honesty of his views open to suspicion. In a recent paper read 
 before the Birmingham and Midland Branch of the British Medi- 
 cal Association, entitled, "A Criticism of the Germ Theory of 
 Disease Based on the Baconian Method," he represents the views 
 of the agnostics as strongly and vigorously as it is possible for 
 them to be put. At the onset of bis remarks, he says he wants to 
 remind those persons who now sneer at his views as those of a 
 mere practioner, that for twelve years he was a hard working and 
 enthusiastic raicroscopist, and that during that time he discovered 
 much which was then unknown and unraveled the minute anatomy 
 of certain structures with a completeness chat has defied further 
 addition. He says that the germ theory is simply an amusing hy- 
 pothesis, by which everything is explained and under which every- 
 thing is squeezed. He says that the fact that the origin of certain 
 diseases is due to a poison has alwavs been recogrnized, but the sus;- 
 gestion of the immediate machinery has curiously varied. The 
 ancient Greeks and Hebrews believed that disease was a -blow from 
 an offended deity, and the Christian's favorite doctrine was that 
 it was a visitation from the devil; for both the modern scientist 
 has substituted the microbe, which is no logical advance over the 
 belief of either. The ancient Jews were very practical and busi- 
 ness like people, and could have written sanitary articles in medi- 
 cal journals much better than some of their descendants do now. 
 They knew the facts of sepsis, and had the most elaborate schemes 
 of antisepsis, whose stringency of detail were not much more ridic- 
 ulous, or probably much less satisfactory, than many of those which 
 have emanated from Lister himself. Mr. Taic then takes up the 
 application of the germ theory to the practice of surgery, and says 
 
PRINCIPLES OF SURGERY, 
 
 that, being a very clumsy barber, hp has no doubt he h?s implanted 
 myriads of germs in fresh v^ounds inflicted on his face while shav- 
 ing, and that no septic results have followed in his own case or in 
 thousands of fellow sufferers. He ridicules the technique of anti- 
 septic surgery, and uses as an illustration of its absurdity an article 
 recently written bv an American, in which, with great enthusiasm, 
 the writer describes the method by which he performs an exceed- 
 ingl}^ simple operation en a child, giving in detail the antiseptic 
 precautions. He observes: "Sterilized gauze, sterilized bandages, 
 and a properly sterilized cradle and nurse," saysMr. Tait, "secures 
 the recovery of the germ -endangered baby, and no doubt a formal 
 operation fee is charged after the danger is all over." Mr. Tait 
 sa3''s that he has done a good deal of operative work, and he has 
 never used anything but absolute cleanliness, and yet his published 
 statistics have never been equalled. He says he has challenged Sir 
 Joseph Lister over and over again to compare results with him, 
 but he has ignored him with lordly indifference. He says that the 
 details of Listerism change with marvellous rapidity, and before 
 they are six months old, are pronounced failures and are replaced 
 by something new. The lastof all these numerous phases isthedis- 
 use of chemical destroyers of genus and the adoption of aseptic sur- 
 gery, which is nothing but perfect cleanliness, a principle which 
 he has been preaching for years, and now, forsooth, it is the new- 
 est Listerism. Mr. Tait says that after his early experience in sur- 
 gery, it is a wonder he ever stuck to it; that duriog his pupilage in 
 Edinburgh, he saw thirty abdominal tumors removed without a 
 single recovery, and that when he left the land of his birth it was 
 with one fully made resolution — that he would never open an ab- 
 domen. In Edinburgh, if he saw the amputation of a thigh Id the 
 old Infirmary on Wednesday, there was a strong probability that 
 the following week he would see the bared bone sticking through 
 the anterior flap. If a breast was removed, an erysipelatory red- 
 dening of the flap would very probably ccGur on the foUov^ing day, 
 and would he half w^ay round the chest before the week was out, 
 and the wound gaping and every thmg going to the bad. lie left 
 Edinburgh, and has been engaged continuously for the past twenty- 
 eight years in making wounds, and he has never seen a case of ery- 
 sipelas in his own practice. The improvement lies in the separa- 
 
PRINCIPLES OF SURGERY. 9 
 
 tion of patients, plenty of cubic space and fresh air and is in nowise 
 the result of chemical germicides, Mr. Tait says that it was Simp- 
 son who cried out most loudly for better ventilation and cleanli- 
 ness, and against the use of dirty hands and sponges, and he has 
 been dead hardly these five and twenty yee;rs, and all his splendid 
 work is as much forgotten as if it had never been done, and the 
 glorious progress which has come out of it is given to a theory, 
 which is no theory at all, but a phantasm, a system which has 
 been proven an inconstancy and a broken leed — a thing vvhich 
 yields at every blast, either to scholastic logic or eclectic experience. 
 It will be seen that Mr. Tait recognizes the existence of a poison 
 which produces disease, but refuses to admit that it is of microbic 
 nature. He insists upon the importance of cleanliness, and upon 
 the avoidance of contaminating wounds with dirt, but fails to say 
 of what dirt consists. He prefers to deal in generalities — to speak 
 of contagion as a condition, not an entity. If it gratifies him to 
 call by the name of dirt what his more advanced contemporaries 
 have resolved into micro-organisms^ it is a weakness of his brain, 
 which should be pardoned on account of the cleverness of his 
 hands. If, in practicing cleanliness, Mr. Tait has practiced aseptic 
 surgery, so much the better for Mf. Tait; but he did it instinc- 
 tively, purposely, and to have expected others to follow an example, 
 for which he could give no reason, would be as illogical as to ex- 
 pect fruit from a tree which had no roots or water in a brook which 
 had no source. 
 
 The followers of Lister have, in the past, been guilty of many 
 absurdities, and in their ranks are still found theorists ^vho ride 
 their hobbies hard. Many apparently contradictory facts still re- 
 main unexplained, and the results of experiments, which seem dia- 
 metrically opposed, huve still not been reconciled, but all this will 
 be remedied in time. When germs can be examined micrcscopi- 
 cally, can be differentiated by appearance, can be cultivated in the 
 laboratory, and can have their effect, when introduced into a 
 healthy organism, accurately foretold, the science of bacteriology 
 is not a farce. When a germ fulfills the requirements of Koch's; 
 when it is always found accompanying a disease; when it can be 
 cultivated from the tissues of the animal dead of the disease, and 
 when it will reproduce the disease if inoculated into a second ani- 
 
10 PRINCIPLES OF SURGERY. 
 
 mal, it certainly seems, to aa unprejudiced mind, that it is the 
 cause of the disease. 
 
 It is, cf course, impossible to demonstrate positively the truth of 
 the '"'"Germ Theory^'''' but such is the case in many other branches 
 of science, and is no reflection upon medicine. No one would ques- 
 tion for a moment the assumption of tbe truth of the ^"•atoiyiic 
 theory,'''' and yet without that basis upon which to build, the proud 
 structure which has been erected by the chemist would fall into 
 chaos. It is impossible for the Christian to demonstrate the exist- 
 ence of a '''Deity,''^ and yet, without the faith inspired by their 
 belief, civilization would totter and barbarism return. 
 
 LECTURE II. 
 
 SURGICAL BACTERIOLOGY. 
 
 Bacteria, Micro-organisms, Microbes or Germs, are synonymous 
 terms for minute vegetable plants belonging to the lowest order of 
 the vegetable kingdom and are closely allied to tbe algae. As the 
 rr»inute cells possess the power of motion, they were for a long 
 time thought to be of the animal kingdom, but this theory has been 
 abandoned. There are two kinds ot bacteria — JSfon-pathogeniG^ or 
 those which do not cause disease, and Pathogenic, or those which 
 cause disease. 
 
 NoN-PATHOGENic germs produce fermentation and putrefaction. 
 They are seen producing fermentation in the manufacture of beer 
 as yeast and in removing dead bodies by putrefaction. 
 
 Pathogenic germs produce disease and are of many kinds, exceed- 
 ing minute in size, being from 1 to 4: MM. in diameter. One 
 writer speaks of them as the ''infinite little,''' another says they 
 require to be magnified seven hundred times to be seen, and still 
 another claims that one thousand of them can pass through the eye 
 of a needle abreast. They are composed of protoplasm, are 
 unicellular, the nuchus and nucleolus has not been found, but prob- 
 
PRINCIPLES OF SURGERY. 11 
 
 ably e.^ist. The protoplasm consist of an albuminous substance 
 called Mycoprotein^ and is incased in a membrane of cellulose con- 
 taining a little fat. So we may define a bacteria by saying: 1. It 
 is a plant; 2. It is a cell; 3. It is formed of protoplasm; 4. It is 
 incased in a membrane. 
 
 Most all bacteria are colorless and transparent, but occasion- 
 ally some are found that are colored, such as bine, red, etc. A 
 great many are capable of motion which is accomplished by the 
 movement of their processes called Cilia; others are not capable of 
 motion and are carried by the fluids cf the bodj^. In looking at a 
 microscopic preparation you will see single bacteria and also will 
 find them in masses, these masses are formed by their investing 
 membrane becoming glutmous and they adhere one to another and 
 are called Zooglea. 
 
 Thp^oky of a Common Botanical Origin of Microbes. — All bac- 
 teria at one time were supposed to have a common origin; it was 
 thought the children of any parent might be a cocci ov spurilli^ and 
 any one of them might produce Tetanus or Erysipelas or any of 
 the specific diseases. ■ This theory has been discarded, and it is 
 now known that the round o^erm beo^ets a round o;erm, the o:erm of 
 suppuration begets a germ of suppuration, the germ of erysipelas 
 begets a germ of erysipelas, there being no possibility of crossing 
 them, as they invariably breed true. 
 
 Three Principal Forms of Bacteria. — We recognize three forms 
 of bacteria: 1.. The round or coccus^ 2. The rod or Bacillus; 3. 
 The curved or Spirillum, The cocci are comparatively easy to 
 kill, and fortunately for the surgeon they are the cause of most 
 of the diseases. 
 
 Combination of Cocci. — If a coccus meets another and they join 
 it is called a DiploGocci\ when four of them join it is called a Mic- 
 rococci tetragones; when they form a chain it is called a Strepto- 
 cocci; when they form like a bunch of grapes it is called a Staphy- 
 lococci. 
 
 Multiplication of Bacteria. — Bacteria are capable of multipli- 
 cation or reproduction which takes place by two processes — Fis- 
 sion and Spore formation. 
 
 Reproduction by fission, when observed under the microscope, 
 the baceria at first is seen to get longer and a little oval in shape, 
 
12 PRINCIPLES OF SURGERY. 
 
 a depressioQ is next seen in tbie bacteria, "which, causes it to assume 
 a dumbbell shape, the depression increases and finally the bacteria 
 splits into two equal halves, the halves grow and soon become as 
 large as the mother cell and is then capable cf propagation and 
 reproduction. 
 
 Reproduction by spore formation : Take a bacillus under the 
 microscope, it looks homogeneous and transparent at first, then 
 near the centre you will see a slight thickening ^vhich gradually 
 increases in size, becomes moie round and approaches the margin 
 ot the cell, it finally reaches the margin of the investing memcrane, 
 produces pressure on it, causing it to disintegrate and the spore 
 burst thr-^ugh and is set free; its subsequent feats depends on the 
 soil it gets into. The cocoi always divides by fission, the hacilli 
 by spoie formation and the sjnrilli may divide either by spore 
 formation or fission. 
 
 Ohaf.acteeistics of Spores. — Spores differ from bacteria in their 
 resisting power to external influences. It is invested by a thick, 
 tough shell, which makes it harder to kill and to render immune. 
 So when dealing \\ith a cocci you can make your material more 
 sterile, because they are easy to kill, but when dealing with a 
 bacilli, which is always accompanied by spores, it is harder to kill, 
 and therefore you will have to use stronger gerixicides than when 
 dealing with a cocci, but, as before said, we are fortunate that the 
 cocci cause most of the diseases. 
 
 Essential Conditions foe the Growth of Germs, — Bacteria are 
 plants and require certain conditions for their growth and repro- 
 duction. The most important conditions are Temperature, Food 
 and Moisture. The temperature varies for different germs, some 
 require low and some high temperatures, but most of them grow 
 better between 86 degrees and 104 degress F. Some grow below 
 86 degrees F., others above 104 degrees F. Most of them find 
 the temperature of the body most delightful. The food must be 
 of organic matter, the best is decomposing organise matter. They 
 require moisture as well as any other plant. A certain degree of 
 heat is necessary for the life of a germ, but if it is carried too high 
 it is death to them; some are killed at 140 degrees F., others at 
 180 degrees F., their hardihood varies with the species, but all 
 perish when kept at 212 degrees F. for any length of time. Moist 
 
PRINCIPLES OF SURGERY. 13 
 
 heat is much more eihcacious than dry heat. Moist heat will kill 
 any germ at 212 degrees F. in five minutes. It is the popular 
 opinion that cold kills bacteria; this is not so, it makes them inca- 
 pable of infection for awhile, but after being thawed out they infect 
 with as much virulency as ever. Cohn subjected germs to a tem- 
 perature of 180 degrees below zero, and then gradually brought 
 them back to their original temperature, and when injected into an 
 animal they produced their specific disease. Acids are death to 
 germs, whereas they thrive in an alkaline media. The germicidal 
 drugs are Bichloride Mercur^^ 1-10,000 will kill them and 1-1,000 
 will render anything sterile. This drug should be used with cau- 
 tion, as it is a powerful poison. Carbolic Acid ranks second, a 
 solution of 1-100 will exterminate germs and a 3 per cent, solution 
 will sterilize instruments. While carbolic acid in water is a power 
 ful germicide, in oils it is inert. Boracic and Salicylic acids are 
 used in a 2 per cent, solution for irrigating wounds. Iodoform is 
 a powder applied to wounds to prevent fermentation and putrefac- 
 tion. It is not an antiseptic in the dry state, as germs will grow 
 in it, but when it comes in contact with the secretions it gives off 
 free iodine, which is an antiseptic. 
 
 DisTEiBUTioN OF Baoteeia IN Natuke. — Bactcria are found every 
 where, en the skin, clothes, in the air, water, mouth, etc., and it 
 is only by the provisions of nature that we are protected. 
 
 Divisions of Pathogenic Bacteria: 
 
 1. Saprophyte — Lives in dead matter only. 
 
 2. Parasite — Lives in living matter only. 
 
 3. Ectogenous — Lives only outside of the body. 
 
 I. Endogenous — Lives only inside of the body. 
 
 5. Aerobic— Eequires oxygen for life. 
 
 6. Anaerobic — Does not require oxygen for life. 
 
 7. Chromogenous —Imparts color to fluids in which it grows. 
 S. ISTon-chromogenous — Does not impart color to fluids. 
 
 9. Pyogenic — Produces pus. 
 
 10. Non-pyogenic — Does not produce pus. 
 
 II. Gasogenic — Grrowth results in the formation of gas. 
 12, Non gasogenic — Does not produce gas on growth. 
 
14 PRINCIPLES OF SURGERY. 
 
 JLECTURK III, 
 
 SURGICAL BACTERIOLOGY— Continued. 
 
 Toxins and Ptomaines. — When a pathogenic germ is put in a 
 test tube or introduced into the tissues of the body under suitable 1 
 conditions, it generates a poison which is known as ^''Toxins or 
 Ptomaines.'''' It is not definitely known how this material is 
 elaborated, and many different theories exist to explain its produc- 
 tion. The simplest and most plausible is that gern s, like all other 
 organisms, have excretions, and that the excrementitious matter 
 which they throw off constitutes the poison. Toxins and Pto- 
 maines are chemical substances, and are not affected, as are bacteria, 
 by either heat or germicides. They closely resemble the vegetable 
 alkaloids — strychnine, morphine and atropine; and when intro- 
 duced into the system cause serious disturbances. There is a char- 
 acteristic difference between bacteria and its ptomaines or toxins; ' 
 bacteria is a living cell, capable of reproduction; toxins or pto- 
 maines do not possess this function of reproduction and produces 
 their effects just as any other alkaloid, and the symptoms are in 
 proportion to the amount and variety injected. The ptomaine or 
 toxin of different germs has distinct characteristics. Thus the 
 ptomaine of the germ of suppuration produces pus, the ptomaine 
 of the germ of lockjaw produces convulsions, and the ptomaine of 
 the germ of diphtheria produces paralysis. 
 
 Entrance of Bacteria Into the Body. — Bacteria comes from 
 without, and are conveyed to the body by actual contact. The 
 air rarely convey germs to a wound, but they are in planted by 
 dirty hands and instruments coming in contact with the '^ound. 
 Lister would not operate, not many years ago, unless the air of the 
 room was made sterile, he had an assistant on either side of the 
 operating table with sprays of antiseptic solutions playing around 
 the wound to sterilize the atmosphere; this source of infection has 
 been proven to be of minor importance, and instead we make our 
 hands sterile, our instruments sterile, and, in fact, everything that 
 
PRINCIPLES OF SURGERY. 15 
 
 is in. danger of coining in contact with the wound. So we make 
 these conclusions: That there are but few bacteria in the atmos- 
 phere; that bacteria are not conveyed to wounds by the air, but b}?" 
 actual contact of dirty hands and instruments. 
 
 Bacteria cannot pass through the unbroken skin or mucous mem- 
 brane, they act as an effectual barrier, and only when there is some 
 lesion or '■'■Infection Atrium^' can they enter. After the germs 
 ha\e entered the body through the broken skin or mucous mem- 
 brane other conditions are necessary before they can cause disease, 
 they may circulate freely in the blood, but will cause no diseased 
 conditions. So we say and prove that it is to their localization, 
 which takes place if they find an impaired or weakened tissue or 
 '•'■LoGxis Minoris ResistenlicB.'''' Experiments prove the above: A 
 solution of the germs of putrefaction was made and injected 
 directly into the blood of a healthy lamb, but no disease resulted; 
 another lamb was taken, his testicles crushed and the germs in- 
 jected and Gangrene resulted; in the last experiment the germs 
 found a weak, injured testicle in which the}'^ could localize. 
 
 Action of I^athogenic Bacteria on the Tissues of the Body. — 
 It is not fully settled how bacteria acts on the living tissues; some 
 produce locally irritation or Inflamation; and the chemical sub- 
 stances produced in this process is absorbed and diffused through- 
 out the body, and in virtue of its ferment-like action greatly in- 
 creases the tissue metamorphosis and acting on the thermic centres 
 produces fever and other constitutional disturbances known as Sep- 
 tic Intoxication cr Toxic Infection. 
 
 Elimination of Pathogenic Bacteria. — 'After the germs have 
 entered the body and finds no suitable soil to live in, how does na- 
 ture dispose of them? It is accomplished by Phagocytosis and Ex- 
 cretion. The blood is not only itself a powerful antiseptic, but it 
 contains a cell called Phagocyte or white blood corpuscle, whose 
 duty it is to protect its home and to attacK all invaders. The 
 phagocyte is capable of swallowing a bacteria, digesting and excre- 
 ting them inca])able of producing disease. When the phagocyte 
 and the germ meets a battle royal ensues, aad the phagocyte is 
 usually the victor, unless the germs are in such numbers to success- 
 fully overpower them, when the reserve guard, the emunctory 
 organs, are ordered to the front. It can b*^ proven that these 
 
16 PRINCIPLES OF SURGERY. 
 
 organs, such as the kidneys, skin and bowels, eliminate disease 
 germs, as you can inoculate an animal with the urine or feces of a 
 patient suffering from Scarlet or Tj^phoid fever and produce the 
 disease. The old physicians called these discharges ^^ Critical dis- 
 oharges,''^ but did not understand it; but it is now proven by the 
 germ theory, as in a case of typhoid fever, when the patient's life 
 is almost despaired of, the kidneys will sometimes commence to act 
 freely, and the patient recovers. So now we know thai the 
 " Critical discharges^- of the old physician is nature trying to elimi- 
 nate the germs which has overpowered her advance guards, the 
 Phagocyte. 
 
 The Study of Bacteria. —Bacteria are studied Microscopically 
 by cultivation and by inoculation. It has only been by recent 
 inventions that we are able to study bacteria microscopically. At 
 firs-t, owing to the minuteness of the organism and the imperfec- 
 tion of Ihe instruments, small progress was made; but with the 
 advent of Abbe's condenser, which gives powerful illumination to 
 the section and allowing the use of high power lens their study is 
 very easy. Then, by a process of staining, we can readily distin- 
 guish them. By the use of aniline dyes we stain the section, and 
 then by washing with alcohol we can remove the stain from the 
 tissue, but on account of the strong affinity for dyes, which the 
 bacteria possess, they are unaffected, or we can further use con- 
 trast stains, and so give the germs a blue color, the cells a yellow 
 color and the tissues black; and in this way we can study their 
 shape, motion, mode of reproduction and in this way learn to dis- 
 tinguish one from another. 
 
 The cultivation of bacteria is carried on in test tubes. In culti- 
 vating them, remember they are plants and for their growth require 
 a suitable soil, warmth and moisture, under these conditions they 
 grow rapidly. The best soil or media is animal broth, solution of 
 sugar, gelatin, blood serum and agar agar^ the latter a jelly-like 
 substance obtained from seaweeds. The media is first heated to 
 kill any germs that may be in it, then, with a clean needle, secure 
 your germ, touch the media, close the tube, put it in an incubator, 
 and in a short while you will have millions of germs. According 
 to Cohn, during one day, a single coccus will proauce 16,000,000, 
 at the end of the second day 281,000,000,000. Some give to the 
 
PRINCIPLES OF SURGERY. 17 
 
 media a red color, others blue, etc., and a skilled observer can 
 recognize the specie by the manner in which they grow and the 
 color given to the media. Much inform atlon concerning bacteria 
 has beeo obtained by inoculating or injecting them under the skin 
 of animals and noting their effect. An animal is taken (rat, guinea 
 pig or rabbit) and the hair is shaved offj the sLin disinfected, so as 
 to be sure you do not implant any other germ, and a solution of 
 the germs is then injected under the skin with a hypodermic 
 syringe, or an. Incision is made in the animal and a piece of the in- 
 fected tissue is implanted ; in three or four days the symptoms of the 
 specific disease the germs experimented with produces will be ap- 
 parent,- and in case of virulent diseases the animal dies. This pro- 
 cess is of great aid to the surgeon in making a diagnosis; his patient 
 may show a tumor, and a positive diagnosis, whether due to syphi- 
 lis or tuberculosis, can't be made; inoculation gives him a certain 
 diagnosis, he takes one of the lower animals, puts a small piece of 
 the tumor in its cellular tissue, if the tumor is syphilitic, the ani- 
 mal will show no symptoms, as man alone possesses the distinction 
 of this disease; but if it be of tubercular origin, the characteristic 
 symptoms are soon displayed. 
 
 Isolation or Yakioits Bacteria. — Certain diseases are produced 
 by a certain germ ; the germ of tuberculosis always produces tuber- 
 culosis, the germ of pneumonia always produces pneumonia, the 
 germ of typhoid fever always produces typhoid fever, etc., and 
 Koch, by his experiments, has set forth these four laws as invari- 
 ably true; and before a germ can be said to produce a disease 
 they must be fulfilled, 
 
 1. The geim must invariably be found accompanying the disease. 
 
 2. When the aniiral dies you must be able to breed the germs 
 in a test tube, and by successive cultivations entirely remove all 
 the tissue of the animal from which they were obtained. 
 
 3. You must be able to reproduce the disease in another animal 
 tvith the cultivated germs, 
 
 4. When this animal dies you must be able to find the same 
 germs in its tissue that were originally used. 
 
 Attenuation: axd Axtago2s'is:!j: or Bactekia. — The germs of differ- 
 ent diseases have been subjected to all sorts of tests, tried under 
 all sorts of conditions, in order to learn their peculiarities. Many 
 2 
 
18 PRINCIPLES OF SURGERY. 
 
 strange facts have been learned. One is that bacteria of great 
 virulence can be rendered weak and comparatively harmless by 
 breeding them under adverse conditions, just as the Bushman of 
 Africa has been deteriorated by existing for years undv^r debilita- 
 tino: climatic conditions. Aaother curious fact is, that certain 
 species of germs have violent antipathy for each other, and, if 
 placed in the same media, will devote all their energies to a con- 
 flict, and it is only after one species has extern: inated the other 
 that multiplication begins. The practical usefulness of these ob- 
 servations is obvious, for already are ^e attempting to cure cancer 
 with the germ of erysipelas owing to their antagonism. 
 
 Theory of Immunity and Peedisposition to Disease. — It has 
 been observed that some people ''''catch diseases''' easily, that 
 others never take them at all, that some people have a predis- 
 position to disease, and others an immunity to it. This is ex- 
 plained by the face that a person who has a tendency to acquire 
 every disease to Tvhich he is exposed has blood and tissues which 
 have feeble resisting power, which presents a favorable soil to the 
 growth and development of germs. A person who does not ac- 
 quire disease to which he is exposed has blood and tissues which 
 have strong resisting power, which presents an unfavorable soil to 
 the growth and development of germs. 
 
 Theories of Fkotection. — One attack of many microbic diseases, 
 such as smallpox or scarlet fever, prevents a subsequent develop- 
 ment of the jjame disease. This is explained by the fact that each 
 germ requires a special food to support its life and vitality; that 
 when it oDce infects an organism it consumes all of the special food 
 the blood contains; that this special food is never replaced, and 
 that owing to its absence the germ cannot again maintain an exist- 
 ence in the organism. 
 
 ( 
 
PRINCIPLES OF SURGERY. 19 
 
 LKCTTJRE IV. 
 
 IXFLAMMATIOIS^. 
 
 Intkoductory Physiology. 
 
 The Blood. — The blood is the most important constitueat of the 
 bed}'-. It is the means bj which ail the tissues are directly oc indi- 
 rectly nourished, and is also the means by which the nraterial 
 resulting from the metabolism of the tissue, as are of no further 
 use in the economy, are carried to the ecretory organs to be re- 
 moved from the body. It also serves to moisten and warm the 
 body. Ic is composea of Blood plasma and Blood corpuscle. The 
 blood plasma is the fluid portion of the blood, it is a clear, yellow, 
 alkaline fluid, specific gravity 1,020. The blood corpuscles rep- 
 resent the solid element of the blood, and are of three kinds — 
 White, Eed and the third blood corpuscle, or blood plates. The 
 White blood corpuscles, are to pathologist the most important. They 
 are round or spherical nucleated mass of protoplasm, having no in- 
 vesting membrane or cell wall, and is about l-2500th of an inch in 
 diameter. Its shape is retained by a delicate skeleton, made up of 
 a reticulum of protoplasm. They possess two very important func- 
 tions, both of which depend on its power of 'changing its shape, 
 viz. : Amoeboid movement and phagocytosis. These endowments 
 are accomplished by the hyaline strings of the reticulated skeleton, 
 which not only gives shape to the cell, but is endowed with muscle- 
 like contraction. In contracting, an arm is thrown out and re- 
 tracted, another is thrown out and retracted, oc the whole cell 
 may flow into it, thus changing its position and accomplishing what 
 is called Amoeboid movement. Phagocytosis is accomplished much 
 in the same way, it throws out an arm on each side of a germ or 
 diatom, the arms meet and so encloses it, it then either digests and 
 assimulates it or it remains in the cell as a foreign body. 
 
 The red corpuscles are much more numerous than the white, in 
 a normal state of health, the proportion being about 1 white to 500 
 red corpuscles. The red corpuscle is a round, biconcave disk, with- 
 
20 PRINCIPLES OF SURGERY. 
 
 out a nucleus, when viewed singly it is yellow, but are red '■'■en 
 masse.'''' It is composed of a colorless, structureless and trans- 
 parent filmy framework or stroma, which is infiltrated in all parts 
 with haemoglobin. It does not possess the function of amoeboid 
 movement or phagocytosis. 
 
 The third blood corpuscle or blood plates, have only been de- 
 monstrated in the last fifteen years. They are much more numerous 
 than the red corpuscles, are round, slightly colored, and much smaller 
 than the red corpuscle and contains no nucleus. It was first 
 thought to be a red corpuscle in infancy, but this theory has been 
 abandoned, as w e now know that the red corpuscle is thrown into 
 the vessels fully developed from the red marrow of bones. The 
 function of the third corpuscle is the production of a clot, as they 
 carry all the ingredients necessary, so, in reality, they act as a 
 guard against hemorrhage. 
 
 The Circulation. — The circulation may be described as the pas- 
 sage of blood, forced or pumped by the heart through the vessels to 
 every part of the body. The heart is provided with valves to pre- 
 vent regurgitation, and by its powerful contraction the blood is 
 sent first through arteries, capillaries, and then through the veins 
 back again to the rio:ht side of the heart. JSTow, as inflammation is 
 so intimately connected with the circulation, we must study the 
 structure of the tubes through which the blood flows. The arteries 
 are formed of three coats, superimposed one on the other; we have, 
 first, the inner coat or Tunica lotima; second, middle coat or 
 Tunica Media; and, third, outer coat or Tunica Adveotitia. The 
 tunica intima is maHe up of layers of elastic tissue lined by endo- 
 thelia cells; the tunica media is made up of muscular tissue, and 
 the tunica adventitia is made up of dense connective tissue and is 
 the strongest and toughest of all the coats. The arteries, then, 
 are seen to be dense, thick, impermeable tubes, not even are their 
 own walls supplied by the blood they carry, but by small arterioles 
 called '■'■vasa vasorum."' A-S the arteries approach the capillaries, 
 their "walls become thinner and thinner, until, when they are 
 reached, they are composed only of one layer of large endothelia 
 cells, which are so thin that the blood f lasma goes in and out the 
 vessels and so supplies the tissues with nutriment. The study of 
 the capillary walls is facilitated by staining them with nitrate of 
 
PRINCIPLES OF SURGERY. 21 
 
 silver, when the cell will be seen to be placed edge to edge and 
 held together by an amorphous cement substance, and at regular 
 intervals very small openings are seen between the cells, called by 
 Arnold ^^ stigmata.''' The capillaries run into veins, whose coats 
 again commence to thicken and become impermeable, until in the 
 large veins the three coats of the arteries are assumed. If a sec- 
 tion of tissue be put under the microscope and the current of blood 
 watched in the vessels, two currents will be seen, one in the middle 
 called the Axial current, the other near the wall of the vessel called 
 the Peripheral current. Both currents run tbe same direction, but 
 the axial current, in which flows the red corpuscles, is about ten 
 times as fast as the peripheral current, in which the white cor- 
 puscles and blood plates flow. These two currents exist in any 
 fluid pumped through an elastic tube, therefore they must exist in 
 the arteries, capillaries and veins. 
 
 Inflammation. — -To define the term is diBBcult, but probably the 
 best is given b}^ Sanderson, as follow : ^ '• Inilammation consists of a 
 series of a histological changes ichich occur in limng tissue when it 
 is injured.^ provided the injury is not sufficient to immediately de- 
 stroy its vitality. 
 
 Causes. — There has been held, as the cause of inflammation, for 
 many years, three theories, the last of which is the most modern. 
 1. Traumatic; 2. Chemical; 3. Microbic. A blow, stab, cut or 
 sprain is a specie of traumatism ; burns of a match, nitric acid, etc., 
 is chemical. But the modern surgeons exclude the above as causes 
 of inflammation and nanae them onh'' as exciting or predisposing 
 causes, creating a place in which the germ may locate- and cause 
 the trouble. Xinety-nine per cent, of suppuration inflammation is 
 caused by a microbe (Senn only gives the microbe as the cause). 
 
 Fathology. — To study the processof inflammatiDU the following 
 artiflcial method has been instituted. A frog is taken and three 
 or four minims of curara is injected subcutaneously, this does not 
 interfere with the circulation, but causes paralysis immediately. 
 
 Make a small slit in his belly, draw out the intestines and irri- 
 gate them with nitrate of silver, place under the microscope and 
 the changes can be readily foUo^ved. When ycu first look every- 
 thing will be normal. 1. As soon as inflammation commences the 
 blood vessels dilate, and the flow of blood is accelerated, due to 
 
22 PRINCIPLES OF SURGERY. 
 
 stimulation of the vaso -dilator nerves, this is the stage of Hyperae- 
 mia. 2. The vessels continue to dilate until their walls are para- 
 lyzed from overdistention, the current becomes slower, caused by 
 more blood coming to the part than can be carried off bj^^ the veins, 
 this is the stage of Congestion. 3. In a short while the current 
 ceases, due to the plugging up of the veins by the white corpuscles 
 accumulating in large numbers, and there is stagnation called the 
 stage of Stasis. "With thpi stage of hyperaemia the red corpuscles 
 remain in the axial current and the white corpuscles in the 
 peripheral current, but with the stage of congestion it is observed 
 that the red corpuscles also go to the periphery. The white cor- 
 puscles next become glutinous and adhere to the wall, and another 
 will come along and knock it off, as if trying to keep up the flow, 
 but they finally adhere to the wall in such numbers as to cause 
 complete stoppage, and we have the stage of stasis. 
 
 In inflammaLion there is always swelling, due to accumulation of 
 the blood in the tissues, which escapes at the same time the fore- 
 going phenomena are taking place. The constituents of the blood 
 go through the vessels wall by two processes — Transudation and 
 Exudation. Transudation is the escape of the fluid element of the 
 blood by percolation. Exudation is the escape of the corpuscular 
 element, and is a much more complicated process: as inflaiimation 
 progresses the stigmato grows larger, a white corpuscle will stop 
 at one of them and will finally work its way through by emigra- 
 tion, stretching the hole larger and then the red corpuscles escape 
 b}'- diapedesis. Although the white corpuscle is larger than the 
 red, it goes throught first, and it does so by virtue of its ameboid 
 movement. Sometimes a rent is made in the wall of the vessel large 
 enough for a quantity of blood to escape, which constitutes a 
 hemorrhao^e and is called Rliexis. 
 
PRINCIPLES OF SURGERY. 23 
 
 LECTURE V. 
 
 IXFLAMMATION.— CoNTmuEi). 
 
 Symptoms. — General.- — These are due to the absorption of the 
 toxins into the system, which toxins ate the product of the germ 
 which caused the inflararaatioa. There is a chill, followed by fever, 
 headache, weakness and nausea. 
 
 Local. — The classification of the local symptoms, enumerated by 
 Celsus 500 years ago, is still recognized as the best. He gave five 
 cardinal symptoms: 
 
 1. Dolar — pain. 
 
 2. Calor — heat. 
 
 3. Rubor — redness. 
 
 4. Tumor — swelling. 
 
 5. Functio laesa — impaired function. 
 
 Intiammatioa is invariably accompanied by pain, which is caused 
 by pr assure on the nerves or by direct inflammation of the nerve 
 filaments. The intensity of the pain varies under certain condi- 
 tions; it will le more intense, everything else being equal, in parts 
 richly supplied by nerves, than in a part with poor innervation; it 
 is less in parts that are elastic and loose, because v^hen the exuda- 
 tions are poured out the tissue can give away and thus lessen the 
 pressure it would produce. The character of the pain differs in 
 different individuals, and in the same individual according to the 
 location of the inflammation, as in inflammation of the skin, the pa- 
 tient will say the pain is burning; in peritonitis, it is darting; in the 
 bone, it is gnawing, and in loose connective tissue, it is throbbing. 
 It differs accordino; to the anatomical tissue involved, the location 
 of the pain is generally at the seat of inflammation, but in rare in- 
 stances it is referred from the seat of inflammation by the nerves 
 elsewhere, as in Pott's disease of the spine the pain is located in 
 the stomach, instead of in the back; in hip joint disease the inflam- 
 mation is in the acetabular cavity, but the pain is referred to the 
 knee and it is often treated for rheumatism of the knee joint. 
 These symptoms are spontaneous, but there is also tenderness on 
 
24 PRINCIPLES OF SURGERY. 
 
 pressure about the part inflamed, which is a great help in. making 
 a diagnosis, as the surgeon cannot only make out the seat of in- 
 flamrcation, but can tell the extent to which it has progressed. 
 The differeace between a neurotic pain and an inflammatory pain 
 is that the neurotic pain is relieved on pressure, and the pain of 
 inflarrimation is intensified. 
 
 Redness is a most natural sequence and is caused by the increased 
 airount of blood to the part. The color varies with the different 
 stages; in the stage of hyperaemia the part is of a bright scarlet 
 hue of arterial blood, and in the stages of congestion and stasis the 
 blood is dammed back, and the part assumes the blue color of ven- ' 
 ous blood. Swelling invariably accompanies inflammation. It is 
 caused by the ditalation of the blood vessels, the escape of the fluid 
 element of the blood by transudation., and is further increased by 
 the exudation of the corpuscular elements of the blood. 
 
 The heat of the body is generated largely in the muscles and 
 glands, and is conveyed to all parts of the body by the blood. This 
 symptom of heat in inflammation is wefl represented by the boiler in 
 a house. From the boiler in the basement the steain is general ed 
 and is carried to the different rooms by pipes, the quantity of heat 
 in the rooms depends upon the amount of steam passing through 
 the pipes, so with the tissues in inflammation, the amount of blood 
 to the part is increased and, consequently, the heat is also in- 
 creased, but never above the maximum temperature of the blood. 
 This symptom is of diagnostic value; by it we can tell whether the 
 swollen part covers a malignant tumor or is the seat of some in- 
 flan,matory trouble, a surface thermometer being applied to the 
 part. 
 
 Deranged function ma}^ be in a direction of increased or dimin- 
 ished physiological activity, as in inflammation of a joint— as the 
 knee renders that joint useless, whereas in the inflammation of a 
 mucous surface, as in a bad cold, the function of secretion is in- * 
 creased and there is a large amount of mucous poured out. 
 
 Termination. — Inflammation may terminate by Resolution, Sup- 
 puration or Necrosis. 
 
 Under favorable conditions and the proper treatment, the inflam- 
 mation will subside and the parts will return to their normal con- 
 dition; this is a most happy termination and is calied termination 
 
PRINCIPLES OF SURGERY. 25 
 
 by resolution, which takes by the removal of the cause of the in- 
 flaramatioD ; the phagocytes exterminates the germs and nature 
 completes the cure by removing the exudations and transudations 
 by the lymphatics- But suppose, in spite of everything you can 
 do, the inflammation goes from bad to worse, the site of the pro- 
 cess enlarges and at one point assumes a purple color, gets soft, you 
 then hope that suppuration will occur, you v^'ait. it may or may not 
 occur, bnt instead necrosis takes place, and you have sloughing, 
 due to the blood being entirely cut off by pressure and the tissues 
 die from want of food. In a boil you find what is called a " Core,*' 
 this is nothing but a mass of tissue which has undergone necrosis. 
 
 Diagnosis. — This is usually simple. The diagnosis is not based 
 or can't be depended on from the general symptoms, but is based 
 on the local symptoms, especially heat. Heat is the most impor- 
 tant symptom, ana without heat, although there may be all the 
 other cardinal symptoms, 3'"ou do not have inflammatioa. 
 
 Pbognosis. — The prognosis is based on 1. The character of the 
 cause; if it be caused by the Gonococci, the prognosis is favorable, 
 and its terminaticn looked for in two or three weeks, but if it is 
 caused b\ the bacilli of Tetanus, the prognosis is grave and the 
 death of your patient expected. 2. The anatomical tissues in- 
 volved, if it is the brain, of course, it will be more grave than the 
 tissues on the back of the neck; if it be the vocal cords, it will be 
 more serious than an infiaraed ingrowing toe nail. 3. General con- 
 dition of the patient: Inflammation occurring in a very feeble old 
 man or in a drunkard or in a person with lowered vitality from 
 any cause, gives a more grave prognosis than wtien occurring in a 
 young, robust, temperate individual. 4. Accessibility of the dis- 
 ease to surgical treatment: If the inflammation be of the mascoid 
 cells, which can onl}^ be reached by a very dangerous operation, the 
 prognosis will be graver than a boil on the back of the neck, which 
 is readily accessible to surgical treatment. 
 
26 PRINCIPLES OF SURGERY. 
 
 LKCTURE VI. 
 
 INFLAMMATIO]^.— Continued. 
 
 Classification. — The various types of inflammation are not due 
 to Siny difference in their pathological changes, but to difference in 
 the intensity of these respective phenomena, so it is not a differ- 
 ence in kind, but in decree. 
 
 The types of inflainraation are modified. 1. B^j cause: As in- 
 flammation produced by the germ of suppuration; inflammation 
 produced by the germ of erysipelas, etc. 2. By degree: Acute, 
 sub-acute and chronic inflaramalion. This does not mean that there 
 are three different kinds of inflammation, for, in fact, they are so 
 much alike that it is only in their onset that we can diagnose one 
 from the other. We speak of acute inflammation when the 
 symptoms of development are rapid, this is a very dangerous form. 
 TV hen the symptoms of development are slower and the inflamma- 
 tion lasts two or three v^eeks. we call it sub-acute inflammation. 
 When the sj/mptoms develop not very fast or very slow and the 
 inflammation does not respond to treatment, we call it chronic in- 
 flammation. 3. By product: In inflammation there is always 
 transudation and exudatioc of the eleirents of the blood into the 
 surrounding tissue. If the transudation of the fluid element is 
 greater than the exudation of the solid element, we call it Inflarc- 
 raator}^ transudate. If the exudation is in excess of the transuda- 
 tion, we call it Inflammatory exudate; this is rarely seen. The 
 difl'erence in the amount of transudate and exudate, which is noticed 
 above, is due to some peculiar microbic change in the tissues. In 
 all inflanimaticns there is always a certain amount of red corpus- 
 cles in the exudation, but not in such quantities as the white, but 
 occasionally the red corpuscles escape in greater amounts than the 
 white corpuscles, and the tissues become stained a bright red, and 
 as the inflammation subsides the haemoglobin dries in the tissues 
 and leaves them permanently colored ; no explanation can be offered 
 for this increased escape of red corpuscles, it is a very serious con- 
 dition and is called Hemorrhagic Inflammation, In some instances 
 
PRINCIPLES OF SURGERY. 27 
 
 the elements of the blood which aie thrown out into the tissues be- 
 come pus, the transudate forming fluid pus, the exudate forming 
 pus corpuscles; this is called Suppurative inflammation and will be 
 treated of in a subsequent lecture. 4. By variety of tissue pri- 
 tnarily effected, (a) Non-vascular tissue. We know there are cer- 
 tain tissues in the bod}' which are non- vascular, and derive their 
 nutrition by percolation of lymph from surrounding arterioles. The 
 cornea c;.nd cartilage is an example of such non -vascular tissue. 
 ]S'o\v remembering the pathology of inflammation, we note that 
 the first changes affected the blood vessels; now as in the cornea, 
 where we have no blood vessels, h^w does inflammation occur? It 
 occurs in this way: If you irrigate the cornea with nitrate of sil- 
 ver, which results in inflammation, we will notice that the blood 
 vessels encircling the cornea becomes dilated, and the lymph and 
 white corpuscles escape, with the result that the lyrcph spaces are 
 found packed with them; soon new blood vessels will form from 
 these vessels and extend to the cornea, and the inflammation pro- 
 ceeds as before described. If resolution takes place, the newly 
 formed bloodvessels shrink and finally disappear, leaving the sight 
 uninjured, but if suppuration occurs the vessels are not obliterated 
 and the sight remains permanently injured. In cartilage, which 
 is still more poorly supplied with blood, the process is almost iden- 
 tical. When irrigated with Silver nicrate, the vessels in the peri- 
 chondrium becomes dilated and throws out lymph and white cor- 
 puscles, and the new vessels then form from the vessels in the peri- 
 chondrium and extends to the cartflage and inflammation then pro- 
 ceeds as before described, (b) Vascular tissue. The spleen and 
 liver is an esarcple. These glands are made up of cells \^hich 
 elaborate their secretions and are called Parenchymatous tissue; 
 they are divided off into lobes and lobules by fibrous tissue, which 
 is called Interstitial tissue. When inflammation first attacks the 
 specific fecreting cells of a gland it is called Parenchymatous in- 
 flammation, and the cells soon disintegrate, causing death. When 
 inflammation attacks the fibrous septa first, it is called Interstitial 
 inflammation, and the organ soon becomes hard and firm. It is ditfi- 
 cult to tell which portion of an organ is first attacked, for in pa- 
 renchymotous inflammation the interstitial is soon also set up and 
 vice versa. When inflammation attacks serous surfaces as the peri- 
 
28 PRINCIPLES OF SURGERY. 
 
 toneum, pleura or synovial membrane, it is called Serous inflam- 
 mation; this may follow several different types, as Effusive Se- 
 rous inflammation, this is caused by the effusion of the fluid ele- 
 ment of the blood, accompanied by very little of the solid element. 
 This is well seen in serous inflammation of the knee joint, when a 
 large amount of serum surrounds the joint; Adhesive Serous in- 
 flammation, this is when the solid elements escape in greater 
 amounts than the fluid element, the surface of the membrane be- 
 comes coated ^ith the corpuscles, causing them to adhere; Sup- 
 purative serous inflammation is merely a later stage of either of 
 the preceding varieties, caused by the pyogenic microbe. 
 
 "When the mucous surfaces are attacked by inflammation, it is 
 called Mucous inflammation, and may follow three types. When 
 any mucous surface is attacked by inflammation, causing an in- 
 creased amount of mucous to be secreted (as in a bad cold), it is 
 called Mucous Catarrhal inflammation; if this goes on to the for- 
 mation of pus it is called Suppurative Mucous inflammation, and 
 when a membrane is formed on the mucous surface it is called 
 Croupous inflammation. This form often attacks the nose and 
 bladder, but is best seen in diphtheria. There is no difference be- 
 tween Membranous Croup and Diphtheria, both are due to a germ 
 which produces the membrane by coagulating the fibrin of the blood. 
 
 LECTURE VII. 
 
 liSTFLAMMATIOT^.— Continued. 
 
 Treatment. — The principle method of treatment of inflammation 
 a generation ago was the so-called Antiphlogistic treatment. This 
 method *vas based on the phlogistic theory, which was tliat inflam- 
 mation was an inflammable condition of the tissues, and must, 
 therefore, be treated Oy depleting the system, which was accom- 
 plished by vivisection, cupping, leeching and the administration of 
 emetics and purgatives. These remedies are used at the present 
 
PRINCIPLES OF SURGERY. 29 
 
 time, but not vMth the same end in view, as we now understand 
 the cause of inflammation, which the older surgecms were ignorant 
 of. The Antiphlogistic treatment has now almost entirely been 
 succeeded by the Antiseptic treatment, which has the advantage 
 of dealing directly with the cause of the inflammation, which is 
 a germ. The Modern treatment can be divided into the Prophy- 
 lactic and (yurative. The former is preventioa of infection, which, 
 is accomplished b}^ the surgeon having his hands, instraments and 
 dressings aseptic. The latter is the application of remedies where 
 bacterial infection has already taken place and may be divided into 
 Local and Constitutional. 
 
 Local Treatment. — -This consist in ihe application of remedies 
 with the view of relieving pain, lessening the swelling and as sooth- 
 ing applications. 1. Bleeding. Venesection was very much prac- 
 ticed in the antiphlogistic treatment, but is scarcely ever resorted 
 to now, for by bleeding the arterial tension is dimirished, and so 
 the "7j25-«-z!er^(9, "thereby lessening the chance of a favorable ter- 
 mination by resolutioQ, Direct abstraction of blood may, under 
 certain conditions, be used to advantage: when the iaflammation 
 is superficial and the part tense and swollen, it relieves the pain by 
 lessening the pressure, but should only be resorted to in the stage 
 of Hyperaemia. Leeches were at one time used, but on account 
 of the liability of their infecting the wound they are no longer 
 used. The safest way of abstracting blood is to cut down to the 
 capillaries with a clean scalpel, and then increase the flow by cup- 
 ping or by the application of waim antiseptic solutions. 
 
 2. Counter irritants. These are useful in some cases, especially 
 when the inflammation is of a chronic variety. The remedies most 
 frequently used are Tr. Iodine, Actual cautery and blisters. These 
 remedies were largely used in the antiphlogistic treatment, but are 
 rarely used at the present time, 
 
 3. Compression. This is a valuable remedy in the treatment of 
 both the early and late stages; it mast bft applied, however, in the 
 acute stage with great care, as sloughing or even gangrene may be 
 the result of tight bandages on a part when the circulation is al- 
 ready enfeebled by injury, but if properly applied it restrains the 
 tendency to excessive swelling and to the collection of serous or 
 bloody discharges between the lips of the wound. In the late or 
 
30 PRINCIPLES OF SURGERY. 
 
 chronic stage, it is the best remedy we possess to promote absorp- 
 tion and resolution. A most eiBcient means of obtaining compres- 
 sion of a part, espeoially the knee joint, is compressed sponges. 
 Two coarse sponges may be flattened over night under a heavy 
 piece of furniture, one of them is then applied to each side of the 
 joinr, which is put un a posterior s{:lint, a long cotton bandage is 
 then applied, after which a stream of water is allowed to trickle 
 on the sponges, which makes them swell and so causing compies- 
 siou. 
 
 4. Cold. Cold is useful in certain stages and harmful in others. 
 It is onl}^ useful in the early stages, when the vessels are dilated 
 and slightly obstructed, and still more appropriate when the inflam- 
 mation is superficial. It produces constriction of the vessels and 
 also has an inhibatory influence on the bacteria. It should never 
 be used in the later stage, as it interferes with the formation of the 
 collateral circulation and produces pain and discomfort. It may 
 be applied either by evaporating lotions or by the use of ice, ap- 
 plied either in a rubber bag or fcy the coil, by which a current of 
 ice water is allov^ed to flow through a rubber or metal coil over 
 the part. Care must be taken to avoid freezing and thus causing 
 sloughing. 
 
 5. Heat. Heat acts as a counter-irritant and also on the circu- 
 lation, relieving stasis and favoring absorption of the exudation. 
 Poultices have been discarded in the treatment of open wounds and, 
 in fact, are seldom ever used at the present time. Heat is now ap- 
 plied as antiseptic fomentations of bichloride mercury, carbolic 
 acid, etc., if the inflammation is not extensive and there is no other 
 contraindication, but in old people with extensive inflammation, 
 we use a less poisonous drug, as boracic acid. Wring out a piece 
 of flannel from the hot solutions, apply to the part, place over it a 
 piece of oil silk, which holds the heat. In this you have all the good 
 qualities of a poultice and do away with its disadvantages — poul- 
 tices are hot beds for bacteria. 
 
 6. Elevation. By elevation through the force of gravity the 
 circulation from the inflamed point is assisted and the supply of 
 blood regulated^ in this manner the pain and swelling is relieved. 
 This is especially useful in inflammation of the extremities. 
 
 7. Physiological rest. This is a most important indication. In 
 
PRINCIPLES OF SURGERY, 31 
 
 inflammation of the stomach, when food can't be retained or 
 digested, it is best to give food by enema and let the stomach rest. 
 In inflammation of the pleura, strap the side with adhesive plaster. 
 In joint inflammation apply a splint. A chronic cystitis may be 
 cured by cystotomy after all other remedies fail, 
 
 8. Parenchymatous injection. This method of treatment has 
 been suggested to arrest the progress of the germ. It consists of 
 iujectmg into the part inflamed an antiseptic solution, as carbolic 
 acid in 3 per cent, strength, and the amount injected to be regu- 
 lated by the internal dose. It is a dangerous treatment and not 
 much employed. 
 
 9. Massage. This consist in rubbing, kneading and manipula- 
 ting the part. If used, a skillful operator shculd be employea. It 
 can only be used in chronic cases, as in acute inflammation the pain 
 would be too great. Medicated ointments may be rubbed in, and 
 are of value; a solution ot Iodide of Potassium in alcohol and some 
 oily substance is recommended. This treatment stimulates the 
 tissues and vessels, ani also aids in the absorption of the inflam- 
 matory productfi. 
 
 Constitutional Treatment. — It is essential to remember that 
 local treatment, whatever its nature may be, is not the only 
 method to bo employed to restore your patient to health, and a 
 careful surgeon will always pay due attention to the general health 
 of his patient and will not let the presence of organic disease else- 
 where be undiscovered. By the use of cocstitutional remedies you 
 assist nature in subduing the inflaramation. 
 
 1. Stimulants. Instead of the old-time treatment, when inflam- 
 mation and fevers were starved, it is now the accepted method to 
 stimulate and build up the patient in every possible way. Stimu- 
 lants, such as whiskey, champagne and sherry, can be administered 
 from the onset of an acute inflammation, unless the patient is sink- 
 ing rapidly, when musk or camphor is best, acting quicker than 
 the former. In chronic types, and when the stomach refuses the 
 above, use beer^ ale, etc. Stirculants must be given in doses large 
 enough to have a decided action. They are especially useful in 
 fevers to sustain the strength, as 'rtell as in chronic wasting disease. 
 In these diseases stimulants, such as whiskey beer and ale, act as 
 food, and it is well to note that they can be taken in larger quan- 
 tities than in health. 
 
32 PRINCIPLES OF SURGEP.Y. 
 
 2. Antipyretics. These drugs, such as Antipyrine, Phenacetine, 
 etc., may somewhat subdue the temperature, but they also have a 
 depressing action on the heart, and are, therefore, little used in 
 inflammation. The best means to lovver the temperature is by the 
 use of baths, baths not only lower the temperature, but are refresh- 
 ing, stimulating and also favor the removal of the poisons excreted 
 by the skin. 
 
 3. Purgatives. Purgatives vf ere freely used in the Antiphlogis- 
 tic treatment, and are still found valuable in certain forms of in- 
 flammation. They are a part of the routine treatment of head in- 
 juries, and if administered promptly in coma, following these in- 
 juries or in apoplexy, they are supposed to remove sources of irri- 
 tation and to leave the system in a condition unfavorable to men- 
 ingeal or cerebral inflammation. Six grains of calomel placed on 
 the tongue and followed in two hours by aa aloes enemata (Powd. 
 aloes one drachm to one pint of soapsudsj. Such a mode of treat- 
 ment is supposed to exert a derivative action by means of which 
 irritation is removed from the brain aad its coverings to distant 
 parts of the economy. The tendency to hyperaemia is certainly 
 diminished. The treatment of peritonitis by purgatives, particu- 
 larly after a laporotomy, has recently come into vogue. They 
 seem to relieve the tympanitis, and by their production of watery 
 stools relieves the engorgement of the intestinal blood vessels, and 
 they also eliminate the germs or their toxins by causing the emptier 
 vessels to absorb the peritoneal exudates. The drugs used are calo 
 mel, Epsom salts and Seidlitz potvders. 
 
 4. Diaphoretics. Although but little used in surgery, diaphore- 
 tics may be found of value, owing to their antipyretic action. 
 They also assist the elimination of poisons by the skin, and as a 
 good many of them are also diuretics they increase the action of 
 kidneys. Sweet Spirits of JSTitre and v^ater are the remedies prin- 
 cipally used. 
 
 5. Emetics. Emetics have long since been discarded in the 
 treatment of inflammation, but were used freely in the antiphlo- 
 gistic treatment. 
 
 6. Anodynes. Ths use of anodynes in chronic inflammation, 
 where the pain is severe and recovery not looked for immediately, 
 should be with caution, as there is danger of the patient using the 
 
PRINCIPLES OF SURGERY. 33 
 
 drug habitually after recovery. They are of great service, as they 
 relieve the pain, which is the worst symptoriQ of inflammation. 
 Morphine is a good preparation to use. The most satisfactory 
 mixture for inflammation of the brain is Chloral and Bromide of 
 potassium in camphorated oil. 
 
 7. Diet. The diet is of the greatest importance. The patient 
 should have plenty of highly nitrogenous and easily digested food, 
 so as to retain his strength. Give a liquid diet, such as animal 
 broth, beef tea and milk, if the digestion is impaired, otherwise 
 give beef steak and eggs. When the stomach can't retain food, 
 give by rectum every four hours, four ounces of peptonized beef 
 juice. 
 
 8. Tonics. Quinine, Tinct. Iron, Tmct. ]^ux Yomicaand Strych- 
 nine are used, and are of great value. 
 
 9. Specifics. When syphilis is the cause of the inflammation, 
 give Mercury and Iodide of Potash. 
 
 R 
 
 Hydrargyi'i Bichlor Cor. griss (i) 
 
 Potassi lodid 5iii (3) 
 
 Tr. Gentianae Comp. §ii (2) 
 
 Aq Dest qs ad §iv (4) 
 
 M. 
 
 Sig. : Two teaspoonfuls after meals. When rheumatism is the 
 cause give salicylate of soda and bicarbonate of potassium. When 
 tuberculosis is the cause give Arsenite cf Iron, Syr. Iodide Iron 
 and Cod Liver oil, pure, if patient can assimulate it. 
 
 LECTURE VIII. 
 
 PROCESS OF REPAIR. 
 
 Regeneration. — Regeneration consists of the process by which 
 normal physiological waste is repaired and by which defects in tissues 
 due to injury are restored. It is divided into Physiological and 
 
 3 
 
34 PRINCIPLES OF SURGERY. 
 
 Surgical regeneration. Physiological regeneration is the process 
 by which normal physiological waste is repaired. We learn, from 
 the study of Physiology, that the cells ot: the body do not have 
 long life (some authors claim that the body is reconstructed every 
 seven years), so after a certain time the cells die and are rubbed 
 off from the body; this is well seen in the palm of the hands and 
 the cells of the internal organs, as the liver, which from arduous 
 labor, die and are cast off. Xow, if there was no way ia which 
 the cells could be replaced, the body would soon become shrunk- 
 ened, but nature provides for this, and by a process of regeneration 
 new cells supply the waste. In early life the cell construction is 
 in excess of the waste, and the body consequently grows; in adult 
 life the processes are equal and the size of the body remains the 
 same, and in old age the waste exceeds the constructioQ and the 
 body atrophies. Surgical regeneration consi<5ts of the process by 
 which defects in tissue due to injury are repaired. We must make 
 a sharp distinction between surgical regeneration and Inflamma- 
 tion. It was formerly thought that inflammation was necessary 
 fcr the healing of a wound; this is absurd, as under aseptic treat- 
 ment a wouud will heal without inflammation. Regeneration is a 
 physiological process; Inflammation is a pathological process; Sur- 
 gical regeneration is a building up or healthy process; Inflamma- 
 tion is a breaking down or diseased process due to micro-organ- 
 isms, while surgical if^generation is due to the effort of nature to 
 resist disease and to overcome injury, and the effort is retarded by 
 inflammation. 
 
 Pkocess of Eepaik in Wounds. — Remembering the explanation 
 of the death cells, how they perform their work, are worn out 
 from the arduous labor and are cast off, it will be w^ell here to 
 study how these cells are replaced. In every organ and structure 
 of the lody there are found what are called '•''Fixed tissue cells,'''' 
 these cells perform no work, have no function, but simply pro- 
 liferates and forms new cells with functions according to whether 
 they were develpf>ed from the fixed tissue cells of the Hypoblast, 
 Mesoblast or Epiblast. In bone we have cells with functions called 
 Sarcoblastic, and we also have cells without functions which form 
 new bone cells and are called Osteoblastic. In connective tissue, 
 which binds different organs togeth^sr, we also find cells which do 
 
PRINCIPLES OF SURGERY. 35 
 
 not bind, bat simply proliferates and forms new cells, these fixed 
 cells are called Epiblastic. Wounds heal by the proliferation of 
 these fixed cells. At one time it was thought that the leucocytes, 
 which were found in such numbers in the injured part, \\ere con- 
 verted into new tissue, this is not so, the leucocytes have no power 
 of forming new tissue, but tbey do give a substance "■Fihrin fer- 
 ment^'''' which is glutinous and holds the lips of the vsound to- 
 gether (sutures are used to assist the leucocytes), and the leuco- 
 cytes, composed as they are of proteid material, on its death de- 
 posits this nutriment, and the fixed cells use it as food, and this is 
 the only way they assist in the formation of new cells. 
 
 Granulation. — Granulation is the process by v\hich new tissue 
 cells are formed in a wound to close the gap, and in the result of 
 the proliferation of the fised tissue cells of the part. If a cut is 
 made, say in the leg, the lips of the wound retracts and the space 
 is filled up with granulation, which is a prodigy of the fixed cells. 
 Thisgraculation tissue will be formed until the gap is entirely filled 
 up and there is nc further need for more. 
 
 Yascularization. — This is a process by which new blood vessels 
 are formed in the granulation tissue. When a wound is made the 
 fixed cells forms a coat over it about one-sixteenth of an inch thick, 
 and unless this coat is supplied with blood the growth is stopped, 
 but nature provides this blood supply. The new vessels are formed 
 from the nearest blood vessel to the part. The first change noticed 
 is the vessel becomes congested and four or five wedge shaped pro- 
 jections form on it, the base of the wedge turned toward the vessel 
 and the apex toward the granulation tissue. The wedge increases 
 in size and begins to be hollowed out at its base, the apex of one 
 wedge next joins the apex of another wedge and thus capillary 
 loops are formed all through the new tissue. These blood vessels 
 are not permanent, for as the granulation cells become converted 
 into more mature tissue and can exist without these vessels, the 
 tissues contract and obliterates them. 
 
 Cicatrization — Cicatrization is the conversion of granulation 
 cells into more mature tissue. A bone cell in proliferating begets 
 a bone cell, a muscle cell begets a muscle cell; so we may say 
 that all cells breed true. If a wound be in a muscle the granula- 
 tion cells are a prodigy of the fixed muscle cells, and when by 
 
36 PRINCIPLES OF SURGERY. 
 
 cicatrization they become mature they \\ill have all the character- 
 istic properties of a muscle cell; the same can be said of bone epi- 
 thelia cells, etc. With the development of more mature tissue 
 from granulation cells by cicatrization, a certain amount of con- 
 traction occurs, due to the fact that in all granulation tissue a cer- 
 tain amount of connective tissue is formed, this contraction forms 
 the cicatrix and serves a good purpose of making the cicatrix 
 smaller and by obliterating the blood vessels. The contraction, 
 may go so far as to be dangerous, as around the elbow joint it 
 may contract to such a degree as to render the joint useless and 
 deformed. 
 
 Epidekmization. . — This is the process by which a wound is cov- 
 ered and is the result of the proliferation of the fixed cells at the 
 margin of the^ound. After granulation and cicatrization has 
 taken place, these cells may be seen coming from the edge of the 
 wound, they are pale and look like the skin of an egg. If a piece 
 of epithelium is left in the wound, proliferation will take place from 
 it also. 
 
 Classification of Healing Wounds. — Old division: 
 
 1. Direct or immediate union. 
 
 2. Plastic inflammation. 
 
 3. Suppurative inflammation. 
 
 This classification was given by John Hunter. He thought 
 when the surface of wounds were brought together they immedi- 
 ately healed; he also thought a wound healed by plastic or suppu- 
 rative inflammation. Under our present kno\\ ledge this theory is 
 absurd, as we know inflammation retards healing. 
 
 New division: 
 
 1. Primary intention (aseptic wound). 
 
 2. Secondary intention (infected wound). 
 
 This classification is proven by observation. All wounds heal 
 by regeneration. A wound healing without inflammation is said 
 to heal by primary intention and is always an aseptic wound. A 
 wound healing after inflammation is said to heal by secondary in- 
 tention and is always an infected wound. 
 
PRINCIPLES OF SURGERY. 37 
 
 LECTURE IX. 
 
 EEGENERATION OF SPECIAL TISSUES. 
 
 Yegetative Capacity of Tissue. — Tissues differ fron] one 
 another in their rapidity of healing, some heal quickly, others 
 slowly, and on this is based their vegetative capacity, which 
 means the power the tissue has of healing. Tissues that heal 
 quickly are said to have a high vegetative capacity, and those that 
 heal slowl}^ are said to be of low vegetative capacity. Muscles 
 are of a lower vegetative capacity than the epidermis, and so they 
 differ all over the body. The vegetative capacity of tissues de- 
 pends on two conditions: 1. On the kind of cell developed from, 
 tbe lov^ er the cell developed from the higher the vegetative capa- 
 city, and the higher the cell developed from the lower the vegeta- 
 tive capacity, as, for illustration, the vegetative capacity of a rab- 
 bit's tissues are higher than that of a man, because the rabbit is 
 of a lower development, and a wound on the rabbit will heal 
 quicker than on a man. 2. Blood supply : the vegetative capacity 
 is higher the more bountiful the blood supply, and tissaes with a 
 poor blood supply have a low vegetative capacity. The nervous 
 tissue is the most highly developed tissue in man, and is conse- 
 quently of low vegetative capacity; epithelium is of low develop- 
 ment and of a high vegetative capacity. 
 
 OoENEA. — When a cut is made in the cornea or any other part, 
 with a poor blood supply and of a low vegetative capacity, it is 
 important to know how tbe wound will heal so as to be able to give 
 a prognosis. The cjrnea is composed of cells placed in a transpa- 
 rent, homogeneous matrix; the vegetative capacity is low on ac- 
 count of its being a tissue of high development and with a poor 
 blood supply. Eepair is due to the proliferation of its fixed tissue 
 cells. If examined under the microscope there will be seen cells 
 M hich ditf er from the regular corneal cells, these are the fixed 
 tissue cells, and when the cornea is injured they proliferate and 
 replace the injured cells. If the wound be aseptic there will be 
 formed just enough cells to repair the injury; cicatrization takes 
 
38 PRINCIPLES OF SURGERY. 
 
 place aDcI the eye returns to its normal appearance with the sight 
 uninjured, but if the pyogenic germ be implanted, which causes 
 the proliferation to go on in excess, the ne^ cells will never be 
 able to transmit light. 
 
 Treatment. The first step is to make the ti ound aseptic; this 
 is hard to do on account of its ccmmijnication with the nose. 
 Irrigate the Tvound, wash off the conjunctiva and eyelids, flush 
 out the lachrymal duct through the nose, remove all blood clots 
 and foreign bodies with a clean needle, press the lips of the wound 
 together and bandage the eye up tight enough to hold them in 
 apposition. IsTever suture the lips together. 
 
 Cartilage. — There are three kinds of cartilage — Hyaline, Fi- 
 brous and Yellow elastic. In each instance they are made up of 
 cartilage cells placed in a homogeneous matrix. Cartilage, although 
 not a highly developed tissue, is of a low, vegetative capacity, on 
 account of its very poor blood supply. The injury may last a long 
 time on account of its low vegetative capacity, but it has fixed 
 cells, which finally proliferate and heals the wound. Xew blood 
 vessels are formed from the vessels in the perichondrium. 
 
 TreatJDent. Render the part aseptic, immobilize it and give 
 nature a chance. 
 
 Epidermis. — The epidermis consists of the epiderma and the 
 derma. The epiderma is divided into four layers. It is a non- 
 vascular tissue, composed of striated epithelia cells, but the rela- 
 tion to the adjacent vascular tissue is so intimate that it may be 
 regarded as a vascular tissue with a high vegetative capacity, con- 
 sequentl}'' it heals readily. Repair takes place by the proliferation 
 of the fixed tissue cells of the part, and is entirely from the margin 
 of the wound, as epithelia begets epithelia cells, and the skin 
 around the wound is the nearest from which proliferation can take 
 place. The new cells are pale, resembling the skin of an egg. 
 The tine taken to cover the wounded surface depends on the size 
 of the wound; if the surface be large, the time may be indefinite, 
 as in cancer of the face where the surface is large it necessarily 
 takes a long time and often it is never covered, for after a long 
 time the process of proliferation stops on account of the cells be- 
 coimng exhausted, when a hard callous will form on the edge of 
 the wound and all signs of healing disappears and you then have 
 
PRINCIPLES OF SURGERY. 39 
 
 an Ulcer to deal with. A wound with a sir all surface is soon cov- 
 ered. 
 
 Treatment. — Up to a fe\^ years ago a wound like the first de- 
 scribed above, without vitality, was a bugbear to the surgeon, the 
 treatment was to give nature a rest, protect the wound and to 
 build up the patient's general healtn. The treatment of to day is 
 different, we do not wait for nature, but force the wound to heal 
 by a process called Skin Grafting, whicti consists of taking skin 
 from other parts of the body and implanting it on the wounded 
 surface, when by ]ts proliferation the surface is covered. "We 
 have two methods of skin grafting, which are generally accepted, 
 Reverdia's and Thiersch's; both methods are in general use, both 
 have their advantages and advocates. They are used under two 
 different circumstances, when a wound fails to heal and when a 
 wound is inflicted. 
 
 E-evekdin's Method. — The wound having had all hemorrhage 
 stopped by means of pressure, is flushed off with normal saline 
 solution. Then the skin on another portion of the body or from 
 some other person is rendered aseptic; with a clean needle lift up 
 the skin and with a sharp sterile scalpel cut off numerous small 
 specks of skin and carry then: to the wound by means of a needle, 
 place them on the wound about one-third of an inch apart, with a 
 knowledge that about two-thirds of your grafts will grow and pro- 
 liferate and so complete the epidermization of the part. 
 
 Thieusch's "Method. — This operation is much more heroic. In- 
 stead of taking inflnitesimal pieces, he tates slips about three-quar- 
 ters of an inch wide and places them on the wound. After the 
 wound has been prepared, the skin on another portion of the body 
 is made aseptic and slips are shaved off with a razor; these are laid 
 on the wound side by side, with their edges touching and a pro- 
 tective dressing is applied. A wound which would not have healed 
 in three or four months can be made to heal by this operation in 
 two weeks. The skin of a friend or of a fresh cadaver can be 
 used. Reverdin's method can be used without anaesthesia, but it 
 is best to administer some aniBsthetic in using Thiersch's method. 
 
 Connective Tissue. — This tissue has an abundant supph' of blood 
 and is of a high vegetative capacity. It embraces both white and 
 yellow elastic tissue. It heals by proliferation of its fixed tissue 
 cells and needs no special treatment. 
 
40 PRINCIPLES OF SURGERY. 
 
 Muscles. — Muscles are of two kinds — Striped and Unstriped. 
 The striped muscles constitute the muscles of the skeleton and 
 are under the control of the will. Unstriped constitute the muscles 
 of the internal organs, as the stomach and intestines, and are not 
 under the control of the will. Unstriped muscles consist of fusi- 
 form cells containing a nucleus and nucleolus. The cells are im- 
 bricated and in broad sheets, which envelopes such organs as the 
 stomach, etc. "When injured, regeneration takes place by prolifer- 
 ation of its fixed tissue cells by Karyokinesis, which goes on very 
 readily. 
 
 Striped muscles are much more common, as Biceps, Triceps, etc. 
 They are invested by fascia and divided into t undies by the 
 Perimysium and into smaller bundles by the Endomysium and the 
 fibres are invested by the Sarcolemma. Between the sarcclemraa 
 and the fibre at various intervals you find the fixed tissue cells, 
 these cells when the muscle is injured proliferates, burst through 
 the sarcolemma and then they divide and sub-divide until the in- 
 jury is repaired. 
 
 Treatment. — When a large muscle is cut, especially if it is cut 
 transversely, it is your duty to suture the ends together, as much so 
 as it is your duty to reduce a fractured bone. Unless you suture 
 the muscle it will be useless to the patient. If the ends retract, 
 and it is difficult to get them together or even to reach them, don't 
 hesitate to make the wound larger. After getting the ends relax 
 the muscle by position (if it is the biceps flex the forearm on the 
 arm), bring the ends together and suture them, using the Mattress 
 suture. Suture the fascia separately. 
 
 Tendon. — Tendons are composed of white fibrous tissue. They 
 are much smaller than muscles, but a great deal stronger; in fact, 
 it is the strongest tissue in the body. One end of a tendon is 
 attached to bone, the other end to muscle, they thus make loco- 
 motion easy and economize space. Tendons are sometimes rup- 
 tured or cut, and the loss of their continuity means the loss of the 
 use of the muscle it is attached to, unless the fixed cells proliferate 
 and fill the gap. A tendon v/hen cut, should be invariably 
 sutured, and when called to a case and on arriving fiud the wound 
 has closed, don't just bind the part up and leave, but find out the 
 extent of the injury, and if any tendons are cut suture them to- 
 
PRINCIPLES OF SURGERY. 41 
 
 gether and be sure you get the right ends in opposition; use the 
 simple suture. Suppose a case comes to you after being injured six 
 months and tells you one of the tendons to his finger has been cut 
 and has not grown together, don't send the patient away, dissect 
 down on the tendon, get the ends and splice them so as make them 
 long enough; sevei the tendon half way through about one inch 
 from each end, split it down near to the end and turn end to end 
 and suture, and you will get a nice result. 
 
 LKCTURE X. 
 
 EEGEISTERATION OF SPEC^IAL TISSUES.— CoNTmuED. 
 
 Blood V^essels.- -This terir includes all thiee types of blood ves- 
 sels, Arteries, Yeias and Capillaries, the structure of each has been 
 considered before. Blood vessels are of a high vegetative capacity, 
 nature recognizing the necessity for their rapid repair when in- 
 jured so endowed them. When a blood vessel is cut the tunica 
 intima and tunica media firmly adhere to each other, they then 
 retract from the tunica adventitia and their edges turn inward. 
 The blood passing over their edges coagulates and forms a throm- 
 bus on their inner side, therebv stopping the flow of blood. The 
 thrombus thus formed is a temporary affair, as it is soon absorbed, 
 but before it is absorbed nature heals the vessel permanently by 
 the proliferation of the fixed tissue cells of the tunica media, which 
 are called Angio blast, and a permanent cicatrix is formed. Up to 
 ten or fifteen years ago the process was not understood; it was 
 thought it was caused by the organization of the thrombus, but 
 this is not true, the lav^ of regeneration from the fixed tissue cells 
 holds good here as in any portion of the body. The older surgeons 
 had the complication of secondary hemorrhage to deal with, they 
 would on amputating a leg, tie the arteries and put the patient to 
 bed, thinking he was all right, but in five or six days secondary 
 hemorrhage would come on, due to the wound being infected from 
 
42 PRINCIPLES OF SURGERY. 
 
 ufing dirty ligatures, the thrombus would disintegrate and the 
 patient's life put at hazards. Wounds in olden times were always 
 infected and never healed by primary intention. "With our mod- 
 ern aseptic surgery we are never bothered with secondary hemor- 
 rhage, so let this be your motto. ^'' Be clean.''' 
 
 Treatment. — The subject of hemorrhage is a big one, and can't 
 be treated of fully here. When the hemorrhage is slight, control 
 it with very hot solutions, which cause coagulation, or by pi assure 
 or elevation, but when a large artery is cut, you musl ligate it; 
 ligate both ends, even if it is only tleediug from one, for when, 
 reaction comes on you are liable to have hemorrhage from the end 
 which did not bleed wMiile the heart w^as depressed. If the artery 
 is only cut half in two, complete the division and tie both ends. 
 
 Nerves. — 'The nervous system is divided into two great divisions. 
 Central and Peripheral. The nervous system is likened unto a tele- 
 graphic system ; you have a central station represented by the brain 
 and spinal cord, and the wires leading from the central station 
 represent the peripheral nerves. The central system is very com- 
 plex, and being of high development, it is of low vegetative 
 capacity, and, therefore when injured, it heals slowly. The peri- 
 pheral nerves are of a high vegetative capacity. They are com- 
 posed of the fibre enclosed in the endoneurium, the fibres are in 
 bundles surrounded by the perineurium and the bundles are 
 grouped together and surrounded by the epineuriura. The nerve 
 fibre is composed of the axiscj^^linder enclosed in the axillemma, 
 this is surrounded by the white substance of Schwann, and this is 
 surrouuded by the neurilemma. At variable intervals alcng the 
 fibre, there are seen constrictions, called the Nodes of Racvier, and 
 at this point between the neurilemma and the white substance of 
 Schwann we find the fixed tissue cells called Neuroblast, and by 
 their proliferation injuries to the n-^rves are repaired. 
 
 Treatment. — ^Cruickshank was the first experimenter to try sutur- 
 ing the ends of divided nerves toojether, but he did not succeed on 
 account of the ignorance existing in his days in regard to asepsis. 
 It is now employed successfully in every day practice, and you had 
 just as well leave the ends of a broken bone unapproxiraated as to 
 leave a divided nerve unsutured. Nerves, when immediately cut, 
 can be easily sutured, and their function will be restored in forty- 
 
PKINCIPLES OF SURGERY. 43 
 
 eight hours. Xever use the regular surgical needle with sharp 
 edges in suturing a nerve, use the common cambric needle, employ- 
 ing an aseptic suture of catgut or silk. The operation was at first 
 thought to be very painful, but if it is done asepticallv, it does not 
 give rise to much pain. If you find it necessary suture the peri- 
 neurial sheath with a separate suture. 
 
 Sometiioes a patient will come to you and say he has lost all 
 sensation in one of his limbs, and on inquiry you find out that in 
 some previous operation or by a fractured bone the nerve has been 
 severed and has not grown together. What will you do? Do this, 
 perform a secondary operation; render the part bloodless by using 
 a tourniquet, make the limb, your hands and instruments sterile, 
 dissect down and find the ends of the nerve, clip oil their bulbous 
 extremities and practice either of these methods: ^^ Sutures a dis- 
 tance^'"' in this the sutures form a scaffolding for the new cells, the 
 sutures are run from one cut end of the nerve to the other, and 
 the new cells are, as it were, carried across on a bridge from one 
 end of the nerve to the other until the breach in its continuity is 
 mended; or you can use the second method, take a chicken bone 
 tube, saw off the ends, decalsify it and make aseptic, put the ends 
 of the nerve in the tube and sew up the wound; the hollow bone 
 causes the cells to proliferate toward the breach until it is finally 
 mended. jSTerve grafting up to this time has not succeeded. 
 
 BoxE. — Bone forms the skeleton or framework of the body, it is 
 the hardest structure in the body, being composed of both animal 
 and mineral matter. Most all bones are hollow internally and 
 coated by a ncembrane called the Endosteum. Externally they 
 are coated by a membrane called the Periosteum. Bones have 
 canals running all through them called Ha version canals, these 
 canals are surrounded by spaces called Lacuna^, which commuQi- 
 cate with each other and the Haversion canals by minute channels 
 call-^d Canaliculi. In the periosteum, endosteurr and lacunae are 
 round cells called osteoblast, which are put there to repair normal 
 physiological waste, but when the bone is injured they take on 
 greater vitality and repair the injury by pouring out granulations 
 called Callus. When first formed the callus is soft and elastic, but 
 after cicatrization occurs the soft uncharacteristic cells become 
 converted into hard bone cells. More callus is formed than is 
 
44 PRINCIPLES OF SURGERY. 
 
 necessary to mend the breach, this will be understood after the 
 process is described. When a bone is broken the osteoblast of the 
 periosteum proliferates and forms callus on the outside, this is 
 calkd External or splint callus; the osteoblast of the endosteum 
 proliferates and forms callus in the medullary cavity, which is called 
 Internal or l-'in callus, and the osteoblast of the lacunae prolifer- 
 ates and forms callus between the divided ends, this is called Inter- 
 mediate or Definitive callus. The callus in each place is thrown 
 out in abundance, the external callus acting as a splint, the inter- 
 nal as a pin, and the intermediate, which is permanent, heals the 
 breach. The internal and external callus after performing their 
 purpose is absorbed. 
 
 Sometimes the callus, owing to some constitutional or local 
 trouble, is formed in excessive amounts, this may be due to syphi- 
 lis, tuberculosis or to the bone not being immovably nxed, and 
 when it occurs the seat of the fracture is the seat of a tumor, which 
 feels like a hard lump. The treatment of the above should be the 
 administration of antisyphilitic remedies, absolute immobility of 
 the bones and confine the patient to bed. Again, callus may be 
 deficit in amount, and this again is due to syphilis, tuberculosis, 
 old age and insufficient blood supply. When the bone is examined 
 you will find no swelling or anything to show that healing has com- 
 menced. The treatment should be directed toward building up 
 the patient's general health; irrigate and thus stimulate the cells 
 to proliferate, this can be done by rubbing the ends together. If 
 this does not effect a union, give the patient an anaesthetic, render 
 everything aseptic, open the limb down to the seat of the fracture, 
 saw off the ends of the bone, drill a hole in each end and fasten 
 them together ^-ith a bone nail. The most satisfactory operation 
 is the Step operation, in this the bone is sawed like a step, each 
 end having a shoulder which fits quite accurately, it is then held 
 in position with silver wire. 
 
 It is a practical fact that when a bone is removed from any part 
 of the body that if the periosteum is left the bone will regenerate 
 from it. A case is reported where the entire collar bone was re- 
 moved and the periosteum left, whereas the entire bone was restored 
 in two or three months. Theoretically it is claimed that unless a 
 small piece of bone is left the bone will not regenerate, but it will, 
 
PRINCIPLES OP SURGERY. 45 
 
 provided the m ound be aseptic, the periosteum sewed up and slightly 
 irrigated. 
 
 Treatment of Fractures. — There are two indications when a 
 fracture occurs, reduce the fracture and keep the fragments in 
 apposition by some mechanical appliance. 
 
 LKCTURE XI. 
 
 suppuratio:n^. 
 
 SuppDRATioN may be defined as the process by which the pro- 
 ducts of inflammation are converted into pus. For many years 
 the phenomena was not understood. About thirty years ago an 
 experimenter, vchil^ exaiDining pus, sawr between and in the pus 
 corpuscles certain minute round bodies, but was unable to explain 
 anything about them. Koch, working on the same line, said he 
 believed they were micro-organisms, and by further investigation 
 he proved that they were germs and not products of inflammation. 
 It is now generally accepted that suppuration is due to a specific 
 germ, and moreover, it can be proven by fulfilling the laws of 
 Koch. These bacteria always accompa.ny suppuration; they can 
 be cultivated; the cultivated germs if injeciecl into an animal will 
 cause suppuration; they will be found in the pus from this animal. 
 It can also be proven clinically as well as bacieriologically that 
 it is due to a germ; if you make a wound clean, it "will heal with- 
 out suppuration, whereas in a dirty wound you invariably have 
 suppuration. After a wound has suppurated by heroic treatment 
 with strong antiseptics, you can kill the germs and suppuration at 
 once ceases. 
 
 Causes. — The causes of suppuration may be divided into predis- 
 posing and essential. 
 
 1. Predisposing. — Diminished vitality of the tissues. If any 
 part of the body is congested or inflamed, or for any reason is de- 
 
46 PRINCIPLES OF SURGERY. 
 
 pressed, you have a weak poiat where the germ may localize and 
 cause suppuratioD. 
 
 Anatomical structure of the part. — Some structures are more 
 liable to suppuration than others; this is explained by the fact that 
 some organs, for instance the liver, has terminal distribution of 
 arteries, these arteries end bluntly and do not anastomose as in 
 other parts, and uonsequentl}^ when they become plugged they have 
 no means of establishing a collateral circulation, and as a result, 
 it is more liable to suppuration than parts where the vessels anas- 
 tomose freely. 
 
 Condition of the blood. — If from any debilitating diseases, as 
 anemia or diabetes, the character of the blood is below par, sup- 
 puration is liable to occur. This is well seen in Diabetes, when 
 sugar circulates freely in the blood, with the result of superficial 
 abscesses all over the body. 
 
 Kumber of germs introduced. — An investigator has recently 
 made a solution of the germs of suppuration, in which he knew 
 how many germs there were to the drop of the solution, and by 
 injecting this solution into animals he found out how many of the 
 germs it took to produce suppuration. Each drop of the solution 
 represented eighteen million germs. Into one animal he injected 
 one drop, another two and another three, but in none of the ani- 
 mals did suppuration occur, but when he injected them in quan- 
 tities amounting to one billion germs suppuration occurred. The 
 action of the white corpuscles or phagocytes explains this. The 
 phagocytes were able to cope with from eighteen to thirty-six mil- 
 lions of the germs, and prevented their producing suppuration, 
 but when a billion were injected they overcame the phagocytes and 
 produced their effect. 
 
 2. Essential cause. — The essential cause is the microbe of suppu- 
 ration, of which we recognize about fifteen varieties. 
 
 StajjhyloGOCcus pyogenes aureus. — As the name indicates this is a 
 round cell, about 1 MM. in diameter, grows in agar agar, blood 
 serum and glycerin, multiplies by direct division and forms bunches: 
 Its peculiarity is that when growing it imparts an orange color to 
 the fluids. 
 
 Staphylococcus p}yogenes alhus. — This is also a round cell, and is 
 only differentiated from the above by its imparting a white ap- 
 TDearance to the media. 
 
PRINCIPLES OF SURGERY. 47 
 
 Staphylococcus pyogenes citreus. — This germ is identical in size 
 and shape vsith the above and grows in the same media. Its dis- 
 tinctive feature is that it imparts a very dark orange color to the 
 media in which it is cultivated. 
 
 Staphylococcus cereus albus. — This is a slightly smaller cocci than 
 the preceding, but otherwise is identical. When growing it forms 
 round, waxy white bodies, sometimes spoken of as its eggs. 
 
 Staphylococcus cereus flavus. — This cocci is identical with the 
 above, with the exception that the bodies formed are round, waxy 
 and yellov7. 
 
 Staphylococcus fiavescens . — This cocci has no distinctive feature, 
 it stands midway between the staphylococcus cereus albus and 
 flavus. It is said to cause stitch bole suppuration. It is found 
 principally on ^he fingers. It multiplies very rapidly and forms 
 bunches. 
 
 Micrococcus pyogenes tenius. — This germ has only recently been 
 discovered. It is found in abscesses which do not cause any 
 marked constitutional disturbances. 
 
 Streptococcus pyogenes. — ^This is the most important specie of all 
 the germs of suppuration. It is a round cocci, mutiplies by fission 
 and forms chains, it multiplies slowly at the ordinary temperatures, 
 but very rapidly above these temperatures. It imparts a bro^Yn 
 hue to the media. 
 
 Bacillus pyogenes fetidus. — This is a rod shaped germ with round 
 ends, possessing two nuclei. It imparts a stinking odor to the 
 media. It is to this bacillus that the stink which is characteristic 
 of abscesses in the vagina is due. 
 
 Bacillus p)yocyaneus. — This is a rod-shaped germ with rounded 
 ends with but one nuclei. It is charactrized by imparting a dark 
 blue color to the media. The blue granulations of an infected 
 wound is due to this bacillus. 
 
 Micrococcus Gonorrhoea. — This is a round cocci usually found in 
 pairs forming a Diplococci. It is found chiefly on mucus mem- 
 branes. 
 
 Bacillus Coli Communis. — This is a rod-shaped germ with blunt 
 ends possessing one nuclei. It grows in all media, but does not 
 liquify it. These bacilli inhabit the intestines, and are supposed 
 to assist digestion, but if any lesion occurs in the intestines and 
 
48 PRINCIPLES OF SURGERY. 
 
 they get into the peritoneal canity they will produce peritonitis. 
 They are harmless "while in the intestinal canal. They are said to 
 be the cause of appendicitis, the appendix becomes predisposed, 
 owing to defective blood supply, the bacilli infects it, causing sup- 
 purative appendicitis. 
 
 In the practice of surgery you \^ ill find that suppuration behaves 
 differently on different occasions, sometimes, as in an abscess, it is 
 localized and on opening the abscess the suppuration ceases, again 
 it has no tendency to localize, but grows ^;^orse. This difference 
 is due to the peculiar character cf the germ causing the suppura- 
 tion. All the staphylococci cause localized suppuration, while the 
 streptococci produce diffuse suppuration. Eecently there has been 
 claimed by some scientist and enemies of bacteriology, that sup- 
 puration can be produced without the pyogenic germ ; one of them 
 took a glass tube, sterilized it and inserted into it some sterilized 
 croton oil and then sewed it in his arm, he claimed that suppura- 
 tion was produced. It is true, he produced something like pus, 
 but it was not pus, it was a travesty and was a puruloid and not a 
 purulent material. Clinically all pus is produced by a specific 
 germ. 
 
 Pus. — Pus is the by-product of suppurative inflammation. It 
 is a thick, milky, cream-like fluid, having little odor, slightly alka- 
 line in reaction, specific gravity 1030. It is composed of pus 
 serum and pus corpuscles. Pus serum consists of the top layer of 
 pus after it stands awhile. It is a clear, transparent, greenish 
 yellow fluid, alkaline in reaction and resembles and is almost iden- 
 tical in chemical composition with liquor sanguinis. Pus corpus- 
 cles form the solid element. They are simply dead leucocytes and 
 embryonal cells. They vary in size according to their source, 
 those formed from the leucocytes are the size of the leucocytes and 
 those from the embryonal cells are the size of the embryonal cells. 
 They are usually round, but are sometimes very fantastic, this is 
 caused by the leucocytes in death's agoay throwing out pseudo- 
 podia iu vain attenptsto protect itself, rigor mortis coming on 
 and catching it in this shape. The appearance of their protoplasm 
 is granular; an ordinary leucocytes or embryonal cell is clear and 
 transparent, but on their death putrefaction sets in and gives them 
 a granular appearance. The leucocytes and embryonal cells have 
 
PRINCIPLES OF SURGERY. 49 
 
 only one nuclei, pus corpuscles have about fifteen, and it is on this 
 accouDt that some observers claim thera to be living cells, and the 
 great number of nuclei are due to the division of their original 
 nucleus, but it has been proven that they are not a result of repro- 
 duction, but of disintegration, and so not an evidence of construc- 
 tion, but of destruction. Acetic acid added to pus corpuscles causes 
 them to become clear and transparent; water causes them to swell; 
 liquor potassae at once destroys them by converting them into a 
 gelatinous mass. 
 
 Clinical Yarieties. — 1. Laudible pus. — This means a good or 
 healthy pus, but the idea of saying any pus is good or healthy is 
 absurd; but the name has been in use so long that it is hard to 
 discard it. It means the best pus out of a bad assortment. It is 
 thick, creamy, white pus, without odor, not irritating and soon 
 ceases, leaving a healthy gram: lation. 
 
 2. Sanious pus. —This means pus stained with blood. It is thin, 
 acrid, irritating and of a dark red color, and indicates serious conse- 
 quences. 
 
 3. Fetid pus. — This means stinking pus. It is commonly found 
 in abscesses near the rectum and in the va2,ina. 
 
 4- Chromatic pus. — This means a brilliantly colored pus, as the 
 dark blue pus produced by the bacillus pyocyaneus. We also some- 
 times see dark red pus, but the bacillus which ])roduces it has not 
 been named. 
 
 5. Serous pus. — This means pus mixed with serum. It is gene- 
 rally found near serous cavities. 
 
 6. Mucous or Muco-purulent pus. — This means pus mixed with 
 mucous. In a bad cold you see mucous flowing from the nose, 
 and if this goes on to a catarrhal condition the mucous becomes 
 mixed with pus. 
 
 7. Inspissated pus. — Sometimes in splitting open an old abscess 
 we find a caseous mass, this is called inspissated pus. It is caused 
 by the serum of the pus being absorbed, leaving the pus corpuscles 
 behind, which forms a dry, cheesy mass. 
 
50 PRINCIPLES OF SURGERY. 
 
 LECTURE XII. 
 
 CLINICAL FORMS OF SUPPURATION 
 
 In accordance to the time taken to convert the products of in- 
 flammation into pus, suppuration is divided into Acute, sub-acute 
 and Chronic suppuration. These terms do not mean that there 
 are different kinds of suppuration, but are simply used to designate 
 the intensity of the process. 
 
 Acute suppuration is caused bj^ a germ of great virnlency and 
 in large numbers. The symptoms come on rapidly and reach their 
 height in two or three days and then subside. In this form all 
 the pus corpuscles are derived from the leucocytes, for the process 
 is so rapid that not enough time is given for the embryonal cells to 
 proliferate. The symptoms are pain, heat, redness and sw^elling. 
 
 Sub- acute suppuration differs from the preceding only in not 
 being as int^'nse, it is produced by a germ of less virulency and 
 not in such numbers.. The symptoms develop slowly and last for 
 a longer time. The source of the pus corpuscles are from both the 
 leucocytes and embryonal cells, as in this form time is given for 
 the embryonal cells to proliferate. The symptoms are the same 
 as in the acute form, but are not as intense, especially the pain. 
 
 Chronic suppuration is produced by an exceedingly attenuated 
 germ, and these are only in small numbers. The symptoms are 
 the same as in the other forms, but they develop more slowly, last 
 longer aud are not so intense. The pus corpuscles are exclu- 
 sively of embryonal cells, as the development is so slow that the 
 stigmata in the \essels heal and do not allow the escape of the 
 leucocytes and those escaped in the earlj'- stage are absorbed. 
 
 Abscess. — An abscess may be defined as a circumscribed collec- 
 tion of pus in tissue. A collection of pus in a preformed sjjace is 
 not an abscess, but a purulent infiltration, as pus in the fallopian 
 tube, peritoneal and thoracic cavity, in these cases Pyo is added to 
 the name of the anatomical cavity as Pyothorax, etc. We have 
 two varieties of abscesses — Acute and Chronic; this does not mean 
 that they differ in kind, but in degree and intensity. The causes 
 
PRINCIPLES OF SURGERY, 51 
 
 which may produce an abscess are numerous, but only two will be 
 considered, predisposing and essential. The predisposing cause is 
 anything which lessens the vitality of the tissues. The essential 
 cause is the germ of suppuration, usually of the staphylococcus 
 variety. 
 
 Pathology. — This germ enters through an '•'•Infection Atrium^'''' 
 penetrate the tissues (usually the cellular tissue), there rapidly iu- 
 ciease in number, and after forming quite an army, attack the 
 tissue, producing inflammation. They first attack the capillaries 
 producing hyperaeraia, followed by transudation and exudation; 
 soon necrosis sets in, which is due to the evil influence of the grerms 
 and their toxins, and to starvation of the tissues, from the blood 
 supply being cut off by pressure. After the death of the tissues, 
 liquif action takes place. This commences in the center and 
 rapidly progresses, until a point is reached where nature has made 
 preparations to protect itself, ifsature does this by the cells at the 
 margin of the diseased tissue, proliferating and building a wall of 
 defence. As soon as the germs rind they can't invade the tissue 
 further they turn their attention entirely to the dead tissue, pep- 
 tonizing it, with the result that we have a bag full of fluid pus. 
 After while nature congratulating herself on having successfully 
 repulsed the enemy, determines she will get them entirely off of 
 her domains; this is accomplished by a process called '•'■pointing.''' 
 The pus is gradually forced to the surface and by pressure on the 
 skin or mucous membrane a dark spot appears, which finally breaks 
 down and a sinus is opened through which the pus escapes. 
 
 Acute Abscess.— The acute or hot abscess usually developes in 
 the connective tissue beneath the skin. The causes are, as before 
 stated, predisposing (traumatism or debility) and essential, which 
 is the germ of suppuration. 
 
 Symptoms. — The constitutional symptoms are chills, fever, ano- 
 rexia and nausea, which are due to the absorption of the toxins. 
 The local symptoms are heat, redness, swelling, pain and fluctua- 
 tion. When an abscess is developing, the pain is in accordance to 
 the number of nerves and the elasticity of the part. The swelling 
 is due to the hyperaemia of the vessels, and to their pouring out 
 exudations and transudations. Heat and redness is localized and due 
 to the increased amount of blood to the part. After the above 
 
52 PRIXCIPLES OF SURGERY. 
 
 symptoms, on careful palpation, you can detect fluctuation, which 
 shows pus has formed. The mode of obtaining fluctuation is to 
 place one finger on each side the sw elling, and by producing un- 
 equal pressure, first with one finger then the other, a wave of fluid 
 is set up which can be readily felt. The swelling will now be 
 noticed to become cone shaped, the surface yellow and unless the 
 abscess is incised ulceration tates place from pressure and the pus 
 escapes. 
 
 Diagnosis. — This is usually simple, being made from the symp- 
 tom of inflammation and fluctuation. But occasionally there is 
 difficulty in telling if it is an abscess or an aneurism, and the two 
 may co-exist, or it may be mistaken for a rapidly growing tumor. 
 The use of the aspirator in these cases clears up the diagnosis. An 
 aspirator is simply a hollow needle fitted on to a syringe. To use 
 the aspirator, render the part aseptic, sterilize the needle by pass- 
 ing it through a flame, and insert it under the skin obliquely for a 
 half an inch before entering the cavity, by this means a valve is 
 formed, \^hich, on withdrawing the needle, prevents the escape of 
 the contents of the ti.mor. After the needle enters the cavity, 
 y[ hich is recognized by the lack of resistance, withdraw the piston, 
 and if it is an abscess you will get pus in the barrel of the syringe, 
 if an aneurism you get blood, and if a tumor you will get a certain 
 amount of serum and epithelia cells and by esamining these under 
 the microscope you can tell the kind of tumor you have to deal 
 with. 
 
 Treatment. — The old treatment consisted in applying a poultice 
 to the abscess until it came to a head or pointed, and then it was 
 incised, but let me caution you, never use a poultice, it has two 
 good qualities, noisture and heat, which can be obtained by im- 
 mersing a piece of cotton in a hot antiseptic solution, applying it 
 and covering with oil silk, which will hold the heat for hours and 
 in this manner you get all the good qualities of a poultice and do 
 away with its disadvantages, the chief of v^hich is the extreme 
 liability to infection. When you are certain there is pus in an 
 abscess or boil, don't wait for poultices or hot fomentations to bring 
 it near the surface, but cut down with a free incision, irrigate 
 the cavity and drain. In cutting down into a deeply seated ab- 
 scess, you must know the anatomy of the part, and if there be 
 
PRINCIPLES OF SURGERY. 53 
 
 large blood vessels or nerves interposed, as in an abscess of the 
 deep tissues of the neck, don't jab your knife down into the cavity, 
 but practice this method. After rendering the part aseptic and 
 your hands and instruments sterile, make a small incision through 
 the sl^in, then with a pair of artery forceps bore your way through 
 the tissues down into the cavity, which, when reached, can be told 
 by the lack of resistance; now open the forceps and thus dilate the 
 sinus you have made; if the abscess be very large continue your 
 boring into the opposite wall from the inside until the forceps show 
 beneath the skin, then slightly open them and cut the skin be- 
 tween the blades. Irrigate the cavity with antiseptic solutions, 
 give free drainage and put on a protective dressing. 
 
 Chronic or Cold Abscess. —These abscesses are usually tuber- 
 cular in origin, the person having previously had tuberculosis of 
 the bones or some other tissue and the bacilli floating around gets 
 into the embryonal cells, causing a cold abscess. Their usual seat 
 is on the back, thighs or knees. 
 
 Causes. — The predisposing cause is the existence of tuberculosis 
 in some of the tissues, and the essential cause is the introduction of 
 the pus germ in these tubercular areas. 
 
 Symptoms. — The local symptoms are vague and uncertain, there 
 is no pain, redness or heat; the only symptom is swelling, which 
 developes exceedinly slow and gives fluctuation on palpation. 
 The constitutional symptoms are those of tuberculosis, a rise of 
 temperature in the evening, diarrhoea, nighl sweats and general 
 emaciation. 
 
 Diagnosis.— The diagnosis is based on the history; inquire into 
 the family history, look at the spine for Pott's disease, at the hip 
 for Coxalgia, and lastly obtain some of the fluid with an aspirator, 
 examine it under the microscope for the Tubercle bacillus. 
 
 Treatment.— There are two principal methods of treatment — 
 Incision and Aspiration. When the primary focus is accessible, it 
 should be treated with a free sweeping incision, dissect out the 
 capsule, irrigate with heroic antiseptics, such as bi-chloride of mer- 
 cury, and close the wound. But if the abscess is so situated that 
 it can't be readily gotten at, practice the second method: Take a 
 large trocar, sterilize it by passing it through a flame and plunge 
 it into the cavity, withdraw the blade and ailow the fluid to run 
 
54 PRINCIPLES OF SURGERY, 
 
 out through the canula, irrigate the cavity through the canula 
 "U'ith strong antiseptic solutions until the solutions return un- 
 colored "with pus, then inject into the cavity 5ss to ^i of a ten per 
 cent, solution of Iodoform in glycerine, withdraw the canula and 
 seal the opening with a piece of adhesive plaster to prevent the 
 escape of the Iodoform; repeat this every two weeks. This treat- 
 ment IS based on the fact that by aspiration you eliminate so many 
 of the bacilli, and b}'' using antiseptics you kill the germs present 
 and the iodoform prevents their further growth. 
 
 LECTURE XIII. 
 
 CLINICAL FORMS OF SUPPURATION.— Continued. 
 
 Phlegmonous Inflammation with Suppuration. — This subject 
 is contrasted with abscesses, an abscess being a circumscribed col- 
 lection of pus, while phlegmonous inflammation is characterized by 
 its tendency to spread and is a much more serious condition. It 
 may be defined as a rapidly spreading inflammation, accompanied 
 by suppuration, usually involving the connective tissue of the ex- 
 tremities and showing no tendency to localize. 
 
 Cause, — The essential cause is the microbe of suppuration. The 
 microbes which cause suppuration are about fifteen in number, of 
 these the Staphylococcus are found in abscesses and the streptococ- 
 cus in phlegmonous inflammation. The predisposing causes are 
 injuries to the connective tissue of the extremities, as in crushing 
 wounds in railroad accidents and in compound fractures. 
 
 Symptoms. —The sViiiptoms generally come on in about four days 
 after the injury, commencing with a chill, followed by a rapid 
 rise of temperature, which may reach 104 to 105 degrees F., rapid 
 bounding pulse, full respiration, skin hot and dry^ the wound angry 
 looking, a bloody, serous discharge comes from it. the tissues boggy 
 and pitting on pressure, the swelling extends up and down the limb 
 and the exudations are rapidly converted into pus. The pro- 
 
PRINCIPLES OF SURGERY. 00 
 
 cess extends along the muscles and nerves, over the arteries and 
 Teins, and when an incision is made into the tissues they look as if 
 they had been dissected out with a knife. 
 
 Treatment.-- -The treatment to save life must be heroic. Thepus 
 is ground down and infiltrated into every part of the tissues, and 
 the operation must, be looked on as a major operation. Give the 
 patient an ana3Sthetic, make the site of the operation clean by using 
 hot water and green soap, alcohol and bi-chloride; make your hands 
 and instruments sterile, and with a free incision expose all the tis- 
 sues involved, follow^ out the course of the pus minutely, sponge 
 the w^ound, irrio^ate with boracic or salicvlic acid solution, give 
 free drainage, apply plenty of absorbing cotton, bandage up the 
 part and put the patient to bed. Watch the patient, and if in three 
 or four days you lind him with fever, remove the dressing and 
 drainage tubes, lay the limb out on the bed o^ er a piece of rubber 
 and resort to continual irrigation. This can be done by putting a 
 fountain syringe on the bed post, and let some feeble antiseptic 
 solution flow over the wound. In this way you wesh off the pus 
 as fast as it is formed and thus its absorption is prevented. The 
 current of water can be nicely regulated with a clothes pin. By 
 feeble antiseptic solutions is noeant non-poisonous solutions; our 
 best antiseptics, bi-chloride of mercury and carbolic acid, are poison- 
 ous and can't be used on such large surfaces, and consequently we 
 resort to feebler antiseptics, such as chloral hydrate, boracic and 
 salicylic acid, acetate of aluminum, etc. A splendid non-poison- 
 ous antiseptic solution can be made by the addition of Tinct. Iodine 
 to water until it assumes a cherry wine color. In extreme cases, 
 where the above means have been resorted to and failed, amputa- 
 tion must be resorted to in order to save life. In amputating 
 always operate high enough up above the infected tissue to secure 
 a healthy flap. The operation under these conditions is extremely 
 grave. 
 
 Paronychia. — Paronychia, whitlow or felon are svonymous 
 terms applied to suppurative inflammation of the Angers. It may 
 form under the skin, tendon or periosteum. 
 
 Cause. — The cause is the microbe of suppuration, it never occurs 
 without this microbe, and if the history of the case be inquired 
 into, it will be found that the skin has been broken by a splinter 
 
56 PRINCIPLES OF SURGERY. 
 
 or other means, thus giving entrance to the germ. It is seen in 
 carpenters, cooks and surgeons very frequently. 
 
 Symptoms. — There is throbbing pain and the finger is swollen, 
 red, hot and congested. 
 
 Treatment. — The treatment usually folloAved, consist of paint- 
 ing the finger with Iodine, or the application of a poultice, and 
 after the doctor finds out the finger is getting worse, he jabs a 
 knife into it, and allows the patient to do the cutting by jumping. 
 J^ever be guilty of treating a case like this. The first treatment 
 is the prophylactic; care for the nails by keeping the skin pushed 
 well back off them, keeps the fingers free from hang nails and use 
 antiseptics from time to time. These suggestions should invariably 
 be carried out by surgeons. 
 
 The abortive treatment amounts to nothing, which is shewn by 
 so much having been Avritten on the subject with still no recog- 
 nized specific. But, of course, you must do something, and the 
 following is the most logical: Keep the hand elevated and the 
 finger enclosed in an ice bag, this keeps down excessive hype- 
 raemia, aad the cold also has a deleterious action on the microbes. 
 If, in spite of all you do, the process goes on to suppuration, don't 
 poultice, render the part aseptic with the usual care, use some 
 local angesthetic as Cocaine or Ethyl chloride spray and with a 
 clean knife make an incision parallel \^ith the long axis of the fin- 
 ger, so as not to cut the tendon in two; cut carefully as the pus 
 may be just under the skin, and by carelessness or by letting the 
 patient do the cutting by jumping, you may cut down to the ten- 
 don unnecessarily, or the pus may be under the periosteum and 
 you will not reach it; so cut carefull}^, evacuate the pus, irrigate the 
 cavity with a strong bi-cholride solution and dress aseptically. 
 Flush out the cavity every two or three days until suppuration 
 ceases. 
 
 Furuncle. —A furuncle or boil is nothing but an abscess of the 
 skin. They are more frequently seen on the back of the neck. 
 There may be only one or two and again they may extend all over 
 the body, which constitutes a disease known as Furunculosis. 
 
 Cause. — The essential cause is the pus genu. The pus germ is 
 capable of penetrating the skin in rare instances, they maj gain 
 admittance through a hair follicle or sodoriferous gland, and when 
 
• PRINCIPLES OF SURGERY. 57 
 
 they enter by these chanoels the}^ generally locate at the point of 
 entrance, causing 9 iuruncle. 
 
 Symptoms. — The first symptom is itching, which comes from a 
 small blotch on the skin, this blotch grows larger and there is pain, 
 redness, swelling and increased local teinperature. The pus soon 
 appears under the skin, stretching it upward and unless incised 
 finally burst through and discharges. 
 
 Tkeatment. — The treatment formerly consisted in the adminis- 
 tration of such drugs as Calcium sulphide. Iron, etc., which were 
 thought to prevent their formation. This is not true, but they do 
 good if the patient is anemic and the digestion is poor. The 
 prophylactic treatment consists of cleanliness. Take a warm bath 
 three or four times a week, using soap free from alkalies and per- 
 fumery; change the underclothing frequently, don't scratch the 
 part with dirty nails and thus implant fresh infection. It this 
 fails, give an antiseptic bath once a week of Sulpho-naphtol (gi to 
 a tub of water). When a furuncle does occur, try to abort it be- 
 fore it points by touching it with pure carbolic acid. If, however, 
 it goes on and pus forms, don't poultice, but render the part aseptic 
 and incise it with a clean knife. Don't try to squeeze the core out 
 and thus bruise and weaken the vitality of the tissues, but with a 
 small curette scoop out the necrotic tissue, irrigate with a strong 
 carbolic acid solution and put on an aseptic dressing. If the patient 
 be an important one, don't envelope the bead in a bandage, but 
 with a little collodion, paint around the wound and apply a piece 
 '^f lint. 
 
 Carbuncle. —A carbuncle is a suppurative and gangrenous in- 
 flammation, the toxic germ w hich causes it is so virulent that 
 death of the tissues result. Some authors make two classes — Malig- 
 nant and Simple. The malignant pustule is due to the germ of 
 anthrax and is distinct from a carbuncle, which is due to the microbe 
 of suppuration. Carbuncles usually occur on the neck or buttocks, 
 between the ages of forty and sixt^?. It may be from one to four- 
 teen inches in diameter. Its characteristic feature is that it has a 
 cribriform surface — that is, it is punctured by four or five holes, 
 whereas a furuncle has only one and on this is based the differen- 
 tial diagnosis. 
 
 Symptoms. — There is throbbing pain, redness, swelling and in- 
 
58 PRINCIPLES OF SURGERY. 
 
 creasea local temperature. It is movable and feels like a hard 
 cartilagenous mass. 
 
 Treatment.— If the carbuncle is seen in its infancy, exterminate 
 it. The tissues beneath are infiltrated with pus, which should be 
 evacuated. Give an anaesthetic, shave and render the part aseptic, 
 then make a crucial incision, dissect back the flaps and with a 
 curette rerEove the necrotic tissue, clip off all dead fragments of 
 tissue with scissors, irrigate with a bi-chloride solution and dress 
 asepticalh^. Irrigate the wound daily until the process ceases. 
 Sometimes it will be found necessary to completely exterminate 
 the carbuncle as if 3^ou were dealing with a cancer. Go bej^oad 
 the infected tissue and remove it bodily. When the above means 
 fail, and the germ still carries on its deadly work, resort to the 
 cautery, take a thermo-cautery and burn over the entire surface. 
 
 The constitutional treatment of all suppurations should not be 
 neglected, give stimulants, good food, and for the pain give an 
 anodyne. 
 
 LECTURE XIV. 
 
 CLINICAL FORMS OF SUPFUFvATION.— Continued. 
 
 Abscess of the Antrum. — An abscess of the antrum is a circum- 
 scribed collection of pus in the Antrum of Highmore, which cavit}'' 
 is situated in the Superior maxilla. This cavity opens in^o the 
 nose through a small outlet, which is only covered hy mucous mem- 
 brane, the roots of the first molar and second bicuspid teeth usu- 
 ally open into it also. 
 
 Cause.-— The essential cause is the pyogenic microbe, which may 
 gain admittance through the roots of the teeth opening into it, or 
 through the opening from the nose. 
 
 Symptoms. — The symptoms are pain which radiates over the 
 whole face. If the pus accumulates swelling will result, and it 
 may go on to such an extent as to cause protrusion of the thin, 
 
PRINCIPLES OF SURGERY. 59 
 
 bony wall, either pushing out on the face or into the orbital cav- 
 ity, causing protrusion of the e^'^eball, and if the process continues 
 the soft tissues alsc become infected. The abscess may break into 
 the nose, discharging out of the anterior nares or posteiioi' nares 
 into the throat. 
 
 Diagnosis. — The diagnosis is based on the symptoms, one side 
 of the face is swollen, the eye protrudes, percussion on the disease 
 side gives a dull sound, while the healthy side gives a tympanitic 
 sound. A small electrical light placed in the mouth, in a dark 
 room with the lips closed, gives a positive diagnosis; on the healthy 
 side the light will be diffused through the bone and a semi-lunar 
 ring of light will show below the eye, but the light on the diseased 
 side is obstructed and does not show below the eye. 
 
 Treatment. — The treatment must be prompt, or else disintegra- 
 tion will occur, causing serious loss of- Hesh and horrible disiigure- 
 ment. If the abscess is caused by a diseased tooth, extract it, and 
 with a gimlet or awl bore through the socket of the tooth into the 
 cavity and let the pus escape. But if you find the teeth healthy, 
 don't pull them out, for a surgeon has no more right to sacrifice a 
 tooth of a patient than he has to sacrifice a limb. In this case 
 enter the antrum through the canine fossa. Make an incision an 
 inch above the first bicuspid tooth down to the bone, and with an 
 awl bore through the fossa and let the pus escape. After evacua- 
 ting the pus by either operation flush out the cavity and give drain- 
 age. Irrigate the cavity daily until pus stops forming. If the 
 abscess is very extensive, continue the boring from the inside of the 
 antrum into the nasal fossa and practice continual irrigation. 
 
 .■\bscess of the Livek. — This consists of a circumscribed collec- 
 tion of pus in liver tissue, and not as often supposed of the capsule 
 or peritoneal covering. 
 
 Causes. — The causes are numerous. The essential cause is the 
 pyogenic microbe, the predisposing causes are stabs, blows or con- 
 tusions of the organ. The most frequent cause is tropical influ- 
 ences. Most of the cases seen are in people living near or having 
 recently visited the Equator, and it is because of the extreme lia- 
 bility cf people living in the tropics to diarrhoea and dysp-ntery, 
 which is caused by infected water. The diarrhoea and dysentery 
 is followed by suppuration of the intestines, and the blood from 
 
60 PRINCIPLES OF SURGERY. 
 
 the intestines is carried directly to the li^er and the germ is also 
 conveyed along \vith it, and it lodges in the liver, forming a throm- 
 bus and an abscess results. 
 
 Symptoms. —The symptoms are very vague and indefinite. They 
 come on at first very slowly, resembling sub-acute suppuration in 
 character, the patient has a general feeling of depression, skin is 
 sallow, tongue foul and coated, slight evening fever; soon night 
 sweats come on, and there is general debility and prostration; the 
 liver begins to enlarge, the ribs over it begin to bulge and on pal- 
 pation you get fluctuation. 
 
 Diagnosis.— In order to make a diagnosis, you must get the his- 
 tory of the patient, whether or not he has at some previous time 
 received a stab in the liver, if the tropics have recentl}'^ been 
 visited; then notice the appearance of the skin and face, the pres- 
 ence of night sweats and th'e liver tender and enlarged, but ivith 
 all these syix ptoms you can't be positive in your diagnosis, so take 
 the old axiom of surgeons, ^'' Never operate for suspected pus until 
 you jyrove it is pus hy the use of the aspirator.'''' So in these cases 
 confirm your diagnosis with the aspirator before operating. Take 
 a small aspirating needle four or five inches long, attach it to the 
 syringe, render the skin aseptic over the site of the operation, ste- 
 rilize the needle over a fiame and insert it just above the rib over 
 which the pus is suspected, insert it freely into the liver tissue and 
 if you do not find the pus where you suspected it, plunge the nee- 
 dle in other directions until you feel the lack of resistance to the 
 needle, which indicates that it has entered the abscess, withdraw 
 the piston and the pus will come into the barrel of the syringe. 
 The pus from a liver abscess is peculiar, being of a dark chocolate 
 brown color, with mucus and disintegrated liver tissue mixed with 
 it. 
 
 Tkeatment. — After making a positive diagnosis of pus you must 
 evacuate it at once, if you wait it may infiltrate the tissues and 
 burst into the abdominal cavity, causing almost sure death. Give 
 an anaesthetic, render the part aseptic and make a free incision, 
 and if necessary remove a rib. When the peritoneum is reached, 
 if you find the visceral and parietal layers adhered, you can pro- 
 ceed with the operation, but if they are not adhered, pack the 
 Avound with Iodoform gauze and wait a week, and by that time 
 
PRINCIPLES OF SURGEPtY. 61 
 
 they will have become adhered. The necessity of having the two 
 layers of peiitoneum adhered is to keep ihe pus out of the abdomi- 
 nal cavity. Having reached the liver, take an aspirating needle 
 and locate the abscess, then with a pair of artery forceps bore a 
 hole into the abscess, following the aspirating nee'lle, dilate the hole 
 with the forceps and with your finger break down any trabeculae 
 in the cavity, irrigate daily, and give complete drainage. When 
 operated on thirty per cent, recover, whereas ninety per cent, die 
 without the operation. 
 
 Abscess of the Breast. — This is a circumscribed collection of 
 pus in the mammary gland. 
 
 Causes. — The essential cause is the pyogenic germs, which reach 
 the gland in many ways. Physiological engorgement v^ ith milk 
 or deficient abstraction of miik will cause it, as when the breast is 
 so sore that the baby can't be allowed to nurse, and fissures on the 
 nipple is another common cause. They are sometimes seen in men 
 and in early life, but are more common in women soon after partu- 
 rition. 
 
 Symptoms. — There is throbbing pain, a feeling of distention and 
 tension, redness, swelling and fluctuation, and if the breast is left 
 alone it will point and discharge. The constitutional symptons are 
 slight chili, fever and anorexia. 
 
 Treatment. — The prophylactic treatment is the most important, 
 and consist of the care of the breast months before delivery. In- 
 quire into the condition of the breast, the nipple may be deeply 
 sunken into the breast, and when the child is born it won't be 
 able to catch it in his mouth; in this case instruct the woman to 
 pull it out daily; again the nipples may be cracked and sore, bathe 
 them and touch with nitrate silver and apply antiseptic solutions. 
 After the birth of the child, see that the breast is emptied regularly, 
 and see that the mother doesn't allow the child to nurse only from 
 one side; vsash off the nipple with a boracic acid solution after the 
 child nurses and then dust with an antiseptic powder, such as calo- 
 mel, but be sure and wash this off before allowing the child to 
 nurse again, or you will cause, as in the case of calomel, an obsti- 
 nate case of diarrhoea. "When suppuration does occur, the cura- 
 tive treatment consist in stopping th<^ child from nursing and 
 in removing the milk with a breast pump. When the abscess 
 
62 PRINCIPLES OF SURGERY. 
 
 forms, as will be shown by the sj'mptoras, liniments may be used 
 to absorb the milk (a liniment of belladona is good), purge the 
 woman with saliae purgatives and give opium for the pain. As 
 soon as possible you must evacuate the pus by making a free in- 
 cision, irrigate the cavity and give free drairage. In making the 
 incision remember your anatomv, how the tubules approa.ch the 
 nipple from all sides, and don't cut crosswise and sever them, thus 
 causing a fistulous opening from which milk constantly oozes and 
 prevents healing. Make your incision parallel with the tubes or 
 as the spokes of a wheel are to the hub, make a large, long cut, 
 break up the trabecule with your finger, irrigate daily and drain. 
 Always reiierber that a large incision heals as quicklj^ as a small 
 one, and when operating always make your incision large, pro- 
 vided there is no large artery or nerve interposed. 
 
 Abscess of the Lung. — This means a circumscribed collection of 
 pus in lung tissue and not a circumscribed collection of tubercular 
 matter. 
 
 Cause. — The essential cause is the pyogenic microbe. The pre- 
 disposing cause is anything which weakens the lung tissue, as an 
 attack of pneumonia, which may leave a solid spot in the lung, 
 which constitutes a ^^ Locus Minoi'is Besistentim.''^ Or the germ 
 may come from the air on some foreign body as a cinder. 
 
 Symptoms. — Pallid face, night sweats, cough, emaciation and 
 expectoration. Locally we have an area, of dullness, loss of lung 
 sound, with increased vocal fremitis. 
 
 Diagnosis. — When you suspect pus never operate until you have 
 confirmed your suspicion with the aspirator. Eender the part and 
 the needle sterile; pass the needle down in the intercostal space 
 into the lung; you may have to aspirate in several places before 
 finding the pus. After securing the fluid carry it to a microscopist 
 and find out whether it is tubercular matter or pus. If it is tuber- 
 cular rcatter don't operate, for your patient is doomed, regardless 
 of all the new serums; but if it is pus the only hope is an early 
 operation. You will often hear of tubercular pus, there is no such 
 thing; pus is produced by the bacillus pj^ogenes and is a purilent 
 material; tubercular matter is produced by the Tubercle bacillus 
 and therefore distinct from pus. 
 
 Treatment. — The operation for the removal of pus from the 
 lungs is very difficult, but although difficult it is your duty as a 
 
PRINCIPLES OF SURGERY. 63 
 
 surgeon to remove it anu try and save life. Resect a rib, reflect 
 the periosteun:, and with bone forceps take cue two or three inches 
 of the rib, carry the dissection down to the pleura, open the pleura 
 and the two layers will be generally found adhered, but if they 
 are not do not continue the operation until you have made them 
 adhere by packing the space with iodoforna gauze. Don't cut down 
 into the lung with a knife, but do 3'our cutting with a thermo- 
 cautery, which seals the vessels as fast as they are cut, and opens 
 up a tunnel down to the pus, irrigate the cavity and insert a drain- 
 age tube of sufficient size to give free drainage. Flush out the 
 cavity daily with a warm antiseptic solution. 
 
 Abscess of the Bbain. — This is a circumscribed collection of 
 pus in brain tissue. 
 
 Cause, — The essential cause is the pyogenic microbe, which 
 reaches the brain in the majority of cases through a suppurative 
 disease of the middle ear, which space is only separated from the 
 bt-ain by a very thin plate of bone. 
 
 Symptoms. — The symptoms are very vague. The patient is irri- 
 table, bad temperament, extravagant, dissipated, flighty, delirious 
 and finally convulsions come on. There is headache and the tem- 
 perature may be high or sub-normal. 
 
 Diagnosis. — The diagnosis is difficult, but after making a diag- 
 nosis, it is sLill harder to locate the seat of the abscess. Bv a 
 thorough knowledge of the physiology of the brain, you can find 
 out the location. Different parts of the brain preside over differ- 
 ent parts of the body, and if in a suspected case, the hand is para- 
 lyzed or contracts, we know the abscess is somewhere near the cen- 
 ter for the hand, or if the patient can't articulate, it is near the cen- 
 ter for speech. In locating the abscess it is better to get a special- 
 ist to assist you, but do not let them operate; they know more 
 about the brain than they do about the knife. 
 
 Treatment. — After making your diagnosis and locating the ab- 
 scess, prompt and heroic measures should be adopted to save your 
 patient's life, for if you wait the abscess will break, causing men- 
 ingitis and the death of your patient. After shaving the scalp and 
 rendering it aseptic, mark the bone over the site of the abscess 
 with an awl or else after cutting up the scalp you will loose your 
 bearings. Dissect up ahorse shoe shaped flap, find the awl hole, 
 
64 PRINCIPLES OF SURGERY. 
 
 and with a trephine saw out a circular piece of bone, cut through 
 the meninges and if 3'ou then don't find the pus aspirate, plunge 
 the needle all about in the hrain until you find pus, then bore 
 down into the cavity of the abscess with a pair of artery forceps, 
 irrigate and drain it thoroughly. The piece of bone is usually put 
 back, but before doing so notch it and also the skin, so as to give 
 exit to the drainage tube. The difference in trephining and tre- 
 pan ing is, in trephining you take out a circular piece of bone, which 
 can be replaced after the operation. In trepaning, which is the 
 old method, the bone was taken out with an instrument like an 
 auger used to bore into wood, and the bone came out in shavings 
 and could not be put back, and a piece of silver plating was put in 
 its place. 
 
 LECTURK XV. 
 
 CLINICAL FORMS OF SUP PURATION.— Continued. 
 
 Before discussing suppuration in the large cavities of the body, it 
 will be well to note the peculiarities characteristic of the process 
 in these cavities. First, it is marked by the rapidity with which it 
 is diffused over the lining membrane; second, it is characterized 
 by the fact that there being no avenue of escape for the pus, it 
 collects in large quantities. 
 
 Suppurative Aktheitis. — This is a suppurative inflammation at- 
 tacking the lining membrane of joints. A joint is composed of two 
 articular surfaces of bone, held together by ligaments and lined by 
 synovial membrane, which secretes a viscid fluid for the lubrication 
 of the joint. 
 
 Cause. — It is caused by the pyogenic microbe, which may be 
 introduced directly as by some external mechanical cause, as a slab 
 or bruise; or indirectly by being conveyed by the blood to the joint, 
 and there finding a weak spot it localizes, causing the trouble. 
 
 Symptoms. — The symptoms are simple. There is an acute, burn- 
 
PRINCIPLES OF SURGERY. 65 
 
 ing pain, due not so much to the severity of the inflammaticn or 
 direct etfect oa the nerves, but to pressure from accumulation of 
 pus. If it is the knee joint the limb will be flexed, mother nature 
 ilexes the limb and thus increases the space around the joint, and 
 relieves the pain by giving room to the exudations; the limb is 
 swollen, there is f'^ver, which was preceded by a chill, nausea, 
 vomiting, anorexia and the sl:iu is flushed. 
 
 UiAGxosis. — The diagnosis is based on the symptoms and history. 
 The patient has recently stuck a nail in the joint or received a stab 
 wouad. If the germ was introduced indirectly you diagnose by 
 the pain, flexed condition of the limb, fever and fluctuation. But 
 to make your diagnosis certain you must confirm it with the ispira- 
 tor. 
 
 Treatment. — The treatment must be prompt and effective; if it 
 be delayed the pressure will become so great as to rupture the cap- 
 sule spontaneously and thus tue surrounding tissue becomes infil- 
 trated. Operate early. Take the knee, for example; make the 
 limb bloodless with Esmarch's banaage, render the part aseptic; 
 make three incisions on each side cf the joint as follows: One above 
 the joint, one opposite it and one just below it. After incising 
 the skin take a long pair of artery forceps and bore through the 
 cavity until the forceps show on the opposite side, open the blades 
 and clip the skin between them; now take a rubber tube, clip 
 numerous holes in it, catch it in the forceps and in removing the 
 forceps you place the drainage tube in position; put in the ihree 
 tubes in this manner and irrigate through them daily with antisep- 
 tic solutions; dress the limb aseptically, using plenty of -absorbing 
 cotton. After the pus stops forming remove the drainage tubes 
 one at a time, the top one first, then in two or three days the 
 middle and about the fifth day the third one. To prevent stiff- 
 ness of the joint, use massage and passive motion. If the above 
 treatur. ent fails from too long delay in operating, amputate the 
 limb to save the patient's life. 
 
 SuppuKATivE Meningitis. — This means suppurative inflammation 
 involving the membranes of the brain or cord. The brain is located 
 in the skull and is invested by three membranes, viz.. from within, 
 outward, Pia Mater, Arachnoid and Dura Mater. All three of 
 
66 PRINCIPLES OF SURGERY. 
 
 these membranes are liable to inflammation if from any cause the 
 pyogenic microbe reaches them. 
 
 Cause. — The most common means by ^hich the germ reaches 
 them is through a compound fractare of the skull. But sonuetimes 
 it is produced without any injury to the skull and we say the germ 
 A^as conveyed by the blood and found a weak spot in the meninges 
 where it could locate. The inflammation may be localized or 
 diffuse; when locall2ed it becomes so by nature throwing out lymph 
 and building a \vaU preventing its further depredations; in other 
 cases nature will be unsuccessful and the inflamir. ation will be 
 diffused over the entire surface of the membrane. 
 
 Symptoms. — Chills, fever, which may be as high as 105 to 107 
 degrees F., intense pain in the head, excitement and delirium, giv- 
 ing gradually away to coma and paralysis. 
 
 Diagnosis. — The diagnosis is based on the history of the case, 
 the fact of previous!}^ having a compound fracture of the skull, 
 opening up a gateway for the entrance of the germs or having 
 previously had concussion of the brain, which weakened the tissues 
 and opened upa^^Zocus Minoris JResente7itiae''' pressure, headache, 
 fever, etc., all help in the diagnosis. 
 
 Prognosis. — The prognosis varies; if the suppuration is localized 
 it is good, but if, as in the majority of cases, the whole of the mem- 
 brane is involved, the prognosis is exceedingly grave. 
 
 Treatment. — The principle treatment is the prophylactic. As 
 nine-tenths of the cases follow compound fractures of the skull, 
 the prophylactic treatment is the proper treatment of the fracture 
 and the wound at the time it occurs. Treat the fracture as a major 
 operation, ancesthesize the patient, shave the head, for it is im- 
 possible to render the scalp aseptic unless you do, neither can you 
 operate with the hair constantly getting in your way; wash the 
 scalp thoroughly with green soap and water, wash the soap off 
 with alcohol, and lastly wash in a 1-1000 bi-chloride solution. 
 Make your hands and instruments sterile and proceed io this man- 
 ner: Make the wound larger if necessary, cut off all pieces of 
 lacerated tissue, take out all splinters of bone, examine the dara 
 and if it is bruised and bloody, incise it and remove the blood clots; 
 if the iDrain is also injured and bloody, remove the blood anil irri- 
 gate the wound with a 1-2000 bi-chloride solution, arrest all 
 
PRINCIPLES OF SURGERY. 67 
 
 hemorrhage and if the brain is not injured you can allow for drain- 
 age and suture the wound up, but if the train is injured and the 
 tissues bruispd and lacerated and the bone splintered, pack the 
 Tvound with iodoform gauze a ad treat it as an open wound. If 
 suppurative meningitis does occur, the case is almost hopeless, but 
 do your best to save life; take out a large piece of the skull (as 
 large as tu'o inches in diameter), irrigate the wound daily and give 
 free drainage. 
 
 SuppuEATivE Plecritis." — This is a suppurative inflammation at- 
 tacking the pleura. The lungs are invested by an envelope of se- 
 rous membrane called the pleura, which consists of tv^o laj^ers, 
 parietal and visceral, the layers are almost in contact and secretes 
 a fluid which lubricates ihe surfaces and makes breathing easy. 
 The suppuration may extend over the entire surface of the pleura, 
 which constitutes a aisease called Empyaemia, 
 
 Cause, —The essential cause is the pus germ, which may reach 
 the pleura directly as a stab cr cut or indirectly through the blood. 
 
 Symptoms. — The process is usually inaugurated by a chill, fol- 
 lowed by fever, which may reach as high as 105 degrees F, , and 
 continue without intermissions. Anorexia, bounding pulse, slight 
 cough, interference with respiration from the collection of pus in 
 the sack, on palpation there is increased dullness, on auscultation 
 the lung sound will be absent and there is sometimes slight bulg- 
 ing in the intercostal spaces. 
 
 Diagnosis. — The diagnosis is based on the symptoms, but must 
 be confirmed by the use of the aspirator; the needle must be thrust 
 obliquel}^ between ihe sixth and seventh ribs and if your diagnosis 
 is right, you will get pus on withdrawing the piston. 
 
 Treatment, — The operation is a coirmoD one, and must be con- 
 sidered a major operation. Aucesthesize the patient, and here it is 
 admitted by the advocates of Ether, that Chloroform is the best 
 anaesthetic. After making everything aseptic, make an incision 
 along the seventh rib, reflect the periosteum and reixove the rib; 
 the space bet\^een the ribs is too small to explore the cavity satis- 
 factorily, neither can you use a large drainage tube. ISTow make 
 an incision directly into the pleural cavity and the pus will gush 
 out. Don't allow the pus to escape too fast, as the patient may 
 die from coilapse; let out a pint, then stick your finger in the hole. 
 
68 PRINCIPLES OF SURGERY. 
 
 "wait a»^"hile and let out another pint, and so on until the cavity is 
 empty. Introduce the ano-er and see if the lung expands and has 
 not lost its elasticity, irrigate with a warm antiseptic solution 
 (about 100 degrees F.); cold solutions will produce a fatal collapse. 
 Insert two or three large drainage tubes and fasten thera so they 
 can't come out or drop into the cavity, irrigate the wound daily. 
 Don't reirove the tubes entirely at once, take them out about a 
 half an Inch every da}", until entiroly removed. In fastening the 
 tubes, some surgeons stitch theno to the skin, but this is painful. 
 Take a large safety pin, stick it through the tube, fasten to the 
 pin a piece of adhesive plaster, and stick this on the skin of the 
 chest. As the tubes are removed, clip off a piece of the plaster 
 and thus shorten it. 
 
 Suppurative Peeicakditis. — This is a suppurative inflammation 
 attacking the pericardii] ra. The heart is invested by a fibrous 
 coat, which is lined by a serous coat. The serous coat pours out a 
 fluid which lubricates the surfaces and allows the heart to contract 
 and dilate without friction. 
 
 Cause, — The cause is the pus germ, which is rarely introduced 
 from without, but the disease is set up as a complication of some 
 other infectious diiiease. 
 
 Symptoms. — The s3^raptoms are not as plain as the surgeon would 
 like them to be. There is usually a chill, followed by fever, rapid, 
 bounding pulse, slight bulging over the heart, percussion over the 
 pericardium gives increased dullness and there is difficulty in breath- 
 ing. 
 
 Diagnosis. — When you are quite confident from the above 
 symptoms that the disease exists, you are perfectly justifiable in 
 aspirating. Introduce the needle in the fifth intercostal space one- 
 half inch to the left of the sternum, carry the point backward, 
 upward and outward about three-quarter inches, and the cavity is 
 reached, -which can be told by lack of resistance. There is on re- 
 cord by one operator of seventy-nine cases, in which the aspirator 
 was used; one was instantly killed, five died in twenty-four hours 
 and the remainder did well after the operation. 
 
 Tkkatmp:nt. — Make a small incision about one inch long in the 
 fifth intercostal space, one inch to the left of the sternum, going 
 through the skin and muscles, then bore aown into the cavity i\ith 
 
PRIXriPLES OF SURGERY. 69 
 
 a pair of artery forceps, irrigate daily through the drainage tnbe, 
 which luust be soft, and must not be introduced far enougli to 
 touch the heart and thus cause pain and discomfort. 
 
 SuppuKATivE PERiToxfTis — This is a suppurative infiaramation 
 attacking tbe peritoneum, xlll the organs of the abdomen, v\ith 
 a few exceptions, are covered by peritoneum, which is frequently 
 the seat of disease. 
 
 Cause. — The cause is the pus germ. It may be introduced 
 directly by a stab wound, by an incision by a dirty surgeon, and 
 by the rupture of an abscess of the appendix, fallopian tube or 
 liver. It is also said to le sometimes infected by the blood. 
 
 Classificatiox. — Peritonitis is divided into acute and sub-acute. 
 The acute is sometimes called septic peritonitis and the sub-acute 
 supptrative peritonitis. Both processes are the same, the only 
 difference is in their onset, post-mortem appearance and the pain. 
 Septic peritonitis acts quickly, the pain is excruciating and the 
 patient dies before pus can be formed. Suppurative peritonitis is 
 a slow process, frequently circumscribed and amenable to surgical 
 treatment. 
 
 Symptoms. — The first symptoms are those of intense shock, 
 tbere is profound ccUapse, depression, fever with no remission up 
 to 107 degrees F., pulse rapid, abdomen swollen, face anxious and 
 pinched, tongue coatsd, clammy skin. These symptoms soon pass 
 otf and the skin becomes dry and red, tongue cracked, pulse bound- 
 ing, abdomen tympanitic, pain excruciating and excessive vomit- 
 ing. The symptoms then seem to get better, but is really a sign 
 of the death of your patient. 
 
 Tkeatmext. — Render everything clean around the patient; open 
 the abdomen, flush out freely with saline solutions and give free 
 drainage 
 
70 PRINCIPLES OF SURGERY. 
 
 LECTURE XVI. 
 
 CLINICAL FORMS OF SUFPUEATION.— Continued. 
 
 SuppuEATiYE Osteomyelitis. — This is ai: acute suppurative in- 
 flammation, affecting the medullary cavity in bone tissue. It is of 
 frequent occurrence, disastrous in its results, often endangering 
 the life and limb of the patient when not diagnosed before the later 
 stages. It is usually seen in long bones, especially the femur, and 
 at a point denoting the junction of the epiphysis and diathesis. It 
 is occasionally seen in the ribs, clavicle and ilium. 
 
 Causes. — The indirect causes are age, sex, cold, traumatism and 
 acute diseases. The direct cauise is the pyogenic microbe. This 
 fact vvas not admitted up to fifteen years ago; it was thought to 
 be due to a specific microbe. But experiments have proven that 
 it is due to the pus germ, as germs from osteomyelitis have been 
 cultured, and when introduced beneath the skin, they cauye ab- 
 scesses identical ^ith those formed by the p3^ogenic microbe and 
 inoculations from these abscesses will cause in an animal having a 
 diseased bone a disease parallel with osueomyelitis. The germ is 
 not generally introduced through a w^ound, it floats in the blood 
 and locates in a weak spoc in the bone, which has been devlltilized 
 by Typhoid fever, measles, etc., and the point is generally at the 
 junction of the epiphysis and diathesis, as this point has less vitality 
 from the tissues being more embryonic, less mature and therefore 
 more liable to bacterial infection. Again the blood vessels at this 
 point have very poor walls, in fact, they are nothing but a series 
 of channels without distinct walls, and the} are four cr Ave times 
 larger than the capillaries which convey away the blood. 
 
 Pathology. — In suppurative osteomyeliris we first have the germ 
 entering the circulation through the skin, tonsils or intestines, it 
 floats in the blood and finding some place in the medullary cavity 
 of a long bone in which it can localize it does so, causing the disease. 
 The capillaries are first attacked, causing hj^peraemia, exudation 
 and transudation from the vessels, which is rapidly converted into 
 pus. The pus is thus enclosed in a bony wall, but finally b}^ pres- 
 
PRINCIPLES OF SURGERY. 71 
 
 sure it spreads through the Ha version canals, reaching the peri- 
 phery of the bone, it then attacks the periosteum, which hnally 
 gives away, and it infiltrates the paraperiosteaJ tissue. Then we 
 have a phlegmonous suppuration of the soft tissues, which extends 
 toward the surface of the limb, causing necrosis of the part b}'' 
 pressure and occluding the blood vessels. Eventually a fistula is 
 formed through which the pus escapes. In ttie abscess cavity of 
 the bone there is found a piece of bone, which has been killed by 
 the disease and has separated from the healthy bone, and lies in 
 the cavity as a foreign body, this is called the Sequestriuiu. The 
 luvolucrura is the bony wall which holds the sequestriuin and the 
 cloicae is the opening in thelnvolucrum to permit the passage of the 
 pus through the fistulous tract. 
 
 Symptoms. — The premonitory symptoms are indisposition, lassi- 
 tude and general weakness. These are socn followed by a chill, 
 fever rangiQg from 103 to 104 degrees F., with no remission, pulse 
 rapid and feeble, breathing shallow and difficult, tongue coated, 
 and cracked, diarrhoea and delirium. The local symptoms are the 
 same as in any cast; of suppuration where the products are confined. 
 The pain vvhich is exquisite is not localized, but usually referred 
 to some neighboring joint. It is described as an intense, boring, 
 tearing, breaking paia and is not relieved by opium. The pain 
 suddenly disappears, which denotes the time at which the pus es- 
 capes from the bone into the surrounding tissue. We have tender- 
 ness exquisitively marked, especially over the part where the sup- 
 puration commenced. The area of tenderness will mark the pro- 
 gress of the disease. Swelling takes place only after the -pus escapes 
 into the paraperiosteal tissue. Eedness and heat are due to the 
 acute inflammation, and also doesn't occur until after the escape 
 of the pus from the bone. The process is now ver}^ rapid, soon 
 involving the whole circumference of the limb. The function of 
 the part is necessarily lost, the patient resting the limb, as the 
 least jar causes intense pain. 
 
 Diagnosis. — As the surgeon is not usually called until during the 
 later stages of the trouble, a sinus can be seen leading through the 
 soft parts down into the bone. The sinus will be surrounded by 
 granulations or proud fiesh. A probe passed into*the medullary 
 cavity will usually detect the sequestrium. Rarely has the surgeon 
 
72 PRINCIPLES OF SURGERY. 
 
 the earlier stages to treat, but the complications resulting after the 
 pus has escaped from the bone. An early diagnosis is irrportant 
 that the successive stages may be aborted. Ninety-nine per cent, 
 of post-mortems for dead bone show osteomyelitis to be the cause. 
 Differential diagnosis is sometimes impossible and requires a care- 
 ful stud J of the various diseases. Inflammatory rheumatism may 
 be taken for it, though osteomyelitis has no swelling until the later 
 stages. It may be mistaken for joint inflammation, suppurative 
 periostitis, phlegmonous mflaramation or even typhoid feyer. 
 
 Prognosis. — The prognosis depends upon the intensity of the dis- 
 ease. It is sometimes fatal in two or three days; so virulent is 
 the germ that death ensues before suppuration begins. This hasty 
 termination is rare, and if surgical aid is employed early enough 
 and the proper measures taken, life is usually saved, but the use- 
 fulness of the limb is scarcely ever restored. 
 
 Ttkeatmekt.-— The palliative treatment consists in the adminis- 
 tration of purgatives, put the patient to bed and elevate the limb, 
 pack the part in ice, thus keeping down excessive hyperaerria and 
 give opium for the pain. There are three stages in which an 
 operation might be performed. 1. Before the bore is perforated; 
 2. After the bone has been perforated, but before the dead bone 
 has separated and an involucrum formed; 3. After the separation 
 of the dead bone and the formation of the involucrum. The opera- 
 tion in the first stage consists of rendering the part aseptic, cut 
 through the soft tissues down to the bone, reflect the periosteum 
 and chisel a small hole in the bone and allow the pus to escape, 
 then curette out all the dead bone, irrigate with bi-chloride of mer- 
 cury and dress asepticali}''. In the second stage cut down into the 
 phlegmonous inflammation, irrigate and disinfect these tissues, find 
 the cloicae, slightly enlarge it, but don't chisel into the bone and 
 tr}'^ and take out the sequestriura, for it hasn't become separated 
 as yet, and you are liable either to take out too much or else not 
 remove all the diseased bone. The operation in the third stage is 
 the most common and is called Sequestrotomy. Render the limb 
 bloodless with Esmarch's bandage, rind the cloicae, take off the 
 roof of the cavity with a chisel, remove the sequestrium, thus leav- 
 ing a troufi-h in the bone, curette out all the dead bone, disinfect 
 
 DO ' 
 
 the cavity with Peroxide of hydrogen or a bichloride solution, close 
 
PRINCIPLES OF SURGERY. 73 
 
 the wound and wait for healing. If the cavity be large, allow the 
 capillaries to bleed into the trough, and when a clot forms it will 
 form a bridge for the new bone tissue. Dr. Senn packs the cavity 
 with decalsifled bone chips, which greatly facilitate restoration of 
 the part. 
 
 LECTURE XVII. 
 
 ULCERATIOI^— FISTULA— SINUS. 
 
 Ulceration, — An ulcer may be defined as a solution of the con- 
 tinuity of the skin or mucous membrane, Yvhich shows no intrinsic 
 tendency to heal. An accurate knowledge of an ulcer and its treat- 
 ment is necessary to every practitioner. They are difficult to treat, 
 being most common amongst the poor, who are ill-fed and nnable 
 to lay up or pay for the proper remedies and treatment. 
 
 Divisions. — Ulcers are divided into superficial, deep, acute and 
 chronic. Superficial ulcers, as their name inaicates, only attack the 
 superficial structures; deep ulcers also involve the deeper struc- 
 tures. Acute ulcers come on quickly, run a definite course and 
 subside; a chronic ulcer comes on slowl3\ shows little inflamma- 
 tion and are hard to heal. 
 
 Causes. — The constitutional causes are certain infectious diseases 
 as syphilis, tuberculosis, leprosy, etc. They also follow disturb- 
 ances to tbe nutrition of the tissues, as in cachexia, anemia, scor- 
 butis and diabetes. The local causes may be a blou or bruise, ap- 
 plication of strong caustics, intense heat or cold, certain disturb- 
 ances in the circulation, as by cutting off the arterial supply by a 
 ligature or pressure or by defective venous return, causing stagna- 
 tion ; defective trophic influence, as seen in ihe perforating ulcer 
 of the foot, where no other cause can be given. 
 
 Anatomical Character. — An ulcer is said to have a floor, mar- 
 gin and an underlying or surrounding tissue. The floor or base 
 is the depressed central part of the sore; it is below the skin level, 
 
74 PRINCIPLES OF SURGERY. 
 
 flat and covered Avith granulation tissue, which varies in color with 
 the type of the ulcer. The margin or border is that part extend- 
 ing from the floor to the skin ; it msLj be vertical, excavated or 
 sloping. The adjacent tissue is hard, dense and even cartilagen- 
 ous in texture, from the spreading of the inflammation. 
 
 Diagnosis. — The diagnosis is based on the character of the 
 wound and its cause. 
 
 Prognosis. — The prognosis depends on the type of the ulcer, 
 cause producing it, general health of the patient, pecuniary con- 
 dition and the ability of the attending surgeon. 
 
 Vaeieties. — There are many varieties described, based on the 
 cause and clinical behavior. 
 
 1. Inflamed ok Tkadmatic Ulcer. — This form is always pro- 
 duced by an injury, as a burn, bruise, etc., which becomes infected. 
 It is not a deep-seated ulcer, and is covered with pale granulation 
 tissue and there is a tendency to heal. 
 
 Treatment.- — -This form yields to rest and disinfection; apply 
 moist antiseptic dressings, which must not be removed too fre- 
 quently and the tvound soon heals. 
 
 2. Indolent, Weak or Callous Ulcers. — This is an ulcer of long 
 standing, which perhaps was originally a traumatic ulcer, but 
 from improper treatment degenerated into this type. They are 
 not deep, and the margins are hard, thick arid granulated. 
 
 Treatment. — Make the wound and the surrounding tissue clean 
 and siimulate the ceils with nitrate of silver, ten per cent, solution 
 of chloride of zinc or a solution of copper sulphate; if these fail, 
 touch the surfaces \;\ith a red hot iron or dissect out the dead tissue 
 and dress aseptically. 
 
 3. Exuberant or Fungous Ulcers.- -This type is just the reverse 
 of the preceding. It makes too great an effort toward healing, and 
 the granular tissue rises above the level of the surrounding tissue; 
 this is the so-cali^d '"''proud flesh,"''' Epidermization is impossible, 
 but in the effort to cover it, it constricts the '•'■proud flesh''' and 
 gives it a pediculated appearance. 
 
 Treatment. — Disinfect and shave off the superfluous tissue down 
 even with the skin, slightly cauterize the surface with nitrate of 
 silver, so as to obliterate the arteries and thus prevent its further 
 growth. Dress with moist antiseptic dressings. 
 
PRINCIPLES OP SURGERY. 75 
 
 4. Ikkitable or ERirHisTic LTlceks. --This type of ulcers are so 
 sensitive that it is impossible to wash them, and unless the part 
 be given absolute treatment you can't cure them. Their most fre- 
 quent site is the rectum or around the margin of the navel. They 
 are deej)ly excavated, discharges a serous pus and very irritable. 
 
 Treatment.-— Remove the cause. If it is the rectum paralyze 
 the sphincter muscle, paint with cocaine and either dissect it out 
 or apply some escharotic, such as carbolic acid or nitrate of siher. 
 
 5. Phagedenic or Gangrenous Ulcers. — This ulcer is due to a 
 microbe of great virulence, which causes rapid cell necrosis. The 
 ulcer spreads very rapidly, one side healing, while the other is in- 
 volving the neighboring tissues. Their most frequent site is on the 
 penis. 
 
 Treatment.— The treatment consists of perfect fumigation with 
 sulphuric acid or actual cautery. Whenever an ulcer won't heal, 
 always substitute the old wound by a burn and it will then heal. 
 
 6. Varicose Ulcers. — This is the most frequent type. It is 
 caused by defective venous return and is usually seen on the lower 
 extremities. The valves in the veins give way, and throagh pres- 
 sure in the veins serum escapes into the surrounding tissue, causing 
 the ulcer. 
 
 Treatment. — Remove the cause and thus stop the transudation 
 of serum, into the tissues. Put the patient in bed, elevate the limb, 
 and so by gravity assist the venous flow. If the patient is poor 
 and can't lay up, strap the leg with flannel or rubber bandages 
 from the toe to the popliteal space. You can never hope to cure 
 the ulcer until the fluid is driven out and kept out of the limb. 
 
 T. Trophic Ulcers. — These are due to defective nervous supply 
 and are difficult to treat, as you can't remove the cause. 
 
 Treatment. — The treatment consists of rest and cleanliness and 
 the use of antiseptic dressings. 
 
 8. Specific Ulcj:rs — This type is due to specific diseases, as 
 syphilis, anthrax, tuberculosis and glanders. 
 
 Treatment. — The treatment must be on general principles, if 
 syphilis, give mercury; if tuberculosis, build up the general health, 
 etc. Dress the ulcer with moist antiseptic dressings. 
 
 General Treatment of Ulcers. — ^Give the part absolute rest and 
 elevate it to promote venous return (a dependant position aggra- 
 
76 PRINCIPLES OF SURGERY. 
 
 Yates tbe conclition). Remove tbe cause producing the ulcer; if 
 due to syphilis, give Iodide of potash; if due to tuberculosis, give 
 cod liver oil; treat the cause that the result may be removed; if 
 it is due to defective circulation elevate or use warm applications. 
 Obtain and maintain asepticity; ail ulcers are caused by a microbe, 
 and therefore j'^ou must employ germicides, in solution or other- 
 wise, as a dressing; never use salves or vasaline. If these methods 
 fail either stimulate with nitrate of silver or help mother nature 
 b}" skin grafting. 
 
 FISTULA. — A- fistula is an abnormal opening from the skin or 
 mucus njembrane -into a normal cavity; as an opening leading 
 from the skin into the pleural cavity, or the opening made in the 
 bladaer by a surgeon. Fistulas are named acording to the 
 anatomical structure involved, as V^esico-vaginal, Recto-vaginal, 
 Gastric, Fistula in ano etc. They are caused by some defective 
 foetal development or bv pressure causing sloughing. 
 
 Treatment. — Freshen the edges, bring them together and suture, 
 using proper antiseptic precautions. 
 
 SINUS. — A sinus is an abnormal opening from the skin or mucous 
 membrane into an abnormal cavity, as from the skin down into 
 the involucrum of the bone, or from the skin or mucous membrane 
 into a tubercular abscess. 
 
 Treatment. — A sinus can only be cured by splitting open the 
 cavity it leads from, and by thorough irrigation you remove the 
 cause and the sinus will heal. 
 
 LKCTURE XVIII. 
 
 GAISTGRKNE. 
 
 Gangrene, Mortification, Necrosis and Sphacelus, aresynomy- 
 raous terms used to designate the death of the tissues '^en masse.'''' 
 These terms, as used by certain English writers of former days, bore 
 a different significance from that of to-day. With them gangrene, 
 
PRINCIPLES OF SURGERY. 77 
 
 mortification and sphacelus meant deatti of the soft tissues, while 
 necrosis was restricted in its meaning to death of bone. A more 
 modern and scientific distinction has teen drawn between these 
 terms; recent literature speaks of gangrene, mortification and 
 sphacelus as death of a pare exposed to the atmosphere, a super- 
 ficial region, where putrefactive bacteria gain ready access; while 
 it describes necrosis as death of an internal organ or an area which 
 is unattended by putrefactive changes. 
 
 Causes, —The general causes are debility and certain constitu- 
 tional diseases, as starvation, old age, long sickness, ej^cessive loss 
 of blood, Bright's disease, diabetes and anything which will vitiate 
 the tissues. The local causes are: 1. [nterference with the arte- 
 rial supply. It is essential to the life and vitality of tissues that 
 they should have an adequate amount of tlood reaching thera, and 
 anything w^hich interferes with the blood supply will therefore cause 
 death of the tissues. These conditions are trauma, as a stab 
 \^ound penetrating some large artery; pressure, as from a tight 
 plaster cast; licjation ; spasms of arteries, thrombosis and em- 
 bolism. 2. Interference with venous return. This is as important 
 as the foregoing cause of gangrene, as for the tissues to be in a 
 healthy condition, not only must the arterial supply be normal, 
 but the venous blood must be carried off to be freshly oxydized; 
 thus anything which staysthis venous return will cause thetrouble. 
 It may be due to a tramnatic blow, as a stab, which, (occludes some 
 large vein; pressure of tight bandages, ligature, thrombus or era- 
 bolus. 3. Defective nervous supply. For a tissue to thrive, not 
 only must it have proper arterial supply and be drained of its \en- 
 ous blood, but must have its trophic nerves in a proper condition, 
 and anything interfering with their normal function is liable to 
 cause gangrene, as by destroying the vaso-motor nerve to a part, 
 anemia and gangrene follow. 4. Direct action of destructive 
 agents on tissue. As a car wheel passing over a limb, crushing it, 
 pressure, as bad sores, inflammation may cause it, exposure to ex- 
 cessive cold, or intense heat, and the direct action of caustics. 
 
 Yaeieties. — There are two varieties of gangrene — Dry and 
 Moist. Dry gangrene is due to interference with the arterial sup- 
 ply to the part, as the result of obliteration or plugging of an 
 artery, without any abnormality of the veneris return. The part 
 
78 PRINCIPLES OF SURGERY. 
 
 becomes dry, bard and atropbied almost as soon as tbe arterial 
 blood is cut off and Avbat little blood was in tbe part is soon drained 
 off by tbe veins. Tbe skin soon becomes leatbery; tbe constitu- 
 tional symptoms are few, because of non-infectioQ and tbe absence 
 of decomposition. Tbe separation between tbe dead and living 
 tissue takes place slowly and witb little danger to tbe life of tbe 
 patient. 
 
 Moist gangrene is produced by some interference to tbe venous 
 return, tbe arterial supply being normal. Tbis causes tbe tissues 
 to become swollen, water logged and surcbarged witb venous 
 blood. Tbe part soon becomes infected and putrefies; tbe absorp- 
 tion of tbe decomposition products, causes general constitutional 
 symptoms to supervene. Often we bave a rapid and fatal termi- 
 nation due to acute septicaemi*'. 
 
 Symptoms. — The general symptoms are due to tbe absorption 
 into tbe system, tbe products of decomposition. Tbe symptoms 
 of septicaemia follow: Cbills, fever, apatby, drowsiness, face 
 asby, then becoming yellowish, pulse rapid and small, respirations 
 shallow, clammy perspiration and finally death. Tbe local symp- 
 toms are important, being more distinct than tbe general. There 
 is pain Which from the first stages, changes in intensity. In the 
 earlier stages it is intense, whether the trouble is due to a tight 
 bandage, an embolus or to acute inflammation. It subsides grad- 
 ually, and when quite lost it shows that tbe trouble has resulted 
 in perfect death to the part and the nerves within it. There is 
 tenderness (pain elicited on pressure), tbis is of value in the diag- 
 nosis, it is acute in tbe earlier stages, gradually subsiding until tbe 
 part has become devitilized, when it is absent altogether. The 
 temperature varies. If tbe gangrene be due to plugging of the 
 artery to the part, the temperature of the anemic part at once falls 
 to sub-normal. If due to acute inflammation, it is first high, but 
 as soon as tbe parts become devitilized, tbe temperature falls below 
 normal. The pulse in the artery to the part is absent when gan- 
 grene is complete, and is cue guide to a correct diagnosis. Swell- 
 ing is present in tbe moist variety, due to tbe surcharged, water- 
 logged condition of the tissues, but in dry gangrene it is absent, 
 the part becomes shriveled and atrophied from lack of moisture. 
 Emphysema is present in moist, but absent in dry gangrene. When 
 
PRINCIPLES OF SURGERY. 79 
 
 present, it can be elicited by manipulation, as a dry, crackling, 
 resonant sound. The color depends on the variety, if due to de- 
 fective arterial supply, the part is pale and anemic; after the 
 tissues die, by virtue of a chemical change, it becomes livid, blue, 
 black, blistering and showing all the usual putrefactive changes. 
 The odor in the dry variety is nil, but in the moist variety a most 
 horrible, unbearable stench is constantly exhumed. The line of 
 demarcation is not a symptom, but is a phenomena often observed . 
 It is a line dra^vn by nature between the dead and living tissue. 
 
 Diagnosis —The diagnosis is usually plain, both by the nose and 
 sight. The dead tissues have an appearance and smell not easily 
 mistaken. Sometimes, as in strangulated hernia, it is difficult to 
 differentiate between gangrene and congestion of the part, i 
 
 Prognosis. — The prognosis depends on the type, age, general 
 health and surroundings of the patient. 
 
 Treatment. — -The prophylactic treatment consists of medicinal 
 and dietetic measures. Use every means possible to favor the 
 blood supply and remove every condition favorable to the develop- 
 ment of gangrene. If the cause of the threatened gangrene can 
 be removed do not hesitate, but act. If it be a strangulated 
 hernia, divide the constricting rino;; if a tight plaster cast, remove 
 it; if inflammation threatens to terminate in gangrene, relieve the 
 tension by a free incision. Try and favor the establishment of the 
 collateral circulation; lower the part, to favor the arterial supply, 
 elevate it to favor venous return, preserve the w^armth of the limb 
 with hot applications and pay special attention to asepsis and anti- 
 sepsis to prevent the invasion of putrefactive bacteria. The cura- 
 tive treatment consists of sustainincj the strength with nourishincr 
 food and stimulants, as quinine and strychoia. If the patient is 
 young and robust, it is best to wait for the line of demarcation; 
 but if old and feeble and the disease shows no signs of becoming 
 limited, an early opsration for the removal of the dead tissue must 
 be resorted to, thus minimizing the danger of general septicaemia 
 from absorption of ptomaines and toxins. 
 
80 PRINCIPLES OF SURGERY. 
 
 LECTURE 
 
 CLTTs^ICA.L FOEMS OF GA^^GRENE. 
 
 PtjoGRESsivE Gaxgkexe. — This is a moist gangrece which fol- 
 lows injuries to the soft tissues and is characterized by rapid ex- 
 tension and fatal termination. 
 
 Cause. — This variety follows large wounds, as after extirpation 
 of a breast. It is still a mooted question whether it is caused by 
 a specific germ. The streptococcus pyogenes is generally found 
 associated \\ith the disease and its virulent action is accounted for 
 by the lowered vitality of the tissues. 
 
 Symptoms. — The symptoms usually appear in a few hours. The 
 local symptoms are evinced at the point of infection. The wound 
 is swollen, red, angry looking, the surrounding tissues have a crim- 
 son tint and there is a sanious discharge from the wound. The 
 tissues then become blue, then black and, in fact, you have all the 
 signs of mortification before you. The tissues crepitate under 3^our 
 fingers, caused from the bursting of air bubbles, the skin is thrown 
 up in blisters, the patient is unconscious, the discharge is putrid 
 and nine out of ten such cases die. The constitutional symptoms 
 caused by the absorption of the toxins are high fever, preceded by 
 a chill, hurried respirations, quick, feeble pulse, the patient is irri- 
 table and anxious, then comes on stupor, delirium and lastly pro- 
 found coma. 
 
 Treatment. The most important treatment is the preventive, 
 which consist in cleanliness. If a limb is broken and the wound 
 is dirty, don't let others clean it, do it: yourself, remove all splin- 
 ters of bone, clip off all small pieces of lacerated tissue and dress 
 aseptically. After the disease has commenced don't wait for any- 
 thing, operate at once. Formerly the line of demarcation was 
 waited for with the result that every case proved fatal before the 
 line was formed. In operating never use Esmarch's bandage, 
 as it raa}'^ force diseased tissue and pus into healthy tissue, causing 
 further complications. Slightly elevate the part and apply a tour- 
 niquet. Amputate, if it be a limb, as far from the diseased tissue 
 
PRINCIPLES OF SURGERY. 81 
 
 as possible, only thinking of the patient's life and not his limb; of 
 conrse, you must use judgment and remember the nearer you go 
 to the trunk the greater will be the shock and general danger. If 
 the operation is successful the symptoms will subside in four or 
 five daj's. If sepsis increases, remove the dressings, and as a last 
 hope resort to continual antiseptic irrigation and stimulation. 
 
 Senile Gangeene. — This is a specie of gangrene which attacks 
 old people, and is due to some degenerative changes in the arteries, 
 causing obstruction to the blood supply. When I say it occurs in 
 old people, I mean people with diseased arteries, no matter if they 
 are thirty or seventy. "^ 7nan is as old as his arteries.'''' 
 
 Cause. — It is usually caused by some form of Endarteritis, which 
 may be from excessive cirinking. The disease is more frequently 
 located on the great toe. 
 
 Symptoms. — Premonitory. — A man v^ill come to you between the 
 ages of forty and seventy, who has either led a fast life or has in- 
 herited artheromatous degeneration and will complain of a tingling 
 sensation in his big toe. When he walks it feels like there is a 
 foreign body between his foot and the ground, the foot may be 
 red and swollen and you ma}'' diagnose an ingrowing nail. 
 
 Developed. —Soon the tissues become a dusky red, gradually 
 turning blue, then black; there is no swelling or odor, the toe be- 
 comes dry and wrinkled, there is no line of demarcation between 
 the diseased and healthy tissue and if rature doesn't stop the pro- 
 cess it will extend &p on the foot a,nd leg. The constitutional 
 symptons are not well marked. 
 
 Pkognosjs. — The prognosis is generally good, as the line of de- 
 marcation usually forms and gives a guide to the surgeon. 
 
 Treatment. — The prophylactic consist in treating the premoni- 
 tory symptoms. Elevate the limb, keep the part warm and clean, 
 scrub the toe with a bi-chlroride solution to prevent infection, pro- 
 hibit tight shoes and wrap the part in cotton. If gangrene does 
 develop, and is progressing slowly, wait for nature to form the 
 line of demarcation; but if it progresses rapidly and shows no 
 signs of abating, operate at once. The amputation should be per- 
 formed just belovN or above the knee. 
 
 Diabetic Gangrene. — This specie of gangrene occurs in combi- 
 nation with a disease known as Diabetes, or sugar in the urine. 
 
 6 
 
82 . PRINCIPLES OF SURGERY, 
 
 The pathology of the disease is not understood, but is probably 
 due to brain, liver or kidney trouble. Besides sugar in the urine, 
 there are eruptions on the skin, as furuncles, carbuncles and some- 
 times local gangrene. This localized gangrene may occur on any 
 part of the body, but usually occurs on the leg. 
 
 Symptoms. — -The symptoms are redness and congestion of the 
 affected part, turning yellow, purple, then black. The line of de- 
 marcation usually forms, but occasionally the trouble spreads and 
 death results from septicaemia. 
 
 Treatment. — The prophylactic treatment consist of treating 
 the cause. Put the patient on a rigid diet containing no sugars or 
 starches. Feed on steaks and green vegetables and use saccharine 
 as a sweetening agent. The fact that diabetic people are alv^ays 
 liable to gangrene, should make you careful in consenting to 
 operate on them, unless the patient is suffering from diseases like 
 hernia and appendicitis, when you should not hesitate. After the 
 gangrene is apparent, vtatch the disease aad if the line of demarca- 
 tion forms, clip off the diseased tissue, disinfect and dress with anti- 
 septic dressings. But should the disease progress, heroic surgery 
 will be the last resort. 
 
 Decubitus Gangrene. — This specie cf gangrene is due to pres- 
 sure, as a bed sore or from improperly applied splints. 
 
 Symptoms. —There is a tingling sensation about the part, with a 
 dusty redness, turning yellow, blue and black. If the part is not 
 relieved of the pressure it sloughs, emitting foul gases, and bloody, 
 acrid discharges. 
 
 Treatment. — The most important is the prophylactic. In ap- 
 plying a splint, see that it is w^ell padded. When your patient is 
 confined to the bed for a long time see that no one area of the 
 body is kept from a proper supply of blood longer than three 
 hours, keep the back clean and bathe it with alcohol once or twice 
 a week to harden the tissues. "When a sore is threatened, remove 
 the cause, which is pressure. If the patient is financially able, get 
 a water bed; if not, use a corcmon rubber bag or towels. When 
 the process does occur you must treat it heroically or the loss of 
 tissue will be frightful. Render the part clean, apply moist anti- 
 septic dressings, and as soon as the necrotic tissue comes away dust 
 the wound with iodoform and apply an antiseptic dressing. 
 
PRINCIPLES OF SURGERY, 83 
 
 Noma or Canckum Oris. — This is an exceedingly rare disease; it 
 attacks the cheeks, usually of children between the ages of three 
 and four. It occurs in epidemics amongst the poverty-stricken 
 chiklren, vvbo have poor food, badly clad and consequently suffer 
 from lowered vitality. It is seen following eruptive fevers. 
 
 Syis[ptoms. — There appears on the mucous membrane of the 
 moutn a livid spot, which turns first red, green and lastly black. 
 This extends through the cheek and opens on the skin, blebs and 
 blisters form, emitting foul gases and discharges. The process 
 may extend to the gums, causing loss of teeth, and even to and 
 causing necrosis of the maxilla. 
 
 Treatment. — Strict hygeine and proper food and clothing will 
 render the disease improbable. The onrative treatment consists of 
 thoroughly removing the diseased tissue, cauterize the surface, and 
 if recovery follows do a plastic operation. Sustain the strength 
 with stimulants and nutritious food. 
 
 Hospital Gangrene. — This is a contagious variety of wound in- 
 fection, which occurs in crowaed v\ ards. The microscopist and 
 bacteriologist would be pleased to see a case of this disease, but 
 since the days of asepsis and antisepsis the disease has not been 
 known. We do not know" whether it is due to a specific microbe 
 or not. It attacks wounds four or five days after they are made, 
 causing acute progressive gangrene, which usually ends fatally. 
 
 Symptoms. —The constitutional symptoms are not well marked. 
 
 Locally the wound looks angry, red and inflamed; next it be- 
 comes yellowish in color, the tissues are soft and a foul smelling 
 discharge is emitted. It gradually spreads, literally eating away 
 the tissues. 
 
 Prognosis. — Eegardless of treatment fifty per cent. die. 
 
 Treatment. — Prevent the disease by modern aseptic naethods. 
 
 When the disease occurs, substain the strength with stimulants 
 and good food, render the part aseptic and take out the tissue until 
 you reach healthy tissue, cauterize it and dress antiseptically. 
 
84 PRINCIPLES OF SURGERY. 
 
 LECTURE XX. 
 
 SHOCK. 
 
 Shock may be defined as profound depression of all the vital 
 powers. It has long been known that patients vi ho met with acci- 
 dents or underwent operations, not of themselves necessarily fatal, 
 often died without an. explanation. In clearing up this phenom- 
 ena, the English surgeons for once got ahead of the scientific Ger- 
 man students. 
 
 Typical Case. — Suppose a man fell from a house and fractured 
 his leg. When gently put on a litter he makes no attempt at 
 movement or speech, his face is pale and pinched, his eyes are 
 sunken, he has a vacant stare, no expression, pulse rapid and 
 thread-like, respiration shallow and sighing, skin covered with a 
 cold, clammy sweat, temperature sub-normal, he replies to ques- 
 tions with indifference, there is no coma, but apathy, spinchters 
 relaxed and feces pass involuntarily, he lays perfectly still, not be- 
 cause his muscles are paralyzed, but simply do not act. This is a 
 clinical picture of shock, and unless prompt measures are taken 
 often proves fatal. 
 
 Causes. — The causes of shock are numerous, and in fact, may 
 be produced by almost anything. Pain long continued will bring 
 about the condition, it being common before the advent of anges- 
 thetics. Extensive burns, v^here the cutaneous extremit}^ of the 
 nerves are destroyed; extensive injuries, though the pain be insig- 
 nificant, as in a dislocated bone, crushing wounds in railroad acci- 
 dents, etc.; excessive hemorrhage, as where a tourniquet slips in 
 an amputation; operations on the genital organs, blows on the 
 head, jugular vein, testacies and stomach and mental emotion will 
 also bring on shock. People at both extremes of life are more lia- 
 ble to shock. Women are less liable to shock than men; invalids 
 less than robust miCn; a person with a quick, nervous temperament 
 is more liable than a slow, stupid, phlegmatic person whose senses 
 are not keen or perceptive. A patient who goes on the operating 
 table with gloomy dreads, suffers more from it than one who goes 
 
PRINCIPLES OF SURGERY. 86 
 
 in confidence and hope; so always send your patient on the table 
 with an assurance of a speedy recovery, and with faith and con- 
 fidence in your ability. Alwa3''s tell a patient what he has got to 
 go through, then let hira decide for himself. If he decides to be 
 operated on, no matter how seriously you think of the operation, 
 it is your duty to cheer bira up with your successes in the opera- 
 tion, and send him to the operating table in a condition to prevent 
 shook. Mental emotion, as mentioned above as a cause of shock, 
 may seem strange, but often causes it, as the hearing of the death 
 of a near relative or having lost a fortune. In a college in Europe 
 the students, having a grudge against the janitor, decided to hold 
 a mock trial, condemn him and go through an execution. The 
 janitor was carried to the forest and condemned to die, he took it 
 as a joke at first, but finally got scared and begged for mercy, 
 but the students wanted revenge. He was blindfolded, his head 
 laid on a block and the executioner told to chop it off. He was 
 struck back of the neck with a vvet towel, and much to the stu- 
 dents surprise, rolled over dead from no injury, but from shocK 
 brought on by mental emotion. 
 
 Pathology.- — The pathology of shock is not understood. There 
 are about fifteen theories to explain it, but only two will claim our 
 attention. These come nearer explaining it than any yet advanced, 
 and they probably act together. 
 
 i. Yascula?' Theory. — The exponents of this theory claim that all 
 the symptoms of shock are due to the variation in the calibre of the 
 blood vessels, which is regulated by the vasomotor nerves. That 
 the stimuli of an injury inhibits the action of these nerves and the 
 vessels become widely dilated. Since the abdomen contains such 
 an abundant vascular supply, the dilation in that region causes an 
 accumulation of blood there (the vessels, when in a dilated condi- 
 tion, being able to hold all the blood in the body), and the brain 
 does not receive a sufficient supply of blood for it to perform its 
 functions and shock results. The symptoms are those of hemor- 
 rhage and in fact, it is intra- vascular hemorrhage into the abdomi- 
 nal vessels. This theory also explains the mental condition, pale 
 face and cold skin. 
 
 ^2. Nervotis Theory. — The advocates of this theory reason from 
 a physiological standpoint. The physiologist tell us that v^hen- 
 
86 PRINCIPLES OF SURGERY. 
 
 ever a nerve is stimulated it performs some function, and on re- 
 peated stimulation the nerve becomes fatigued and fails to respond 
 to the stimuli. Xot\ they claim that if the repetition of a slight 
 stimulus, will so fatigue a nerve as to inhibit its action, one great 
 stimuli will produce the same effect, as when the auditor}' nerve is 
 stimulated by a loud sound you are unable to hear until the nerve 
 has rested. So it is in shock. The stimulus produced by the in- 
 jury so fatigues the higher nerve centres that they are incapable 
 of perforning their functions, and the person is in a state of col- 
 lapse or shock until the centres are revived by rest. 
 
 STMPTOiis. — The face is so changed as to be unrecognizable, it 
 has a pale, cadaveric, sickly, white appsarance, eyes sunken, eye- 
 lids droopbd, nose puckered, the skin of the body is white, cold, 
 shrivelled and bathed in a clammy sweat. The mind is not seri- 
 ously affected, there is no delirium or unconsciousness, but he acts 
 slowly and doesn't comprehend his position. The muscles are not 
 paralyzed, the patient being able but not inclined to move. The 
 respirations are feeble and shallow, only the upper portion of the 
 lungs being used. The pulse is rapid and feeble and gives a flick- 
 ering sensation to your fingers. The temperature is sub-normal, 
 which gives a differential diagnosis from a chill, as in a chill the 
 other symptoms are present, but the temperature is above normal. 
 
 Termixatiox. — [f reaction occurs the symptoms gradually disap- 
 pear. Color comes in the lips and cheeks, the fingernails lose their 
 leaden color, warmth returns, the patient turns in the bed and 
 vomits, pulse gets stronger and more regular, respiration fuller and 
 the temperature becomes normal. When the patient shows none 
 of the signs of reaction, and the symptoms supervene as pictured 
 in the first of this lecture, no treatment seems to do any good, the 
 patient gradually sinks and dies. 
 
 Diagnosis. — Tbe diagnosis is based on the symptoms and the 
 history. It may be confounded with hemorrhage, but the treat- 
 ment of both are the same. 
 
 Prognosis, — The prognosis is uncertain. Patients apparent)}'' at 
 death's door may recover, whilst those about whom no anxiety has 
 been felt suddenly gets worse acd dies. 
 
 Treatment. — The prophylactic treatment is important. Always 
 before commencing a serious operation put your patient in as good 
 
PRINCIPLES OF SURGERY. 87 
 
 condition as possible, encouraoe him and implant in his mind that 
 he will recover, but be sure and warn the parents and friends. 
 Give drugs to prevent shock, the best of which is quinine; if you 
 are going to operate at one o'clock give him rive grains at six 
 o'clock in the morning, five grains at nine o'clock aad ten grains 
 at twelve o'clock. If the heart is weak, administer one-tenth to 
 one-fifteenth of a grain of strj^chnia nitrate an hour before the 
 operation, alcohol is also good, but never give it just before the 
 operation, unless by the rectum, as it will cause vomiting if given 
 by the stomach. It was ths old custom to give ^ grain of 
 morphia to 1-100 grain of atropine, but quinine is now prefer- 
 able. Avoid loss of blood, time and heat. The modern surgeons 
 with their anaesthetics, go about their work too slow, the time is 
 notlost so much from slowness of operating, but because the proper 
 preparations have not been made, so see that you have everything 
 necessary to complete the operation before starting. Avoid loss 
 of blood by doing quick work, by being careful about the tourni- 
 quet and by using plenty of artery forceps. Avoid loss of heat, 
 don't douche the patient wath cold solutions and keep off draughts. 
 
 If shock does occur, get the patient to bed, don't do anything 
 while he is on the table. Keep him absolutely quiet, exclude rela- 
 tions from the room and give absolute physiological rest. Get the 
 patient warm, wrap a hot blanket next to his skin, put hot bottles, 
 flat irons or bricks to his feet, stimulate him uith morphia 1-6 
 to atropia 1-100, give one-tenth grains of strychnia and re- 
 peat in a half an hour, give whiskey by the mouth unless the 
 patient is nauseated, then give it per rectum. Hot coffee injected 
 into the rectum is an efficient remedy, it gives heat as well as 
 being a stimulant. Lower the head and thus let blood flow by 
 gravity to the anemic brain. Practice anto-transfusion, this is ac- 
 complished by bandaging the legs and arms and thus force blood 
 to the brain. If this fails practice transfusion. In former days 
 blood vvas used from other animals and forced into a \ein, this 
 has given at\ay to the normal saline solution (one teaspoonful of 
 salt to a pint of ^ater); boil this, and when it falls to the tem- 
 perature of the body, inject directly into a vein or into the sub- 
 cutaneous tissue. The effect is sometimes vvonderful. 
 
 The question of operating dunng shock is a difficult one to an- 
 swer. If called to a man who has been crushed in a railroad acci- 
 
PKINCIPLES OF SURGERY. 
 
 dent it is best not to add the shock of an operation to the shock 
 caused by the injury, for you are almost sure to kill the patient, 
 bat sometimes the shock is intensified and prolonged by the pain, 
 shock succeeds shock and you had better operate. 
 
 LECTURE XXI. 
 
 SEPTICEMIA. 
 
 Septicemia or Sepsis is a fever produced by the absorption into 
 the system of the products of fermentation or of putrefaction. The 
 term is a general one and includes the three following conditions: 
 
 1. Aseptic oe Fermentation Fever. — This form is due to the 
 absorption into the system of the products of aseptic tissue necrosis. 
 
 Cause. — It has long oeen known that liquids which were non- 
 poisonous when injected into the system would cause fever; normal 
 saline solutions and trypsin will do it. These liquids, when injected 
 into the system, are supposed to cause the fever by breaking up 
 the white blood corpuscles and liberating the fibrin ferment which 
 produces fever. So in this form of fever it may be caused by using 
 strong antiseptic solutions, which produce necrosis or disintegra- 
 tion of the tissue, which are absorbed or by closing a wound before 
 the capillary bleeding stops, thereby forming a clot which disin- 
 tegrates and is absorbed. 
 
 Symptoms. — The symptoms are plain. After performing an 
 opBration and using strong antiseptics, in about twenty-four hours 
 you will find your patient with a temperature of 100 to 103 de- 
 grees F., pulse quick, but there is nothing to indicate sickness, 
 there is no anorexia or prostration, the patient says he feels well 
 and may not stop walking around his room. The fever lasts from 
 one to four days and suddenly subsides. 
 
 Prognosis. —Good. 
 
 Treatment. — The curative treatment is "7^^7," for the patient 
 will be well in forty-eight hours, but by proper technique you can 
 
PRINCIPLES OF SURaERY, 89 
 
 prevent the fever and thus save yourself and patient the anxiety. 
 iSever have your antiseptics too strong^; obtain thorough haem- 
 ostasis before closing the wound and you will not be bothered with 
 aseptic fever. 
 
 2. Sapremia or Septic Intoxication. — Sapremia is due to the 
 absorption into the s\^stein of the products of putrefaction; not of 
 the germs, but of their products, ^''Toxins and Ptomaines^ 
 
 Cause. — The cause is the presence in the wound of dead tissue, 
 which has become infected by micro-organisnas causing it to 
 putrefy, with the formation of toxins and ptomaines, which are 
 absorbed into the system The poison is, therefore, formed in the 
 wound, and does not come from ivithout. 
 
 Symptoms. — In about forty-eight hours after the operation there 
 is a chill. ITp to this time the wound does well, regardless of the 
 piece of dead tissue it contains, this is beca'ise it takes the germs 
 about this long to get in their work. The chill is severe, the teeth 
 chatter and the bed shakes; fev^r follows, which may reach LOi 
 to 105 degrees F. The symptoms come on suddenly, due to the 
 sudden introduction of poison into the system, and they reach 
 their maximum intensity from the first, just as when any other 
 alkaloid, as strychine or morphia, is introduced into the system. 
 The fever is continuous; pulse rapid, strong and bounding, unless 
 the dose of the poison is large, when it is rapid and feeble; the 
 digestive system is horribly upset, anorexia, vomiting and diar- 
 rhoea supervenes and the patient refuses all food; the urine is con- 
 centrated, of a high color and loaded with urates; on standing it 
 has a mudd}^ appearance. The nervous symptoms commence with 
 the chill; there is depri^ssion, terror, irritability; he is restless and 
 inquires anxiously about himself; in a short while he becomes 
 comatose, the pulse growls weaker and vveaker and gradually 
 ceases. Locally the wound will be found to contain a piece of 
 dead putrefying tissue. 
 
 Diagnosis. — The diagnosis is based on the symptoius and the 
 fact of finding dead putrefying tissue in the wound, which the 
 nose readily detects on examination. 
 
 Prognosis. — This depends on the amount of the poison absorbed 
 and the resisting power of your patient. If the aose is sufficient 
 to kill you can do no good, but if the first dose is small it depends 
 
90 PRINCIPLES OF SURGERY, 
 
 on yoar abilit}^ as a surgeon and the situation of the wound v^hich, 
 if accessible to operative interferences, makes the prognosis good. 
 
 Treatment. — The prophyhictic treatment consist of measures, 
 which prevent the decomposition of dead tissue when it is left in a 
 wound through necessity, which if possible, should be avoided, 
 but in doing a Hysterectomy you are compelled to leave a dead 
 stump, and the strictest aseptic precautions must be taken to keep 
 it from putrefying. r>ry the surface, dust with iodoform and dress 
 with plenty of antiseptic gauze. After the disease has developed, 
 the curative treatment consist of opening the wound, removing all 
 dead tissue and thoroughly disenfecting the wounded surfaces. 
 Administer tonics, of which quinine is the best (three grains, three 
 a da\7^); if the pulse is weak give one-tenth grain strychnia, or fif- 
 teen drops of digitalis, injected under the skin, but the latter is lia- 
 ble to produce an abscess, give whiskey or champagne with a free 
 hand, even until the face flushes and it can be detected on the 
 breath. 
 
 3. Fkogkessive Septicemia or Septic Infection. — Progressive 
 septicemia is due to the introduction into the system of living 
 pathogenic micro-organisms. The poison is produced outside the 
 body and conveyed to it and thus makes the disease not very 
 amenable to su.^gery. 
 
 Cause. — The cause is the presence in the blood and tissues of 
 germs, which multiply and produce their specific poison. How 
 these germs get into the body and how they act is not known. 
 The disease occurs from small as well as from large wounds. The 
 exact nature of the germ is not known, but the strejjtococr-.us is 
 usually found combined with other germs. 
 
 Symptoms. —If the pathology of sapraeraia is remembered you 
 will know the symptoms of septic infe'^tion, as the only difference 
 is, in sapremia the poison is produced in the wound and in this 
 type it is formed outside the body. The symptoms in this type 
 comes on more slowly and insidiously and the disease is much more 
 grave. The wound may be inflamed and angry looking, but usu- 
 ally there is no marked change: the chill is not severe, the fever 
 may be ele\:ated to 106-107 degrees F., or it may be sub-nor- 
 mal, 97-98 degrees F., and in this case the temperature never 
 becomes normal, pulse weak, rapid, and as the disease progresses 
 
PRINCIPLES OP SURGERY. 91 
 
 becomes more and more irregular. All surgeons agree that septi- 
 cemia, with a good pulse and high temperature, is more favorable 
 to the patient than septicemia "with a low temperature. The face 
 has a peculiar look, it is a gasping white, pallid and drawn with 
 dark circles around the eyes, there is indifference, apathy, says he 
 feels well, soon the brain breaks down, and he mutters deliriously, 
 the skin is yellow, cheeks flushed, anorexia, nausea, vomiting and 
 there is diarrhoea in half the cases, the urine is concentrated and 
 loaded with urates. 
 
 Diagnosis, — It is differentiated from sapremia by not finding 
 dead tissue in the wound, and by the symptoms coming on 
 slowly. It can be differentiated from Typhoid fever by T3^phoid 
 fever having a prodromal stage, with a gradual rise of tempera- 
 ture. The most important symptom in the diagnosis is the mental 
 condition. 
 
 Peognosis. — The prognosis depends on the intensity of the poison 
 and the resisting power of the patient, but is always very grave. 
 
 Treatment, — All we can do is to assist mother nature, the poison 
 is being generated in all portions of the body and cannot be bene- 
 fited by surgery. The prophlactic treatment consist of the proper 
 treatment of the wound; keep io clean and prevent the entrance 
 of the germ by appropriate antiseptic applications. The curative 
 treatment consists of the local disinfection of the wound, and as 
 soon as the disease develops give perfect drainage, which in all 
 probabilities should have been done at the time of ttie operation, 
 but v^ as neglected. Administer tonics, stimulants and highly 
 nutritious food. If possible tne new serum treatment should be 
 tried. 
 
92 PRINCIPLES OF SURGERY, 
 
 LECTURK XXII. 
 
 PYEMIA. 
 
 Pyemia is caused by the entrance into the ci'^culation of pus or 
 the products of pus, and is characterized by recurrent chills, in- 
 termittent fever and by the formation of metastatic abscesses on 
 different portions of the bocl^^ This disease was frequent before 
 the advent of antiseptic surgery, but is almost unknown at the 
 present day. 
 
 Causes. — The essential cause is the pus microbe. It invariably 
 occurs after suppuration; this has been proven both clinicallj" and 
 bacteriologically. In ev6ry case the streptococcus or the staphy- 
 lococcus has been found in the blood. Some observers claim that 
 the streptococcus is the microbe concerned, others that it is the 
 staphylococcus, but in reality both are concerned; the streptococ- 
 cus being found more abundant in the acute malignant type and 
 the staphylococcus in the more chronic type which sometimes yields 
 to treatment. Koch injected pus from a pyemic abscess into an 
 animal, and an ordinary suppurative abscess resulted, pus from 
 this was injected intravenously causing all the evidences of pye- 
 mia. The predisposing causes consist In the localization on the 
 body of a suppurating wound near a vein. The disease does not 
 occur in every case of suppuration, but if the suppuration is deep, 
 as in a bone, the pus is more liable to enter the circulation. 
 
 Pathology. — We have a wound either surgically or accidentally 
 inflicted which becomes infected with the pus germ. The germs 
 proliferate, causing suppuration, this gradually extends through 
 the tissues until a vein is reached; the tunica adventitia is attacked 
 and finally the tunica intin. a is reached causes Phlebitis. 
 The tunica intima becomes rough, causing the white corpuscles 
 to accumulate on it, forming a thrombus, which extends along 
 the vein toward the heart. This is, of course an infected 
 thrombus, which soon disintegrates and emboli are carried into the 
 circulation, and being infected they cause an abscess wherever they 
 lodge. The terras thrombus, embolus and infarction may need 
 
PRINCIPLES OF SURGERY. 93 
 
 some explanation. A thrombus consist in the formation of an 
 intravascular clot. It may be caused by any irritant applied to or 
 neat a vessel, v^hich causes roughening of the tanica intima and 
 corpuscles accumulate, causing a clot (so it is obvious that the 
 fluidity of the blood depends on the smooth healthy condition of 
 the lining of the vessels). There are many kinds of thrombi, 
 Arterial, Venous, White (when composed chiefly of white and third 
 corpuscles). Red when composed chiefly of rea corpuscles. Parietal 
 TV hen it occupies the side Ol the vessel and Obstructive when it 
 entirely closes the luraeu of tue vessel. A thrombus, if not in- 
 fected, may undergo resolution, but if infected it disintegrates and 
 an embolus results. When a thrombus grows rapidly and reaches 
 a bifurcation of a vein, its point projects into the vein with its rapid 
 flowing blood, and the end is broken ofl" aud carried into the circu- 
 lation, and this constitutes an Embolus. An embolus then consist 
 of a small foreign bodj^ in the blood. It goes through the heart 
 into the lungs, here it usually lodges unless it is small enough to 
 pass through the capillaries, when it may lodge in the liver, kidney 
 or spleen. Fat may cause an embolus, as after a fractured bone, 
 but in each case the result is the same, no matter where it ledges 
 the blood is cut off from the distant tissues supplied by the plugged 
 artery, constituting an Infarction. An infarction is a bloodless or 
 anemic part of an organ, caused oy the occlusion of the nourishing 
 vessel by an embolus. The bloodless part is triangular, apex to- 
 ward the plug, base looking avvay from it. As soon as the plug 
 forms, usually some capillary ruptures and blood is poured out into 
 the tissues, this is called Hemorrhagic infarction. When an in- 
 farction occurs the collateral branches do their best to supply the 
 part and in some organs it is accomplished, but in organs w^ith ter- 
 minal arteries like the kidney and spleen there is no means of estab- 
 lishing the collateral circulation and necrosis resulcs, which if the 
 embolus be aseptic will end in resolution, but if it be infected and 
 therefore the seat of microbic growth, the dead tissue will be at- 
 tacked, causing suppuration, with the formation of metastatic ab- 
 scesses at the seat of localization of the emboli ami also in other 
 organs. 
 
 Symptoms. — It can be inferred from the cause that the disease 
 does not rapidly follow the infection of the wound, as it always 
 
94 PKINCIPLES OF SURGERY. 
 
 follows suppuration and time must be given for the germs to get in 
 their jvork. It usually occurs from nine to ten days after the in- 
 fliction of the wound. In about six days after the iufiiction of the 
 wound the patient becomes restless, anorexia and great thirst comes 
 on; when the wound is examined you will not find a laudible or so- 
 called healthy pus, but there is a sanious, serous, ill- smelling fluid 
 escaping, the part is swollen, lips of wound everted and the granu- 
 lations have a yellowish-gra3dsh cast. About the ninth day there 
 will be a severe chill which will last about an hour, skin cold and 
 pallid, but the thermometer shows a temperature of 103-104 degrees 
 F. The fever continues four or five hours and gradually drops, but 
 never leaves entirely. Then comes profuse per spiration and depres- 
 sion. The fever is not intermittent, but remittent in character, and 
 the chills recur at irregular intervals, from one to three a day. The 
 pulse keeps pace with the temperature, but is always "weaker and 
 quicker than normal. The mental faculties are not affected, there 
 is no stupor, unconsciousness, nor apathy, the patient fully recognizes 
 his position. In the later stages the great exhaustion and prostra- 
 tion brings on coma, in which state he dies. The digestive system 
 is not seriously disturbed, there is loss of appetite and thirst, but 
 no diarrhoea. The skin is peculiarlv changed, it is yellow, simu- 
 lating jaundice, but the white of the eyes are not affected, as in 
 jaundice. In a short while abscesses will occur in various portions 
 of the body and the symptoms depend on where it is located; if in 
 the lungs, there will be difficult breathing and increased dullness 
 on percussion; in the liver there is localized peritonitis; in the 
 spleen, there is increase in size of the organ and tenderness; if in a 
 joint, the symptoms will be those of suppurative arthritis. 
 
 Morbid Anatomy. — In making a post-mortem you will find a 
 wound on the body which has suppurated and close by you will 
 find a vein v^ith clotted blood in it, trace the clot up toward the 
 heart and its apex "will be found projecting into a bifurcation of the 
 vein and its end broken off. The lungs have a number of abscesses 
 in it, usually at the periphery beneath the pleura, the liver and 
 spleen is also studded with abscesses and some joint filled with pus. 
 
 Diagnosis. — The diagnosis is based on the history; on the fact 
 of a suppurating wound, a sudden chill, with repetition of same at 
 irregular intervals, variable temperature, prostration, yellow skin 
 and on the abscesses on various portions of the body. 
 
PRINCIPLES OF SURGERY. 95 
 
 Prognosis. — The prognosis is based on the acuteness and inten- 
 sity of the disease. Acute pyemia usually terminates fatally in 
 live or six days. In the chronic type, where the fever is not high 
 and abscesses do not form, the prognosis is not quite so grave. 
 
 Tkeatment. — The prophylactic treatment is the most important 
 and on this I would lay particular stress, as we can prevent the 
 disease, but are powerless in curing it. Prevent suppuration and 
 you prevent pyemia, and to prevent suppuration you must carry 
 out the laws of asepsis, which have been laid down in a previous 
 lecture. If the disease developes, you must do rigid secondary 
 sterilization; curette the wound, disinfect with a strong bi-chloride 
 solution or chloride of zinc, and dress antiseptically. Some sur- 
 geons ligate the plugged vein, others amputate, but it is best to 
 dissect out the clot. The local treatment at any rate can't be re- 
 lied upon, and we have to depend on constitutional remedies, tonics 
 as quinine, gentian, nux vomica, etc.; stimulants as whiskey, 
 which must be given in unmeasured quantities, strychnine, digi- 
 talis and good nourishing food. 
 
 When secondary metastatic abscesses occur, incise freely, irrigate 
 and drain. When suppuration exist in any cavity it should be 
 treated as laid down previously. 
 
 LECTURE XXIII. 
 
 ERYSIPELAS. 
 
 Erysipelas is an acute non-suppurating inflammation of the skin, 
 characterized by a crimson blush and a continued fever. 
 
 Cause. — This disease has long been known, but only recently 
 has it been proven to be of micro? >ic origin. It has long been 
 known to be a contagious disease and with the discovery of its 
 microbic origin many experimenters attempted to isolate the germ, 
 but not until 1S83 was it isolated, and then by Febleisen. It is 
 almost identical with the pus germ, ceing slightly larger than the 
 
96 PRINCIPLES OF SURGERY. 
 
 streptococcus pyogenes and a little larger than the staphyloccccns. 
 It is a round germ, multiplies by tission or direct segmentation and 
 forms serpentine chains. It grows in all media, the most favorable 
 tempBrature is S5 degrees F., and there is no growth at or above 
 104 degrees F. Owing to the fact that the germ resembles the 
 pus germ, many observers claim they are identical, but they are 
 distinct; the germ of erysipelas does not produce pus, and when 
 pus does occur in an erysipelatos wound it is because it has also 
 become infected with the pus germ. 
 
 Pathology — When erysipelas starts, it is due to the entrance 
 into the skin of the streptococcus erysipelatis, and as the unbroken 
 skin acts as a barrier to the germs, there ixust be some breach of 
 continuity. After entering through an ^''Infection Atrium^'''' it 
 localizes, in the superficial lymphatics of the skin and produces its 
 effects. The germs are immovable, but they proliferate so fast 
 that the disease rapidly spreads in the direction of and also against 
 the lymph stream, and its current is soon stopped. The germ is 
 exceedingly short lived, not being able to live in the same locality 
 over three days and therefore it travels from one point to an- 
 other, like a tramp in quest ol food. For the foregoing reason, 
 remedies are applied to prev^ent their migrating and thus check- 
 ing the disease. Some observers claim that when localized the 
 leucocytes kill them; while others say that on account of being so 
 vigorous they soon exhaust tbe food at the point of localization 
 and then they move to better supplied parts for their food. 
 
 Symptoms. — General. — The disease has a sharp period of incuba- 
 tion, which has been proven by observation on man and experi- 
 ments on animals to be from fifteen to sixty-one hours. After this 
 time the symptoms are ushered in by a chill, which is sometimes 
 replaced in children by convulsions, there accompanies the chill 
 its characteristic phenomena, pain in the back, pallid skin and 
 sunken eyes. As reaction comes on the fever rises to 102-108 
 degrees F., and never ceases until the disease is eradicated, it is 
 intermittant but continuous. The pulse is at hrst quickened, but 
 in a few days becomes weak from the effect of the poison on the 
 heart. The respirations are quick, shallow and irregular. The 
 stomach is horribly upset, there is anorexia, nausea, vomiting and 
 diarrhoea. 
 
PRINCIPLES OF SURGERY. 97 
 
 Local. — IVhen you find a patient vAith the abov^e symptoms, if 
 he has been recently operated on, examine the wound, and if he 
 has been accidentally injured he will direct your attention to the 
 wound, which he says, is tino;ling, burning and smarting. On 
 examination you will find a wound with a crimson blush, which 
 is at nrst limited, but it gradually extends to neighboring tissue. 
 It steadily progresses in a zigzag manner, the division between it 
 and the healthy tissue being well marked. The part is swollen, 
 its extent depending on the tissue involved; if it is loose it will be 
 considerable, if tight it will be moderate.' The pain is severe, and 
 is described as a burning, tingling, scalding pain. The tissues feel 
 tight and drawn. When the disease has nearly run its course 
 there will be desquamation. The wound will never show pus un- 
 less there is double infection. If the disease be watched in three 
 days it will berioticed that the primary focus has healed, the germs 
 having exhausted the food at that point and a new S.eld will be 
 invaded. So if the proliferation of the germs can be prevented 
 you can cure the disease in three days, but if this is not accom- 
 plished the disease will last for weeks. 
 
 Yaeieties. — There is but one variety and but one germ, but the 
 following divisions are made according to difference in degree and 
 clinical features. 
 
 Phlegmonous Erysipelas. — This is a type of the disease where 
 we have the co-existence of suppuration and erysipelas at the same 
 time and same point, due to mixed infection. There are all the 
 symptoms described befoie, and in addition there is pus. This is 
 the most dangerous type of erysipelas. The symptoms of erysipe- 
 las are overshadowed by those of suppuration and there is danger 
 of the disease terminating in Pyemia or Septicemia. 
 
 Facial Erysipelas. — The medical fraternity speak of this type 
 as Idiopathic erysipelas, which means the disease is of spontaneous 
 origin, occuring without an '^infection atrium.'^'' This theory is 
 absurd, a relic of ignorance, nothing arises spontaneously and the 
 term Idiopathic is now being obliterated from medical literature. 
 There must be an "/;2/ec2^/c»7i atrium/'' through w^hich the germ 
 may enter or else there will be no symptoms of erysipelas. Often 
 on close examination it is difficult to find a breach in the skin, but 
 on close scrutiny around the alae of the nose it can be found or it 
 
 7 
 
98 PRINCIPLES OF SURGERY. 
 
 may have been so rainute that it has healed before the onset of 
 the disease In about fifteen to sixty-one hours after the infection 
 there is a chill, followed b}^ fever. The skin near the nose will 
 show a crimson blush and there is nausea and anorexia. The dis- 
 ease gradually extends to the cheek, then to the soft tissues around 
 the eye, which may become so swollen as to close the lids; it then 
 crosses over the nose to the other eye p.nd cheek, then it ruos up on 
 the forehead along the hair to the back of the ear, finally coales- 
 cing behind the head. Strange to say it never attacks the chin or 
 the posterior surface of the neck. This type of the disease is usu- 
 ally self -limited and ceases in about ten days, causing little anxiety, 
 although the disease may become very serious by the germ extend- 
 ing to the brain through the lymphatics, causing meningitis. This 
 complication can be readily recognized by the fever being accom- 
 panied by delirium ^hich does abate with the disease. 
 
 Erysipelas Neonatoedm. — This type of the disease was formerly 
 very common, but is rarely seen now. It attacks the umbilical 
 cord of new born children and was of frequent occurrence in ''■lying 
 in hospitals'" before the days of antisepsis and asepsis. Soon 
 after birth there appears a crimson blush at the umbilicus, which 
 gradually extends around the body, there is a chill or convulsion 
 and. bullae form. This type usually ends fatally. 
 
 Erysipelas of Mucous Membranes. — This type attacks mucous 
 surfaces as the mouth, tonsils, rectum or vagina. The symptoms 
 are the same as delineated above, except on account of the natural 
 crimson hue of mucous membranes this symptom can't be observed. 
 ]^(either does it show on negroes when attacking the skin, and we 
 diagnose by general symptoms. 
 
 Diagnosis. — Tne diagnosis in well marked cases is plain. The 
 fact of the patient having a wound or an 'Hnfection atrium^''' the 
 chill, fever, crimson blush around the wound, which extends in a 
 zigzag manner, swelling, heat and a burning, scalding pain. It is 
 different iated from Erythema by finding healthy tissue between 
 the red discoloration of the skin, whereas in erysipelas the dis- 
 coloration is uniform; from Lymphangitis, by its attacking the 
 superlicial lymphatics, whereas lymphangitis attacks the deep 
 lymphatica, but in reality it is nothing but a superficial lymphan- 
 gitis. Phlebitis can be differentiated from it by the red color fol- 
 
PRINCIPLES OP SURGERY. 99 
 
 lowing the anatomical course of the veins and the veins in phlebitis 
 feel lii^e cordo. Phlegmonous inflammation can be differentiated 
 by its starting deep down in the tissues and approaching the sur- 
 face, while erysipelas starts superficially and penetrates deepl3^ 
 
 Prognosis. — The prognosis is good in uncomplicated erysipelas, 
 but very grave when there are complications, such as suppuration, 
 pyemia or septicemia. 
 
 Treatment. — Twenty years ago erj'^sipelas attacked the wounds 
 in half the operations, but since the advent of aseptic surgery the 
 disease has been banished, and when it does occur it is due to 
 bungling and dirty work. Treat wounds and make \^ ounds by 
 the laws laid down previously, and you will never have erysipelas. 
 If the disease does develop, the treatment must be both local and 
 constitutional. The local applications are numerous, almost every 
 drug in the pharmacopeia has had their endorser, which shows 
 there is no specific, and as erysipelas is a self-limiting disease you 
 can't put much dependence in drugs. Those mostly used at pres- 
 ent are Iodine, Nitrate of Silver, injections of Carbolic Acid, and 
 Bi-chloride Mercury, Oxide Zinc, Ichthyol, hot and cold applications 
 and numerous others. Take my advice and leave these drugs alone 
 and practice the following: Eender the part clean with green soap, 
 wash then with alcohol, and then use a bi-chloride solution to kill 
 any pus germs that may be lurking around and thus prevent com- 
 plications, IN'ow apply a compress saturated with a not antiseptic 
 solution; apply it this way, take a thick wad of cotton and some 
 feeble antiseptic solution, such as 1-1000 bi-chloride, 1-203 carbolic 
 acid or acetate of aluminum and place it in a pan and heat it con- 
 tinually over an alcohol lamp, \^ ring out the cotton pad and apply 
 to the part; repeat every hour. The object of this treatment is 
 thorough cleanliness to prevent complications by the pus germ, 
 heat lessens pain and you exterminate the germs of erysipelas as 
 it can't stand a ten perature over 104: degrees F., and the solution 
 must be up to 110-120 degrees F. ; the temperature of the skin is 
 thus raised above 10-1 degrees F. and the germs are killed. jSever 
 use salves or caustics. Constitutional remedies must be given to 
 preserve the strength. Give stimulants in large quantities, good 
 easily digested food and tonics as quinine and iron. Never use the 
 coal tar products, they are too depressing. Give opium for the 
 
100 PRINCIPLES OF SURGERY. 
 
 pain, of which Dover's powder is the best. If complications 
 occur treat them on general principles. 
 
 Curative Power or Erysipelas A:NrD Its Therapeutical Use. — 
 It was observed many years ago that patients suffering from can- 
 cer which resisted all remedies, when attacked by erysipelas were 
 cured cf the cancer, that sarcoma of bones was cured by an attack 
 of erysipelas, etc. A German physician observed in the case of 
 his son, VNho was nearly dead from diphtheria, that after he was 
 attacked b}^ erysipelas of the mouth in the course of the disease, 
 that the membranes were thrown off and the son recovered. And 
 so it has been found that the germ of erj^sipelas is antagonistic to the 
 germs of many diseases. Many patients have been killed by inject- 
 ing the germs of erysipelas into them for the cure of cancer, but 
 now we are using their toxins instead of the germs, and the treat- 
 ment is not so dangerous. Dr. Kohle, an ardent supporter of the 
 antagonism of this germ to the germ of cancer, reports two or three 
 hundred cases of cancer, which had been given up as past the pale of 
 surgery, which he treated successfully b}'' inoculating theiE with 
 the mixed toxins of the Streptococcus erysipelatis and Bacillus pro- 
 digiosus. Other doctors, viz. : Senn, of Chicago, and Keen, of 
 Philadelphia, have tried Dr. Kohle's treatment without success. 
 In spite of the results attained, I believe we are on the verge of a 
 great discovery for the cure of this disease, as well as for diph- 
 theria. The toxins, when injected into man, do not produce ery- 
 sipelas, but their chemical properties has a deleterious effect on the 
 germs cf cancer and diphtheria. 
 
PRINCIPLES OF SURGERY. 101 
 
 LECTURE XXIV. 
 
 TETAXUS— SCURVY. 
 
 Tetanus or Lockjaw is an infectious disease, in which the srerm 
 that produces it acts on the Cerebro-spinal nervous system, pro- 
 ducing rigidity and spasms of definite groups of muscles. This 
 disease has long been known and was supposed to be due to ner- 
 vous reflex irritability^ from a wound to the centers. This theory 
 is still held by some, but has been abandoned by the better in- 
 formed surgecns. It is now known to be an infectious disease, 
 due to a specific microbe; the following observations should con- 
 vince the most skeptical: A bullock which had died from lockjaw, 
 "v^ as eaten by a lot of slaves and every one of them died from the 
 disease, showing that there was some specific poison in tha meat. 
 A horse, having died from lockjaw in a certain stall of a stable, 
 vs^hich was afterwards used by a bitch in having puppies, seven of 
 the pups died from the disease, and the children that played with 
 them also contracted the disease. Recently it has been recorded 
 where a woman, while walking across a barn yard, fell and wounded 
 her elbow, she contracted lockjaw and died; on investigation it 
 was found that not long before a horse had died of tetanus in the 
 yard, and the germs were planted in the soil and in this way she 
 contracted the disease. 
 
 Cause. — The disease is caused by a specific microbe. Tt is due 
 to the many experiments of Xicolaier who, in 1S84, published his 
 discovery of the germ. He proved that it is a bacillus, rod-shaped 
 and is peculiar in having a spore near one end, which gave it the 
 appearance of a drum stick. It is an anaerobic germ, and there- 
 fore requires the exclusion of oxygen for its growth, and this is an 
 important point to remember in the treatment. Great difficulty 
 has been experienced in its cultivation; it gro^s in sterilized blood 
 serum and in gelatin after the addition of grape sugar; it groves 
 best at 80 degrees F., but will also grow above and below this; it 
 is the most resisting germ we have to deal with, but is killed after 
 ten minutes boiling or steaming; it multiplies by spore formation 
 
102 PRINCIPLES OF SURGERY. 
 
 and grows in man only when inoculated deep enough to be out of 
 contact of oxygen. Tnis germ is exceedingly common and widely 
 distributed, being found in manure, street dust, garden soil, old 
 mortar and bricks. Owing to the fact of its beinor an anaerobic 
 germ, infection is rare, except when a deep soil is upturned. There 
 is on record a very peculiar coincident. Daring an earthquake 
 ttiere was demolished two old stoce churches, which were only a 
 tew miles apart. In each there were two or three hundred wor- 
 shippers, and a great man}?- were injured. In one case seventy 
 were injured, out of which forty died of lockjaw; wbile one hun- 
 dred and fifty w^ere injured in the other case none contracted the 
 disease. On exarcination the bacillus of tetanus was found in the 
 former case and none were found in the latter. The germ can't 
 enter the body unless there be an ''infection atriiwi,'''' there is no 
 such thing as idiopathic tetanus. The germ proliferates and 
 grows, but is not disseminated through the body, it localizes and 
 is never found in the blood. The symptoms arise from the absorp- 
 tion into the sj^stem of the toxins or ptomaines produced by the 
 germs. Their toxins are described as being of four kind, and 
 different sj'^mptoms are given for each, but this is too theoretical 
 to indulge in. The germ may enter through any abrasion, but 
 usually gains admittance through wounds on the feet or hands, as 
 these members are more liable to both injury and infection. It 
 occurs in men oftener than in women, oa account of their being 
 more liable to injury. It is most frequently seen in jockej^s, stable 
 boys, gardeners and street cleaners, who by their occupation, are 
 more exposed to tbe germ. The wound must be a deep punctured 
 wound, so as to exclude oxygen. 
 
 Cli^jical Varieties. — 1. Acute, This develops only a few hours 
 after tbe infliction of the wound. The symptoms are severe and 
 intense, ending in great prostration and death. 2. Chronic. 
 This comes on in two or three weeks after infection. Tbe symp- 
 toms are less severe and recovery may occur. This difference in 
 type is either due to the dilTerence in the virulency of the germ or 
 to tne resisting powder of the patient. 
 
 SvMi'ToMs. — Suppose a man working in a garden sticks the prong 
 of a rake in his foot, or in walking across a barn yard sticks a nail 
 in his foot. In two or three weeks he becomes indisposed, cross, 
 
PRINCIPLES OF SURGERY. 103 
 
 irritable, irnder the weather, despondent, forbodes evil and anx- 
 iously ponders over his condition. lie complains of chilliness and 
 slio'ht stirfness about his neck, he tries to eat and accidentally dis- 
 covers that he can't open his mouth sufjiciently to drink or to re- 
 ceive his food. There is no pain or swelling, nothing abnormal is 
 found except the inabiJity to open his mouth, due to rigidity of 
 the muscles of mastication. He becomes alarmed and sends for 
 the doctor or treats it lighty and irons his neck for ^'- Crick'"' in 
 the muscles. Soon, however, there is pain, the stiffness of the 
 neck increases and the jaws are firmly locked ; the muscles of the 
 back now become involved, they contract and as a result the head 
 is thrown back, the spiae is arched and the body assumes the posi- 
 tion known as Opisthotonos, the head and heels being the only 
 parts touching the bed. The muscles of the thoi'ax next con- 
 tract, then the diaphragm, which results in obstruction to respira- 
 tion. The face has a peculiar look, the muscles are contracted, no 
 expression and the risorious muscle contracting, produces the ghastly 
 grin called '^ Bisiis Sardonicus.''^ There is pain through the whole 
 body and the slightest noise or touch or even a draught of air 
 throws him into a convulsion. He has no control over his urine, 
 can'c eat or take any nourishment, the pulse is quick and weak, 
 the temperature may be up to 103-108 degrees F., respirations 
 shallow and labored, and he finally dies from the excrucinting 
 pain, exhaustion and starvation. Chronic tetanus only differs from 
 the above typical case, in not being as intense, the jaws not so 
 firmly locked, slight stiffness about neck and there are no convul- 
 sions. 
 
 Diagnosis. — The positive diagnosis is easy. The fact of there 
 being a wound which was inflicted by a nail or a rake which is 
 contaminated by the germs of tetanus. On the symptoms, jaws 
 locked, muscles contracted, etc. The differential diagnosis is more 
 complicated. It may be confounded with hysteria, especially in 
 young girls, where the jaws are locked, but you differentiate it by 
 the jaws not being firmly locked, no fever and b}^ there being no 
 marked change in the pulse. It can be differentiated from strych- 
 nia poison by the history, and in strychnia poison the convulsions 
 come on as soon as the drug is taken, in tetanus they come on from 
 day to day, and in strychnia poison the jaws are rarely involved. 
 
104 PRINCIPLES OF SURGERY. 
 
 It can be differentiated from hydrophobia by the history, the per- 
 son having been bitten by a rabid animal. In tetanus the period 
 of inoculation is much shorter and the muscles of mastication are 
 effected, vphereas in hydrophobia the muscles of deglutition are in- 
 Yolv^ed. 
 
 Pkogxgsis.' — Seventy-five per cent, of all cases die. One writer 
 says that all cases that resist the disease for five days get well. 
 In the acute form all die, while in the chronic typa a great many 
 recover. 
 
 Treatment. — Prophylactic. — This treatment is of the greatest 
 importance. Twenty years ago half the operations were followed 
 by lockjaw; surgeons of repute lost as many patients from it as 
 those of non-repute, and patients were always informed that teta- 
 nus v\as one of the dangers of the operation. To-day surgeons 
 never fear lockjaw if they do aseptic surgery. If a patient comes 
 to you with a dirty punctured wound, it is your duty to sterilize it 
 to its utmost depths. Don't depend on sticking a syringe in the 
 hole and throwing antiseptic solutions into the wound, but split 
 the part open, remove every particle of dirt, disinfect it with bi- 
 chloride mercury 1-2000, pack with antiseptic gauze and allow 
 access of oxygen. This procedure looks cruel, but it is your duty ; 
 tetanus is still a common trouble, and if in every twenty punctured 
 wounds you prevent one case by the operation, you save one life 
 arid give the others a wound which may be a little longer healing. 
 
 Curative. — When a case develops, and in the acute form, you 
 can do nothing but administer an anodyne and give him aix easy 
 death. If it is in the chronic form, give chloroform for the pain 
 (this is the best drug in both forms), as soon as the convulsions 
 commence, give it continually, if you are compelled to leave get 
 your assistant to administer it. Don't give it to the extent of com. 
 plete anaesthesia, lut give it like you v^ ould in an obstretric case. 
 Give morphia and atropine, which acts well in conjunction with 
 the chloroform {\-\ grain morphia to 1-150 grains of atropia and 
 repeat in three hours). Give b}^ rectum 30 grains each of chloral 
 hydrate and bromide of potash. Give good nourishing food In 
 mild cases, pull out a tooth and feed through the hcle or introduce 
 an elastic catheter through the nose, through the oesophagus into 
 the stomach and give through this one pint of egg nog every four 
 
PRINCIPLES OF SURGERY. 105 
 
 hours. In some cases neither of the above will do, then resort to 
 enemas. Most doctors have no faith in enemas, but a patient can 
 be kept alive and in fact will fatten on nutrient enemas if properly 
 administered. In giving an enema, remember that the rectum 
 can't digest food, but it v^ill absorb it, if it be predigested. Don't 
 give over three enemas in the twenty-four hours, or you will irritate 
 the rectum and it wont retain ihe food. "Wash out the rectum 
 once in twenty-four yours to remove the food which has not been 
 absorbed and will ferment if allowed to remain. Don't give over 
 four to six ounces at a time, and have it about the temperature of 
 the blood. Focd material can be used to suit the patient's purse 
 and the fancy of the doctor, but any predigested nutritious food 
 will do. Xever put pure milk into the rectum, as it will not be 
 absorbed, predigest it with pepsin. Yalentine's meat juice is good. 
 The most satisfactory enema I have ever used is as follows: 
 
 R 
 
 Whiskey ^ss (5- ounce) 
 
 Yelk of egg No. 1 
 
 Valentine's Meat Juice ^ss {i ounce) 
 
 Peptonized Milk ,f iv (4 ounces) 
 
 Beat the yolk, add the whiskey and beat until the egg is cooked, 
 add the meat juice and milk hot, put in a tun: bier until it is the 
 temperature of the blood, then with an ordinary syringe with a 
 catheter attached throw it into the rectum. This is about all you 
 can do. It is absolutely necessary to have a good nurse, make her 
 wear rubber shoes, darken the room, stop all talking and noise and 
 some cases will recover. Try the new antitoxin that has just come 
 out. 
 
 SCURVY. — This disease is not due to a germ. It is a constitu- 
 tional disease caused by improper diet or to bad bygenic surround- 
 ings. It is characterized by interference with nutrition and by 
 hemorrhages in various portions of the body. The disease was un- 
 known before the fifteenth century, but with the discovery of 
 America, with the extension of navigation, with the advent of the 
 spirit of venture into the Artie region the disease developed and 
 has raged in epidemic form very often since. Northern writers, 
 in dealing with this subject, seem to take a peculiar delight in men- 
 tioning the epidemic at Hendersonville as an example of privation, 
 
106 PRINCIPLES OF SURGERY. 
 
 neglect and cruelty. This comes with very poor grace from a 
 class of people vsho refused to send palliative drugs and food, and 
 v( ho would not allow their own surgeons to administer help to their 
 suffering brothers, when both of these privileges were extended to 
 them. 
 
 Cause. — It is caused by the food not containing a sufficient 
 amount of vegetable acids, by eating continually nothing but canned 
 goods and drinking impure water, etc. People who live in pens, 
 prison's and in ships, where the bilge water is foul are those who 
 contract the disease. 
 
 Symptoms. — The disease comos on slowly. A sailor who has 
 been active, strong and robust aboard some ship, becomes sloathful, 
 drowsy, depressed, loses strength, pain in his back, skin yellow 
 and sallow, finally becoming scaly and cracked, his gums become 
 tender, oedematous, blue ]n color and bleeds easily; the skin then 
 becomes spotted, petechial spots appear at the base of the hair, 
 tbese desquimates and finally ulcerates; the heart is weak, he be- 
 comes emaciated and dies from prostration. 
 
 Diagnosis. — The diagnosis is based on the history and syna p- 
 toms. It can be told from Purpura Hemorrhagica by the cach- 
 exia, persistent pains and fetid breath, and from Anemia by the 
 microscope. 
 
 Pkognosis.-— The prognosis depends on the stage in which you 
 see the patient. If you see him in the early stage, it is good, but 
 if you do not see him until the later stages it is exceedingly grave. 
 
 Treatment. — The prophylactic treatment consists in having 
 proper food and proper hygenic surroundings. K a ship is going 
 off on a long voyage, it should be well ventilated, stock it with 
 live stock, fresh food and pure water. Amongst the most valuable 
 antiscorbutics are: Eggs, milk, onions, potatoes, turnips, cran- 
 berries, limes, lemons and sourkraut. If the disease developes the 
 curative treatment consists almost exclusively of dietetics; give the 
 above-mentioned articles of diet and also give medicines as tonics. 
 Use antiseptics on the ulcers to prevent gangrene. 
 
PRINCIPLES OF SURGERY. 107 
 
 LKCTURK XXV. 
 
 WOUNDS. 
 
 A wound may be defined as a sudden solution of the continuity 
 of soft tissues. This definition excludes fracturt^s, although a frac- 
 ture is a wound, but not of the soft tissues, and will be discussed 
 elsewhere. An ulcer, technically, is not a wound, because it is 
 produced by slow disintegration aud not by sudden solution of the 
 tissues. The term " Woioirr^ applies to some external mechanical 
 force or violence which rents tbe tissues. The frequency which 
 wounds occur, and the number of times you will be called to treat 
 them, show their importance. 
 
 Varieties. — Wounds are divided into accidental, operative, open, 
 subcutaneous, aseptic and septic. Accidental wounds are wounds 
 inflicted accidentally by some unexpected violence. Operative 
 wounds are wounds made after careful consideration to relieve pain 
 or to save life. Open wounds are wounds in which there is a 
 breach in the skin or mucous membranes, and is exposed to the 
 air. Subcutaneous wounds involve the subcutaneous tissues, the 
 skin or mucous membrane remaining intact, as the rupture of a 
 muscle or tendon, and not being in contact with the air they are 
 not infected by germs. Aseptic v^ounds do not become inflamed 
 on account of the pyogenic germs being excluded when the w^ound 
 was inflicted, by nature's resisting the action of the germs or by 
 the use of antisepsis and asepsis which prevents inflammation. 
 Septic wounds are wouds which, at the time of infliction or after- 
 wards, have become infected by pyogenic germs which produce 
 inflammation. 
 
 Cause. — The causes are too numerous to mention. But all 
 wounds are due to some sudden application of mechanical force. 
 It may be by a knife, brick bat, club, pistol ball, or an arrow or any 
 mechanical force. 
 
 Pathology. — The pathology is the same, no matter what the 
 location or cause of the wound, and the process of healing is also 
 the same viz.: Surgical regeneration. In ever37^ wound there is 
 
108 PRINCIPLES OF SURGERY. 
 
 death of cells in proportion to the cause; in a wound made by a 
 sharp i-:nife, the death is limited to the cells traversed by the sharp 
 edge, whereas a wound made by a brick bat, the death of the cells 
 is much more extensive; but in each case the patholooy is the 
 same, there is death of cells which are replaced by granulation, 
 vascularization, cicatrization and epidermization. 
 
 Symptoms. — The symptoms are the same in all wounds, viz.: 
 Pain, Hemorrhage, Gaping and Impairment of function. Every 
 wound is accompanied by pain, the character and intensity v^arying 
 with the cause, anatomical location and the susceptibility of the 
 individual. A wound made with a sharp knife imparts to ihe brain 
 a sharp, stinging pain, which soon becomes a smarting pain, and 
 may last for hours and then subside. A wound made by a dull, 
 bruising instrument, causes no pain immediateh'' after infliction, 
 but it comes on slowly, gradually growing worse. Some tissues 
 give more pain thaa others when wounded; as a wound of the 
 sensitive finger compared to a wound on the back. Jn soixe indi- 
 viduals tbe pain from the same wound i« more acute than in others, 
 and in the same individual under different circumstances, a nervous, 
 debilitated person suffers more pain under the same injury than a 
 robust, phlegmatic person, and the remark will be made that he had 
 more ner^e, but it is just the reverse. The same persons will suffer 
 more on different occasions, as a man cut while his stomach is full 
 and he is well stimulated will not suffer much pain, but the next 
 day, if he is debilitated, he will suffer considerabl}^. Hemorrhage 
 is an invariable symptom and varies according to the force or in- 
 strument causing the wound and the constitution of the individual. 
 If the w^ound was made by a knife, the hemorrhage occurs instan- 
 taneously, but if made by a cog wheel, it does not come on for 
 some time, for the vessels are ground in two, the ends are lacerated 
 and fringed and often the lumen of the vessel closed, but in a icnife 
 cut the vessels are cleanly divided and nothing is left to prevent 
 the hemorrhage at once. Hemorrhage may be Arterial, Venous 
 or Capillar}'', depending on the vessel cut. If an artery is cut, we 
 have arterial hemorrhage, and the blood is of a bright, crimson 
 color and comes in spurts. If a vein is cut, w^e have venous hemor- 
 rhage, the blood is of a dark blue color and welds up slowly and 
 steadily. If a capillary is cut, we have capillary hemorrhage, the 
 
PRINCIPLES OF SURGERY. 109 
 
 blood is intermediate in color and comes to the surface like sweat. 
 Gaping is seen in all wounds. This is a fortunate provision, as it 
 provides tor drainage. It is due to the elasticity of the tissues. 
 The skin is the most elastic tissue in the body, muscles co?ne next, 
 and in a wound the skin retracts showing the muscles and the 
 muscles retracting more than the fascia, show it beneath. 
 
 Complications. — Local. —Inflammation is not a natural sequence^ 
 but a complication due to infection, and the wound fails to heal by 
 primary intention. It becomes red, swollen, oedematous and hot. 
 The treatraeni- consists in asepsis to prevent contamination and the 
 general treatment for inflammation when it does occur as laid down 
 previousl}'. Suppuration is usually a sequence of inflammation. 
 The wound becomes infected and inflamed, if the germ is virulent 
 pus forms and you get fluctuation on palpation. The treatment 
 consists of preventing the complication by asepsis, and \^ hen it 
 occurs the general treatment for suppuration must be carried out. 
 Gangrene occuring in a wound is a sequence of suppuration. Thtj 
 wound becomes inflam^ed, suppurates and finally there is death of 
 the soft tissues, due to the virulency of the germ, pressure and to 
 the direct action of the toxins generated. The prevention consists 
 of the proper treatment of the wound, and when gangrene does 
 occur carry out the treatment as laid doT^ n previously. Erysipelas 
 may become a complication, due to infection by the Streptococcus 
 Erysipelas. The treatment is the same as for erysipelas, given 
 elsewhere. 
 
 Constitutional complications. — Shock may be a complication, due 
 to the sudden infliction of the wound. The patient falls insensible, 
 pulse irregular, respirations shallow, sub-normal temperature, pale 
 face, etc. Treat as laid down previously. Traumatic delirium is 
 seen after wounds to the genital organs or after severe pain. 
 There is no fever, hue the patient talks out of his head, tjssts on 
 the bed, mutters to himself and for days knows nothing of his con- 
 dition, Thepatholog}'^ of this delirium is not known, it usually fol- 
 lows laparotomies for the removal of the ovaries. There will be 
 little shock, but when the patient recovers from the an^ieslhetic this 
 delirium comes on. Delirium tremens is a complication due to ex- 
 cessive drinking. It occurs in hard, continual drinkers, and is not 
 seen in individuals who get on periodical sprees. A man who 
 
110 PRINCIPLES OF SURGERY. 
 
 takes tive or six drinks a day, but who was never drunk in his 
 life, il: injured or operated on, is extremely liable to delirium 
 tremens. x\ typical case was confined in the Virginia Hospital 
 some time since. He was a respectable looking miner, and was 
 suffering from a compound fracture. He was hardy and robust, 
 but gradually became nervous and shaky. He said he never ,vas 
 drunk, but had daily taken ten drinks. This man might have 
 gone on working in the mines all his life and not been bothered, 
 but receiving this fracture caused the trouble. He commenced 
 picking at the bed clothes, tried to take the splint off, saw women 
 at the windows, snakes and rats in the room, and while the nurse 
 was absent got up and walked around the room regardless of the 
 pain. He had to be overpowered and tied in bed. The delirium 
 comes on slowly, they answer questions intelligently, but remem- 
 bers nothing about them afterwards. They always imagine they 
 see women at the windows and reptiles in the room. Fat embolus 
 may be a complication. An individual having received an injury 
 which involves the fatty tissue or fractures a bone, macerating the 
 fat in the medullary cavity, causing it to disintegrate and become 
 partly liquified, the fat may enter some large vein or lymphatic 
 and is carried to the heart. From there it is pumped into the 
 lunw, where it lodges in some small bronchiole, producing fat em- 
 bolus. It usually occurs from tv\eaty-four to forty-eight hours 
 after the infliction of the wound. Up to this time the patient may 
 have been doing well, when suddenly there is depression and ac- 
 celerated breathing, quickened pulse and dyspnosa. The patient 
 sits up in bed, gasps once or twice and falls back dead; or the em- 
 bolus may be small when the symptoms are not so alarming and 
 on examining the urine, fat globules va ill be found which has passed 
 through the lungs and has been excreted by the kidneys. Septi- 
 cemia, Pyemia and Tetanus may be a complication and has been 
 fully discussed. 
 
 Diagnosis. — The diagnosis is simple, but is more difficult to tell 
 the nature of the instrument producing the wound. 
 
 Pkogxcsis. — The prognosis depends upon the nature, character 
 and location of the wound. 
 
 Tkeatment. — 1. Local. — Arrest hemorrhage and always use the 
 simplest methods. Never apply heroic measures unless actually 
 
PRINCIPLES OF SURGERY. Ill 
 
 necessary, as tbey retard healing. Elevate the part which acts 
 by diminishing the "w* a tcrgo'''' and by favoring venous return. 
 Pressure long and faithfully applied, either as a tampon, gauze or 
 sponge. Heat and cold are useful, but cold devitilizes the tissues 
 and retards healing; heat is ver}'' useful, apply a tampon, saturated 
 in water at 110 degrees F., to the bleeding surface; it acts not 
 only by contracting the vessel, but also coagulates the albumen of 
 the blood. If all these means fail, use torsion or ligate the vessel. 
 In using torsion, catch the vessel -with a pair of haemostatic forceps, 
 and twist it until the end in the forceps comes off. In lighting a 
 vessel use aseptic oat gut or silk. Catgut is the best if you are 
 sure it is aseptic, as it will be absorbed. 
 
 Secure Asepsis.- — Make the wound clean, remove any gross im- 
 purities as glass, cloth, garden dirt, etc. If there are any slugs of 
 devitilized tissue remove them. Kow endeavor to render aseptic, 
 go about this gently and never use antiseptics any stronger than 
 actually necessary, a 1-1000 bi-chloride solution not only kills the 
 germs, but all the cells it comes in contact with. 
 
 Effect accurate coaptation. — It is your duty to bring the surfaces 
 in apposition accurately, muscle to muscle, fascia to fascia and skin 
 to skin. If it is a trivial wound coaptation may be effected by 
 placing strips of adhesive plaster on each side the wound, then 
 stitch from one piece to the other or you can use oolloidion and 
 cotton. But wounds of any size require sutures. Use catgut or 
 silk and not onlj^ suture the skin together, but to get jjerfect coap- 
 tation, you must carry your sutures deep into the tivssues. If you 
 do not carry your sutures deep enough you will have dead spaces 
 in tbe wound, in which blood clots and serum stagnates, causing 
 pain and a good media in which germs can grov\. 
 
 Provide for drainage. — Owing to the fact that you can't get 
 perfect haemostasis, you will have to provide for drainage or else 
 the fluid oozing from the wound wnll collect and separate the lips 
 of the wound and also cause severe pain. If v^ou do not fear 
 hemorrhage, use capillary drainage by inserting into the bottom 
 of the wound and letting the ends project out, a strip of gauze or 
 a bundle of catgut sutures. If suppuration or hemorrhage is 
 feared, drainage tubes of rubber or glass are best to use. Remove 
 the drainage tubes as soon as they have done their work, usually 
 
112 PRINCIPLES OF SURGERY. 
 
 after tv\ enty-four to forty-eight hours, but no law cau be laid do^'^ n. 
 Rubber tubes can be boiled to disinfect them without injury. 
 
 Apply a lyrotective dressing. — The object of this dressing is two- 
 fold, it absorbs the secretions and prevents infection from without. 
 Gauze or cotton can be used and should be impregnated with an- 
 tiseptic solutions. I he dressings should not be changed any 
 oftener than necessary, but as often as the case demands. It 
 should be removed if there is fever, pain and when it becomes 
 saturated with the secretions. If none of the above occur, let it 
 remain until healing occurs. In changing the dressing, observe 
 carefully the laws of asepsis. 
 
 Mai7ita{n physiological r^sz!.— Having carried out the above in- 
 dications, put the patient in bed and maintain physiological rest. 
 If the eyb is injured, exclude light; if the ear, exclude sound; if 
 the intestines, feed per rectum; if the bladder, give drainage. 
 
 li. Genei^rd. — Eelieve pain by giving anodynes, provided they do 
 not interfere with important functions; as after a laparotomy you 
 would not give opium, as it constipates vrhen you wish free action 
 of the bowels. Combat complicaticns as septicemia, pyemia, ery- 
 sipelas, etc., and when they occur, treat them as laid dovyn pre- 
 viously. Encourage the patient, give whiskey as a stimulant aad 
 last, but not least, give plenty of good nourishing food. 
 
 LECTURE XXVI. 
 
 SPECIAL WOUNDS. 
 
 Incised Wounds. — An incised wound is a wound made by an in- 
 strument possessing a smooth, sharp, cutting edge, and is char- 
 acterized by the fact that only the cells directly in the path of the 
 instrument are killed. The wound does not slough and is easily 
 repaired. Such wounds, if coaptation is effected, will heal in ten 
 or twelve days by primary intention. These wounds build up a 
 surgeons reputation. 
 
PRINCIPLES OF SURGERY. 113 
 
 Causes.— These wounds are either inflicted on the operating 
 table by a surgeon with a scalpel or scissors, or accidentRlly by a 
 sword, butcher's knife, hatchet or glass. They are constantly 
 occuring and. demand the surgeon's attention. 
 
 Sy]\[ptoms. — The symptoms are pain, which is immediately felt, 
 is sharp, severe and cutting in character, and unless the wound is 
 infected subsides in a few hours; hemorrhage, which is profuse on 
 account of the vessels being cleanly divided, the amount depend- 
 ing on the vessel cut; gaping is considerable, and is only limited 
 by the contractility and elasticity of the tissues passed through. 
 
 Treatment. — As these wounds heal readily, the treatment is that 
 for wounds in general. Arrest hemorrhage by pressure, elevation 
 and hot applications, if these fail use torsion or ligate the vessel. 
 ISTever use styptics, such as Persulphate iron, Monsel's solution, 
 etc., it is true they arrest hemorrhage, but do so by destruction of 
 the superficial cells, coagulating the albumen and thus retard heal- 
 ing. Secure asepsis by washing the wound and surrounding skin 
 with green soap, alcohol and a bi-chloride solution. Approximate 
 the surfaces, either by sutures, laying a piece of adhesive plaster 
 on each side and stitch from one piece to the other, or by gauze 
 and collodion. I^ever put adhesive plaster in direct contact with 
 a wound, and it is no^ even safe to put it across a wound separated 
 by gauze or cotton. Drainage is not usually necessary in these 
 wounds. Apply a dressing of gauze or cotton and bind it firmly 
 with a roller bandage. Unless one of the three indications, fever, 
 pain and a saturated dressing be evinced, do not remove the dress- 
 ings for four or five days, and in that time the stitches can be re- 
 moved. 
 
 Lacerated and Contused Wounds. — A lacerated wound is made 
 by some tearing force. A. contused wound is made by some 
 crushing force. It is at once evident then, from the causes of 
 these two varieties of wounds, that they are always combined; an 
 instrument that makes a tearing wound crushes at the same time, 
 as a wound made by a cog wheel; and a force making a crushing 
 wound also tears, as in a blow from a brick. The two then will 
 be considered together. The characteristic of these wounds is the 
 excessive destruction of tissue; cells distant from the wound are 
 devitilized, causing necrosis and making it impossible for the wound 
 
114 PRINCIPLES OF SURGERY. 
 
 to heal by piimar}'- intention. The best that can be hoped for is 
 that the devitilized tissue will separate by dry necrosis. 
 
 Cause.. — These causes are numerous and have already been 
 enumerated. These wounds are much more common now than 
 they were twenty years ago, owing to the invention of large quan- 
 tities of machinery. 
 
 Symptoms. — Hemorriiage is not great at the time of infliction, 
 although large vessels may have been severed; this is due to the 
 mechanica] closure of the vessels by the grinding and pressure of 
 the force causing the wound, and the ends of the vessels are left 
 ragged, and the blood flowing over it causes it to coagulate and 
 arrest the hmorrhage. But hemorrhage may come on later and 
 it is your duty to find any large vessels that have been severed and 
 ligate them. Shock is always present in this variety of wounds, 
 but is seldom seen in incised wounds. This helps to explain why 
 we have hemorrhage immediately in incised wounds and none in 
 lacerated wounds, as in lacerated wounds the heart is depressed 
 from shock, and is not in incised wiounds. Pain is sometiires en- 
 tirely absent, the severe injury obtunding the sensibility at the 
 time, hut there is excruciating pain soon after the injury. 
 
 Treatment. — All lacerated and contused wounds are infected, 
 and the most difficult and important task is their disinfection. A 
 man dragged underneath a car wheel has every description of filth 
 in his wound, clothes, manure, cinders, gravel, etc. ; a man injured 
 by a cog wheel in a factory has dirty hands, besides the wound is 
 contaminated by the filthy lubricating oil on the wheel. The first 
 indication is to clean the hand, give an anaesthetic; grease the hand 
 with sweeli oil, this oil is also infected, but it removes the grease 
 and dirt; now wash it with green soap and a nail brush, com- 
 mencing six or eight inches from the wound and finally attacking 
 it, then wash with alcohol to remove the soap and also for its an- 
 tiseptic properties, and lastly wash in a bi-chloride or carbolic acid 
 solution. Decide how you will treat the wound; iC it is necessary 
 amputate; if not, remove all the dead lacerated tissue with a pair 
 of curved scissors, take out all splinters of bone, remove your tour- 
 niquet and tie all bleeding vessels. Xever approximate the 
 wounded surfaces, for it is almost impossible for you to remove 
 all the dead tissue and it won't do to close the wound v^ith dead 
 
PRINCIPLES OF SURGERY. 115 
 
 tissue in it. So leave it open, dust with lodofoim, pack with 
 gauze and dress with plenty of absorbing cotton. ISTever let the 
 dressing remain long enough to become saturated. "Watch the 
 patient, don't leave him unless you leave a competent nurse who 
 can apply a tourniquet if necessary, as there is danger of slough- 
 ing or the heart's action becoming stronger after reaction, causmg 
 dangerous hemorrhage. If the wound be infected there may be 
 necrosis or even gangrene. After healthy granulations appear, 
 the wounded surfaces may be approximated by what is called 
 secondary suturing. 
 
 Punctured "Wounds. — These wounds are caused by pointed in- 
 strumeats. 'i'hey are characterized by occupying only a small sur- 
 face, but penetrating deep into the tissues, the outward appear- 
 ance being no evidence of the severity of the injury. 
 
 Cause. — Any pointed instrument, as a needle, pin, stiletto or 
 dagger. Wounds made by these instruments resemble incised 
 wounds, as they are all clean, sharp edged instruments. A splinter 
 of wood, nail or fence paling, causes a punctured wound, but they 
 make wounds resembling lacterated or contused wounds, and there- 
 fore the nature of the wound depends on the character of the in- 
 flicting instruirent. 
 
 Symptoms. — The symptoms depend on the location of the wound. 
 Hemorrhage is not usually great, unless some great blood vessels 
 lay directly in the track of the penetrating instrument and is 
 punctured. The amount of pain depends on the nature of the in- 
 strument; if it is produced by a sword, the pain is considerable, 
 but if produced by a dull instrument like a paling, the pain is not 
 so severe. The amount of shock depends on the nature of the in- 
 stilment, a sharp edge causing less shock than a blunt instrument. 
 When an instrument like a dagger is stuck into a cavity, as the 
 abdomen, and the point does not appear on the opposite side, it is 
 called a Penetrating wound; if the point does show on the back 
 or side, it is called a Perforating wound. 
 
 Treatment. — The treatment depends on the anatomical location 
 and the nature of the instrument inflicting the wound. If the in- 
 strument punctures some important cavitv or blood vessel interfer- 
 ence is justifiable, but if the wound is made by a clean, sharp in- 
 strument like a dagger, and does not involve any important organ, 
 
116 PRINCIPLES OF SURGERY. 
 
 cavitv or blood vessel, all that is necessary is to wash the surface 
 of the wound with green soap, alcohol and a bi-chloride solution 
 and apply an. occlusive dressing. If the wound was inflicted by a 
 paling or rusty nail, it is 3^our duty to lay the wound open with a 
 free incision down to the very bottom of the tract, thoroughly dis- 
 infect it, pack i\'ith gauze and allow it to heal by granulation. In 
 a wound made by a knife, dagger or needle, the infection is wiped 
 off ot it by the skin and clothes and superficial disinfection is all 
 that is needed; but in the case of a nail or paling, the wound is 
 infected to its very bottom, and you can't disinfect it without 
 splitting the part open. 
 
 Gunshot "Wounds. — On this subject volumns have been written, 
 but now in these civil times their occurrence is so rare we need 
 only give its consideration a passing glance. Gunshot wounds are 
 caused by missiles that have been projected b} force derived from 
 explosives. They are characterized by partaking of the nature of 
 both punctured and lacerated wounds; punctured because the 
 missile penetrates deeply and only shows a slight wound on the 
 surface; lacerated because the tissues are crushed and torn into. 
 
 Causes. — The causes are numerous. Any missile from a small 
 bird shot to a mammoth shell. The most common causes are 
 missiles fired from shot guns, pistols and rifles. A shot gun at 
 short range makes a round hole like a pistol ball, and it is hard to 
 tell one from the other. A pistol bullet varies from a 23 to a 48 
 calibre, which designates the diameter of the bail in decimals of an 
 inch. They are usually round, and do not possess very great 
 penetrating power. The rifle ball has changed considerably in re- 
 cent years. They formerly weighed as much as an ounce, but are 
 now only 30 calibre, coated with nickle, round or cone ?haped and 
 more penetrating than the old ball. A round bullet produces a 
 contused bruised wound, whereas a cone shaped bullet acts as a 
 wedge and produces a lacerated wound. The velocity of the old 
 rifles was only two or three hundred yards; the new rifle's velocity 
 is from one to two miles. In a smooth bore rifle the bullet rotates 
 at right angles to its axis; a rifled bore causes it to rotate in a line 
 with its axis. A round bullet produces ecchymosis at the point 
 of entrance, mashes and lacerates the tissue, and has little pene- 
 trating power; the cone shaped ballet possesses great penetrating 
 power and if it strikes a bone it shatters it. 
 
PRINCIPLES OF SURGERY. 117 
 
 Sympto^[s. — Pain is variable. Mea in the excitement of battle 
 have been shot without being aware of it. During the late war a 
 gallant officer was shot through the tibial artery and never knew 
 he was shot, until an orderly told bim his boot was running over 
 w^ith blood. Other individuals will suffer horribly froo: slight 
 wounds. The pain also varies with the kind of bullet struck with, 
 a round ball causing more pain than a cone shaped ball. Old 
 soldiers tell us they felt as if they had been struck by an axe when 
 shot. The amount of hemorrhage depends on the anatomical loca- 
 tion ; if a large artery is severed, it will be severe and is greater in 
 a wound produced by a cone shaped ball than when produced by 
 a round ball. Shock is generally profound, especially in soldiers 
 that have been fighting all day without food or drink. Thirst is 
 an invariable accompaniment, but why, we do not know. 
 
 Injukies to Special Tissues.— When a person is shot, and the 
 ball perforates the entire body, the point of exit will be larger 
 than the point of entrance; this is due to the fact that the velocity 
 of the ball is lessened and the skin at the point of exit has no sup- 
 port. It is the same principle as driving a nail through a plank, 
 the point of exit will be larger and shattered from non-support. 
 The skin is usually livid and soiled with grease from the bullet. 
 The fascia is peculiarly affected; made up as it is of interlacing 
 fibres of conaective tissue, the ball does not tear through it, but 
 pushes the fibres aside and the hole closes again. This is unfor- 
 tunate, for it prevents drainage and is also a bother in probing for 
 the ballet. It also may cause the ball to he deflected from its 
 course, either lessening the injury or causing greater damage. 
 Muscles are bruised and pulpified. Tendons usually escape the 
 ball by slipping to one side. Blood vessels, if situated so as to be 
 able to slip to one side, may escape, but the modern bullet usually 
 penetrates them. Bonos were only perforated by balls from the 
 old rides, but the modern rifles and balls splinter them into a hun- 
 dred fragoaents; so in the next war compound fractures will be 
 more common. ISTerves are usually severed on account of being 
 situated deeply, and often supported by bon'^. Great cavities as 
 the skull or abdomen may be penetrated. The abdomen may be 
 punctured, producing serious damage, although the bowels may be 
 pushed aside and escape injury. 
 
118 PRINCIPLES OF SURGERY. 
 
 Diagnosis. — The diagnosis is based on the history; the fact of 
 having been shot and on the appearance of the Tvound, 
 
 Peognosis. — The prognosis depends on the nature of the injury, 
 temperature and anatomical location. If the temperature fails 
 below normal, say 96 degrees F., the prognosis is very grave. 
 
 Treatment. — Stop the hemorrhage, relieve pain and combat 
 shock; do all this on the field of battle or at the place of accident. 
 There are many disadvantages in treating these wounds even in 
 civil life. You are alwa^^s called to the country or hunting field 
 where you are nut prepared for emergencies. But you should al- 
 ways be equal to the occasion; put on a tourniquet, give morphia 
 for the pain and whiskey for the shock until you can remove him 
 to better surroundings. The local treatment is all that is neces- 
 sary, disinfect the a'^ ound and apply a dressing. Don't go probing 
 after the ball, it will become encapsulated and do no harm, and if 
 it does you can take it out when the patient is better prepared to 
 stand the operation. The rule given to assistant surgeons United 
 States Army is \vhen a man is shot in battle, do nothing but ar- 
 rest the hemorrhage, relieve the pain and combat shock, then send 
 the man to the rear, and if he has no vital organ involved he is 
 left unmolested. If called t^^ a person shot in the brain or abdo- 
 men you must operate at once, and under the strictest asepsis. 
 The finger is the best probe, and always use it, unless the tract is 
 too deep; then use a Xelatou's probe, ^hich is the best artificial 
 probe we have; it expandsinto a brlb at one end v;hich is covered 
 with porcelain and when it comes in contact ^vith the lead, marks 
 are left on it, Xo two cases are treated alike, you must simply 
 meet every indication. Disinfect the wound, making it larger if 
 necessary with a free incision, remove the ball if indicated, arrest 
 hemorrhage and apply an occlusive dressing. 
 
PRINCIPLES OF SURGERY. 119 
 
 LECTURE XXVII, 
 
 SPECIAL WOUj^DS.— Continued. 
 
 Arrow Wounds. — Arrow wounds are wounds inflicted bv 
 arrows. They are characterized by the fact that they present 
 features of both punctured and contused wounds. 
 
 Cause. — The cause is an arrow head of stone fastened to a shaft 
 by leather fired from a bow, 
 
 Stmptons. — The symptoms are those of a punctured and con- 
 tused wound in general. The shaft is usually seen projecting from 
 the wound. 
 
 Treatment. — An arrow head, unlike a bullet, will not become 
 uncapsulated, and if allowed to remain in the tissues will cause 
 suppuration, and therefore no matter where it is situated it must 
 be removed. The common mistake is to try and withdraw the 
 head by making traction on the shaft. IsTever do this, for you 
 will pull the head frorr the shaft and thus lose the shaft as a guide 
 in operating. If the arrow almost perforates a limb, it is best to 
 push on the shaft until the head shows on the opposite, incise the 
 skin and remove it. But if th^ arrow is stopped by a bone, you 
 must dissect down to the head, following the shaft as a guide, re- 
 move it with forceps, disinfect thf' wound with a bi-chloride solu- 
 tion, pack with gauze and dress the wound. The rule given in 
 case of a bullet wound on a battle field holds good here; do noth- 
 ing on the field but relieve the pain, clip the shaft off two oi three 
 inches from the wound, put on an occlusive dressing and remove 
 the patient to the hospital for further treatment. 
 
 Brush Burns. — This is a superficial abrasion produced by the 
 contact of some rapid moving substance against the soft tissues of 
 the body. They may be produced by the soft tissues coming in 
 contact with a rapidly moviag belt on a piece of machinery, a rope 
 slipping rapidly through the hands or by an involuntary slide down 
 an incline (as a cellar door). They are characterized by the fact 
 that the superficial tissues, which come in contact with the mov- 
 ing body, is killed, leading a deep eschar, with no hemorrhage, but 
 
120 PRINCIPLES OF SURGERY. 
 
 intense pain. Later the eschar sloughs, leaving a raw surface 
 which heals slowly. 
 
 Tkeatmekt.— The treatment consists of thorough disinfection, 
 the application of an antiseptic compress for two or three days, 
 when the scab will be separated, then treat as any superficial ex- 
 posed wound. 
 
 Dissecting Wounds, —Dissecting wonuds are wounds caused by 
 the introductioaof septic material into the system from dead putre- 
 fying organic bodies. They occur chiefly in surgeons and 
 students who conduct post-mortem examinations and in butchers 
 iand cooks, who handle putrefying organic matter. 
 
 Cause. — The exact nature of the poison causing the trouble is 
 not known, it arises from putrefaction of organic matter. For 
 the development of grave symptoms, the poison must be exceed- 
 ingly virulent or the person infected must be in a state of lowered 
 vitality. In a strong, robust individual, the symptoms are not 
 marked; neither are they marked if the poison is weak and the in- 
 dividual debilitated, but if the individual is weak and the poison 
 virulent, the symptoms are severe, and death often results. There 
 must be an '■'■infection atrium,'''' for the perfect unbroken skin acts 
 as a barrier against infection, but if a student is pricked by the 
 pcint of a dissecting knife, or he has hang nails or a little sore on 
 his finger, he is liable to become infected. 
 
 Symptoms. — The symptoms vary extremely. They may be from 
 a slight irritation or suppuration to chat of rapid progressive gan- 
 grene. Soiretimet the wound becomes red, swollen and inflamed 
 and then subsides; again, other cases will make rapid progress for 
 the w3rse, red lines will rrark the h'^mphatics near the wound; the 
 part becomes oedematous and stvollen, extreme depression and 
 death follows. 
 
 Treatment. — Don't dissect or come in contact with putrefying 
 organic matter with abrasions on the skin. But if while making 
 a post-mortem examination, or vvhile dissecting or handling putre- 
 fying organic matter an individual is wounded, you must heroically 
 disinfect the wound. Withdraw the poison by suction, examine 
 the wound, and if it is small and punctured, enlarge it and irrigate 
 wath a 1-500 bi-chloride solution or touch it with chloride zinc, 
 dust with iodoform and dress. If no symptoms develop in three 
 
PRINCIPLES OF SURGERY. 121 
 
 days the patient is safe and must simply wait for the wound to 
 ileal, but if the above symptoms develop, and the wound goes from 
 bad to worse, don't v^ait for the formation ot pus, but make 
 numerous free incisions through the inflaired tissues parallel with 
 the long axis of the limb, and thus let the secretions escape; disin- 
 fect the part, apply occlusive dressings and treat on general surgi- 
 cal principles. If abscesses form on the body, incise and irrigate 
 them. Give constitutional remedies, as the patient mav have the 
 complication of septicemia. Give quinine in tonic doses, iron to 
 tone up the system and increase the red corpuscles, strychnia as a 
 cardiac stimulant, whiskey and plenty of concentrated nourishing 
 food. 
 
 Stings of Insects, —These are punctured wounds, inflicted by 
 the bite of various small animals. Although trivial in most in- 
 stances, as the bite of a flea, bed bug or louse, they are exceed- 
 ingl}^ painful when inflicted by a yellow jacket, wasp, bee and 
 hornet. The bite of the spider, centipede, tarantulge and scorpions 
 mav producel alarming symptoms. These wounds are character- 
 ized not only as a punctured wound, but by the injection of poison 
 into the wound at the same time. The poison comes from some 
 gland, may be mixed with the saliva, and it is important to know 
 in the treatment that the poison from all insects is acid in reaction. 
 
 Symptoms. — The symptoms depend on the animal inflicting the 
 wound. The local sj^mptoms are a mild inflammation, irritable 
 pain, heat and swelling. If the wound be examined, it will be 
 found to be a small puncture and the sting wdll be protruding from 
 it. The constiluiional symptoms are cardiac depression, interfer- 
 ence with respiration, collapse and in some cases death results. 
 
 Treatment. — Examine the wound and remove the sting, disin- 
 fect c:.nd apply an occlusive dressing to prevent infection. Eelieve 
 the pain by the use of some alkali, as ammonia or bicarbonate soda. 
 Prevent complications. If the wound is made where the above 
 remedies can't be had, iiake a poultice out of the soil and apply it 
 to the w^ound to relieve the pain. The constitutional treatment 
 consists of meeting the symptoms as they develop, strychnia for 
 cardiac depression and quinine as a tonic. 
 
 Bites of Serpents. — These are wounds inflicted by the fangs of 
 poisonous snakes. They are rarely seen in this section, but are 
 
122 PRINCIPLES OF SURGERY. 
 
 common in the mountainous regions of Yirginia and North Caro- 
 lina, The importance of this subject will be recognized when you 
 learn that in India 20,U00 people die annually from snake bites. 
 In India twenty poisonous varieties are known, whereas in this 
 country we only have four, rattlesnake, adder, moccasin and in 
 Texas the "Gila monster.*' Of course, there are many different 
 varieties of each, of the above, but there are only four great fami- 
 lies. The poision from each are almost identical in nature, the 
 treatment for each the same, and therefore they ^ill be considered 
 together. 
 
 Description. — A poisonous snake is always short, with a blunt 
 tail and a coffin shaped head. The upper jaw is movable, being 
 on a joint, so that in addition to opening its mouth with its lower 
 jaw, it can raise the upper jaw and can therefore swollow an obj-^ct 
 as large as its head. This arrangement of the jaw is peculiar to 
 the snake and crocodile. Snakes have teeth, tut they do not use 
 them in inflicting wounds. For inflicting wounds they have fangs, 
 which occupies the position of the canine teeth of the upper javv; 
 they are about three-quarters of an inch long, sharp pointed and 
 curved like a scythe. They are not hollow, but mucous memberane 
 runs down behiQd them and thus converts them into a kind of hy- 
 podermic syringe. They are movable, and when not in actiou lay 
 back on the roof of the mouth. They are two in number, one on 
 each side. The poison is contained in a sack situated behind the 
 eye, which communicates by a duct (which has a sphincter muscle, 
 so as not to allow the poison to escape except when voluntarily 
 relaxed) with the canal behind the fang. The poison varies in 
 color from a pale green to a dark orange, it is thick and transpa- 
 rent, resembling light molasses. It is of an acid reaction and from 
 ten to fifteen minims in bulk. The venom is the most powerful 
 organic poison known; chemists have tried to analyze it without 
 success. One chemist says that rattlesnake poison contains two 
 proteids, which causes its dangerous effects. The poison acts on 
 tissues peculiarly. It causes necrosis of the cells that it comes in 
 contact with and produces uncoagubility of the blood. A case in 
 which death resulted on post-mortem the blood was found perfectly 
 fluid, and would not coagulate after exposure to the air in cans. 
 The red corpuscles lose their shape, disintegrates and run to- 
 
PRINCIPLES OF SURGERY. 123 
 
 gether. The capillaries lose tbeir elasticity and not being able to 
 withstand the blood pressure, the blood is forced out into the 
 tissues. The poison acts too quickly for inliammation to occur. 
 When a snake bites be does so in this way: Seeing an. approaching 
 enemy, he curls up, only leaving his head and about two inches of 
 his body out, his tail vibrates, head moves from side to side, eyes 
 flashes, the body becomes stiff and the muscles of the back acting, 
 sends the head forw^ard, burying the fangs deep into the enemy; 
 he then shakes his head from side to side to extricate the fangs. A 
 snake can'r jump over two-thirds his length, and can't bite while 
 running; he must be coiled up. 
 
 Symptoms. — Local. — Examine the wound, and it will shov^ two 
 parallel punctures about one inch apart. The surrounding tissues 
 are black, gangrenous, swollen, oedematous, and soon disintegrate. 
 The pain is severe and gradually grows worse. Constitutional. — 
 There is giddiness at the time of infliction, becoming fainty, nause- 
 ated, the skin is cold and clammy, heart weak and intermittent, 
 respirations depressed, delirium, collapse, coma and death from 
 paralysis of respiration. 
 
 Diagnosis. — The diagnosis is based on tae history, local symp- 
 toms, a double punctured wound, change in the tissues and on the 
 snake itself. 
 
 Prognosis. — The prognosis depends on the variety of snake in- 
 flicting the wound and the amount of poison injected. The bite of 
 a Cobra is always fatal, whereas a rattlesnake bite need not be fatal 
 if heroic treatment is adopted. A snake has but ten drops of poi- 
 son, and if the wound was inflicted through the clothing, part of 
 it will be lost or if the snake bites the dog which is accompanying 
 the hunter, and then bites the hunter, the prognosis for the hunter 
 is good, bnt bad for the dog, as the dog received nearly all the 
 poison from being bitten first. 
 
 Treatment. — The treatment must be prom pt and heroic. At ply 
 a tourniquet at once between the wound and the heart. On ac- 
 count of the length of snake-; in this country and their inability to 
 reach over two-thirds their length, the v^ound is generally on the 
 extremities. If the wound is on the foot, apply the tourniquet 
 about the knee; if on the hand, apply it below the elbow. As 
 these wounds usually occur in the field or woods, you will not have 
 
124 PRINCIPLES OF SURGERY. 
 
 the necessary appliances, you will have to provide a tourniquet on 
 the spur of the moment; take a handkerchief or grape vine, put it 
 around the limb and twist it tight with a stick. As soon as this is 
 done make an effort to withdraw the poison, split open the part 
 vfith a scalpel and let it bleed, then with a cupping glass or by 
 sucking (be sure you have no crack or fissure on your lips) remove 
 the poison. If you are near a house, use a tumbler as a cupping 
 glass. iSiow thoroughly disinfect the ^vound, using the hoi iron, 
 nitrate of silver or a strong bi- chloride solution. The constiutional 
 treatment is important, and for this purpose whiskey is ^'^■par ex- 
 cellence^'''' but remember it is not a chemical antidote, but only a 
 heart stimulant, and oaly give it to its stimulating extent. As 
 many people have been killed by whiskey" given in excessive quan- 
 tities as by the snake poison. After the pulse and respirations 
 improve you will wonder what to do with the tourniquet, you 
 can't leave it on, as it will produce gangrene, and you can't take 
 it off, for you know there is still enough poison in the limb to im- 
 mediately kill the patient if it is allowed to get in the circulation. 
 You can't remove the poison, so the only thing to do is to give it 
 to him in broken doses. Take the tourniquet off for a half a min- 
 ute, reapply it, stimulate the patient with whiskey and digitalis 
 until the pulse again regains itself, repeat the operation and keep 
 on doing so until the patient is out of danger and all the poison has 
 been introduced into the system. 
 
 Note. — At the springs three years ago there was a young natu- 
 ralist, lie w^as making at that time a special study uf reptiles. 
 He bought tbe snakes from the mountaineers and with a scalpel he 
 dissected them. The scalpel usually lay upon his desk, posing as 
 a piece of ornament to his room. While at the springs he fell in 
 love with a beautiful girl, whose name was '"Carrie." One day, 
 V hile revelling in the enchanting dreams of this fair one, he care- 
 lessly picked up his scalpel and began to trace her name upon his 
 arm. As he dreamed of his love, ardently and passionately, he 
 traced and retraced the letters cf her name until they stood out 
 bathed in his own blood. Suddenly pain and swelling peculiar to 
 snake bite developed, and in great haste I was called in to see 
 him. When I arrived he had all the symptoms of a snake bite, but 
 said he had not been bitten, but had been scratching on his arm 
 
PRINCIPLES OF SURGERY. 125 
 
 Tvith the scalpel which he used for his dissections. The first thing 
 obtainable was a solution of Xitrate of Silver, and I applied it to 
 his arm. The letters "Carrie" came out in bold black letters, diag- 
 nosing for n:e his trouble, both as to the snake poison and his girl. 
 A tourniquet was applied, ana after a vigorous fight the young man 
 recovered. 
 
 LECTURE XXVIII. 
 
 SPECIAL WOUKDS.— Continued. 
 
 Contusions and Bruises. — A bruise or contusion is a subcutaneous 
 wound inflicted by the sudden impact of a blunt body against the 
 skin. They vary in degree and intensity from a pinch or black 
 eye to thf^ pulpiflcation of a limb, such as occur in railroad acci- 
 dents. 
 
 Pathology. — There is a breach of continuity of the subcutaneous 
 tissue, without injury to the skin or mucous membrane covering it. 
 Blood vessels and muscles may be ruptured, tissue and fascia 
 divided, but the wound is protected from external influences by the 
 unbroken skin or mucous membrane. 
 
 Symptoms. — The symptoms come on immediately. There is 
 always more or less shock, being symptomatic in the case of a 
 pinch, but real in more severe cases; it may be transitory or may 
 last a long time, even causing death. Pain is not immediately felt, 
 the impact of the blunt body obtunds the nerves, but it finally 
 comes on and increases until agony is endured. It will subside in 
 about an hour, unless hemorrhage is severe or the wound is infected, 
 when it will be severe and lasting. Swelling is always an accom- 
 paniment, due to the escape of plasma into the tissues; it varies in 
 amount nut only in accordance to the size of the vessel injured, but 
 as to whether the adjacent tissue is loose, when it will be great and 
 when tight it wiU not bemnch. Discoloration invariably follows, 
 due to the escape of blood into the tissue, and the disintegration 
 
126 PRINCIPLES OF SURGERY. 
 
 of the corpuscles, causing the tissues to be pigmented. The tissues 
 are first black, then a greenish yellow; the part finally returning 
 to its normal color. The exact chemical change which causes th(!se 
 various colors is not knovrn. Loss of function always follow these 
 "wounds; if it is the hand, its function will be impaired; if the eye, 
 the sight "^vill be impaired, etc. 
 
 Diagnosis. — The diagnosis is based on the history and symptoms. 
 Discoloration is the most important diagnostic symptom, as it 
 shows that a blood vessel has been ruptured. 
 
 Peogxosis. — The prognosis depends on the nature and. the loca- 
 tion of the wound. Some bruises are so trivial as to pass un- 
 noticed, while others are so severe that death soon elapses. 
 
 Tkeatmen't. — General. — The first thing to do is to combat shock, 
 using the remedies of which you are familiar. Relieve the pain 
 with morphia if it is severe, or if not use some of the coal tar pro- 
 ducts, such as Antikamnia or Phenacetine. Local. — To hasten 
 healing cany out this treatment. Give the part rest, if it be a 
 hand, put it in a sling; if a leg, place the patient in bed and ele- 
 vate tte limb; elevation is important, for in bruises there is con- 
 cealed hemorrhage going on and by this tieatraent you lessen pain 
 and prevent sucti an influx of blood to the part by gravity. Com- 
 pression is indicated, but must be applied logically. It does good 
 by checking hemorrhage, checks excessive transudation and pro- 
 motes resolution and restoration of the part to its normal condition. 
 To get compression, a pad of cotton and a roller bandage is all 
 that is necessary. From the operations you have witnessed, you 
 no doubt think that cotton is ased extravagantly, but not so, Tve 
 apply it net cnlv as an absorbent and protector, but also to obtain 
 pressure; it is elastic, resilient and the simplest and most conve- 
 nient way to get compression. If, however, you feel that the cotton 
 is not sufficient, use a flannel or rubber bandage, With the rubber 
 bandage ycu can get any amount of compression you desire. If 
 you haven't the rubber bandage or wish the bandage to remain for 
 a long time with access of air to the part, get a piece of flannel 
 and cut it bias (if you tear it you loose the effect of its elasticty), 
 and apply it with steady, uniform tension. Heat and cold is use- 
 ful if applied logically. Cold is useful when you have a hot, in- 
 flamed, painful wound, but in using it you run the risk of so de- 
 
PRINCIPLES OF SURGERY. 127 
 
 vitilizing the tissue that gangrene may result. If the -wound is not 
 very extensive apply ice bags or ice water, but never allow ice to 
 come in contact with the skin. If the above modes are too severe, 
 use evaporating lotions, such as camphor, witch hazel and arnica; 
 these remedies, although the old woman's stand-by in bruises, only 
 do good bj their rapid evaporation, due to their containing about 
 90 per cent, of alcohol, their other uses are '■^nil."- If you have 
 to write a prescription, order alcohol and color it with some bland 
 drug. Heat is useful, but remember when using cold or heat that 
 their affect is about the same, and don't go to either extreme. 
 Heat is useful when the injury is severe and gangrene is feared. 
 You can use either dry or moist heat. A salt bag is a good way 
 to obtain dry heat, maiie a salt bag, put in a pot and heat it and 
 apply to the part, or you use hot water bags, and if the weight 
 from this is too severe, apply hot flannels. Moist heat can be ob- 
 tained by the douoh, using water as hot as can be borne; place the 
 part over a tub and j)our the water over it, or you can use hot an- 
 tiseptic fomentations applied with a flannel or carbolized cotton. 
 A hot poultice is also valuable. Massage is also very valuable. 
 It is accoraplish'^d by delicately manipulating the thumb on the 
 bruised area. It stimulates the blood flow, and favors resolution 
 by breaking up the blood clots. 
 
 BuENs AND Scalds. —A burn is an injury inflicted by dry heat. 
 A scald is an injury inflicted by moist heat. Burns and scalds are 
 identical in their pathology and treatment and will therefore be 
 considered together. Most authors classify these injuries into 
 fifteen varieties, but I will only describe three — burns of the first, 
 second and third degree. Those of the first degree only involves 
 the superficial layers of the skin; in the second degree, not oniy is 
 theepiderma involved, but it penetrates into the rete raucosura and 
 involves the corium. Burns of the third degree are still deeper 
 and more destructive than the former; it destroys the skin and in- 
 volves the subcutaneous tissue, muscles and fasdia and even the 
 bones may be carbonized. 
 
 Cause. — The cause is the application of intense dry or moist 
 heat to the tissues. The degree of the burn depends on the tem- 
 perature of the heat applied and the duration the tissues are sub- 
 jected to it. 
 
128 PRINCIPLES OF SL'RGERY. 
 
 Pathology.- — This consists in the destruction of tissue by coagu- 
 lation of the albumen of the cells, followed by necrosis or gangrene. 
 The coagulation may not only be confined to the cell albumen, but 
 may coagulate the albumen of the blood in the vessels. 
 
 Symptoms, — t^ain is sharp and excruciating from the first. The 
 amount and character depends on the depth and extent of the burn; 
 that is a hurn of the first degree, is much more painful than a burn, 
 of the third degree, this is because the nerves in burns of the first 
 degree are simply exposed and irritated, whereas in burns of the 
 third degree the nerves are destroyed. Eedness follows quickly 
 and is more prominent at the margins of the burn; this is due to 
 the inhibition of the vaso-constrictor nerves and consequent con- 
 gestion of the blood vessels. Swelling quickly folio vv burns, and 
 is due to the alteration of the capillary walls, causing increased 
 porosity by enlargement of the stigmata and stomata, and thus the 
 escape of fluid is reodered easy. The amount of swelling depends 
 whether the tissue injured is loose or tight. Vesication or forma- 
 tion of blebs, due to the separation of the layers of skin and the 
 accumulation of serum, is always seen in burns of the first degree, 
 rarely in those of the second degree and never in burns of the third 
 degree. Eschar formation, this consists of the destruction of a 
 large mass of cells, which die and are separated from the adjacent 
 tissue. The eschar is sometimes black and again may be yellow or 
 white. The eschar may fall off dry, but if it becomes infected and 
 pulpified it will slough off. To summarize: Burns of the first de- 
 gree are characterized by hyperaemia of the skin, only the epiderma 
 is involved, there is erythema and blebs or blisters form. Burns 
 of the second degree are characterized by the burn, not only in- 
 volving the epiderma, but also the deeper layers of the skin, and 
 there may be the formation of blebs and blisters. Burns of the 
 third degree are characterized by eschar formation and by involv- 
 ing the deeper structures as muscles, etc. There is usually shock, 
 which in bad burns may be followed by prostration, delirium and 
 death. If the patient escapes without shock, he is still not out of 
 danger for ten days, for about the third day, congestion of some 
 of the internal organs may occur, due to reflex action, and jeopardize 
 the patient's life. And even ten days after the burn there is dan- 
 ger of ulceration of the duodenum, which shows itself as a bloody 
 
PRINCIPLES OF SURGERY. 129 
 
 diarrhoea, follo\\ed b}"- peritonitis. The pathology of this ulcer is 
 obscure; ic is thought to be due to pieces of the scorched blood 
 vessels being carried to the duodeum, causing irritation and ulcera- 
 tion. 
 
 Diagnosis. — The diagnosis is based on the history and symptoms. 
 
 Peognosis. — The prognosis is based on the depth and extent of 
 the burn, and on the age of the patient (old and young people 
 stand burns badly). The depth of the wound doesn't make much 
 difference as the extent of surface involved, as a person may have 
 a leg or arm burnt off and recover, but if the same person was 
 burned over tv\o-thirds of his body, he would surely die. The 
 reason why people die who are burnt over two-thirds of their body, 
 is due either to increased conduction of heat from the body, stop- 
 page of the excretion of CO2 by the skin or to the stoppage of the 
 absorption of O by the skin. The first theory is ra ore generally 
 accepted. 
 
 Teeatmbnt. — The general treatment consist of relieving pain 
 and combating shock, the remedies for each you are familiar with. 
 The local treatment practiced by the laity and some physicians is a 
 shame and a crime, a lasting disgrace to civilization. Well do I 
 remember, while a boy visiting in the country, when a playmate 
 of mine was burnt by powder; he was smeared with soot, molasses 
 and grease, and his head stuck in a flour barrel. These remedies 
 are used because they stop the pain by excluding the air from the 
 wound, but this can be accomplished without using these infected, 
 dirty remedies. J^ever use Carron oil. This filthy mixture has 
 long been in use; its name being derived by its being discovered 
 by a surgeon to a large iron factory in Carron, England, where 
 burns were of daily occurrence. It is true, it stops the pain by 
 excluding the air, but it is one of the best culture medias I know 
 of. Dress the hand so as to exclude air and prevent infection, and 
 the wound will heal under one dressing. Render the part clean, 
 and if necessary to accomplish it, give an ansesthetic. Clip away 
 all fragments of skin, remove all dirt and cloth, wash it in green 
 soap, alcohol and a bi-chloride solution, if the surface is small, but 
 if large use a n on- toxic antiseptic as boracic acid, acetate of alumi- 
 num, etc., dust with one of the numerous antiseptic powders, of 
 which iodoform is the best, apply a piece of gauze, then a thick 
 
 9 
 
130 PRINCIPLES OF SURGERY. 
 
 layer of cotton, a fold of oil silk over this and lastly a neat band- 
 agre. This dressino: can usually stay on until healmo: occurs. In 
 addition to the above, you must prevent defornaity by means of 
 splints after putting the part in its anatomical position. If neces- 
 sary assist healing by skin grafting. 
 
 LECTURB XXIX. 
 
 IIS'FLUENCE OF CONSTITUTIONAL CONDITIONS UPON 
 
 INJURIES. 
 
 The subject which \\e will now discuss is one of great ircport- 
 ance, and is generally not included in text-books. It is the sub- 
 ject of considering the general health of a patient, which should 
 influence you in deciding to operate and its influence in the conva- 
 lescent stage after the operation. Sir James Padgett says that be- 
 fore performing the most trivial operation, you should first consider 
 the danger to v^our patient and should examine him at least as care- 
 fully as you would for life insurance, where only a few thousand 
 dollars are involvled, whereas in the former case there is a life at 
 stake. The importance of this subject is aptly illustrated by the 
 common remark often of late noticed in the newspapers in writing 
 up a death notice of a man w^ho has been operated on, it is stated 
 very satirically that the "operation was a success, but the patient 
 died." It is true that some patients do not die from the opera- 
 tion, for that in its technique was a success, but they die fi-om some 
 constitutional condition, some accompanying but unnoticed trouble 
 which crops out and kills the patients after a successful operation. 
 There are, of course, some operations of such necessity that you 
 are justifiable in not considering the patient's health, such as 
 strangulated hernia, progressive gangrene, etc., but there are 
 others, such as decorating surgery, such as removing a deformity 
 or dissecticg out a scar, of which little thought is given, and just 
 ouch operations are sonietimes attended by serious consequences, 
 all from the lack of cousidering the patient's general health before 
 
PRINCIPLES OP SURGERY. 131 
 
 operating. So before operating the following conditions should be 
 looked into: 
 
 Age. — Children under five years of age stand surgery badly. 
 This statement is the conclusion of many surgeons of long experi- 
 ence. They stand shock badly, have little resisting power to loss 
 of blood, can't be kept quiet and stand anaesthesia badly. So 
 avoid operating on a child if possible. A person between five and 
 fifteen is the best patient a surgeon can have. They stand shock 
 well, their organs are in good working order and free frona func- 
 tional diseases, their mind is in a tranquil state, being not worried 
 about business or the future. From fifteen to forty the danger 
 increases, and from forty to seventy it rapidly increases, as the 
 patients are depressed, anxious in regard to the future, their or- 
 gans are diseased, and everything looks gloomy. Old people may 
 be divided, however, into four classes. The first class are those 
 who are fat, pale and flabby, they are lazy and indolent, witti a 
 weak pulse; this class is a poor one for surgery aod can't stand 
 much operative interferences. The second class are those who are 
 fat, hard}^ and vigorous. They sleep well, eat hardily and take 
 plenty of exercise, they are ruddy, strong and healthy; these 
 people are better by far for surgical workthau the first class. The 
 third class are those who are dried up, Aviry, tough, vigorous and 
 are active busy bodies; these take surgery best ot an}^ class of old 
 peoole. The fourth class are those who are dried up, shriveled, 
 becrippled "en toto," who have a weak pulse, a bad digestion and 
 are anemic; this is the vvorst class of all for surgery. In opera- 
 ting on an old person, do as little cutting as possible, guard against 
 loss of blood and shock, keep him wslyio. and, above all, do not 
 feed him too mach, they can't stand as much food as the young. 
 
 Sex. — As a general rule women stand surgery better than men. 
 This is because women ace not as liable to constitutional diseases 
 as men, such as syphilis; they do not indulge so much in alcoholic 
 drinks and are not su restless, they are used to being housed up. 
 ISTever operate on women during the menstrual period, unless actu- 
 ally necessary, f^r from some unaccountable cause there will be 
 fever and irritability. Never operate on pregnant wore en, unless 
 there is a large ovarian tumor or a hernia, for fear of the compli- 
 cation of abortion. It is also best not to operate during lactation, 
 
132 PRINCIPLES OF SURGERY. 
 
 although the patients usually do well. Under no circumstances 
 must you operate on the mamma during lactation, as hemorrhage 
 ■will be se\'ere, hard to stop and sinuses will be opened up through 
 which milk will escape and thus retard healing. 
 
 YiGOE AND Weakness. — It is not the strong, robust man that 
 makes the best patient. They may look ruddy and say they have 
 the constitution of an ox, but their convalescence is not as satis- 
 factory as the pale, weak patient. This is because a man used to 
 hard work, gross food and outdoor life, v^hen operated on, the 
 change of life, dread of the fulure and shock often kills him. 
 "While a pale, weak man, who has been lying in the hospital for 
 months and looks on the operation as the only means of saving his 
 life, will do well and make a speedy recovery. 
 
 OsEsriY AND Plethoka. — Obesiiy is a bad complication. Some- 
 times a fat man will make a good patient, provided he is 3^oung 
 and the fat is hereditary. But when seen in a man over forty, it 
 is due to laziness and he will be a hard patient to manage. He is 
 an elephant on your hands, can^t be shifted on the bed, can't be 
 kept clean and bed sores will form. When an incision is made 
 through the skin of a fat man, it will be found thin from pressure; 
 you can't approximate the wound, you can't get compression and 
 the fatty tissue is liable to break down and become necrotic. 
 Plethora is not a contraindication to surgery. They generally do 
 well, unless the plethora be from organic disease. Do not get a 
 plethoric individual mixed with a man like a beer wagon driver or 
 an inn keeper, whose full bloodedness is clue to organic disease 
 caused by alcohol; these people are horrible subjects. 
 
 Alcoholism.— A patient addicted to alcohol is the worse subject 
 a surgeon has to deal with; there can be no complication as bad. 
 J^ever operate on a habitual arunkard, unless actually necessary, as 
 for appendicitis or hernia. The operation on such subjects is 
 usually followed by delirium tremens and results fatally. Opium 
 is almost as great a barrier to surgery as alcohol. The}" are in the 
 habit of quieting their nerves by opium, and after the operation 
 are compelled to have it and in larger doses. It locks up the 
 bowels and does great harm, especially after laparotomies. 
 
 Tuberculosis. — Tubercular patients, unless the disease has at- 
 tacked the lungs or liver, do well after an operation. Tuberculo- 
 
PRINCIPLES OF SURGERY. 133 
 
 sis of a bone or gland does not indicate adversely in deciding to 
 operate; they stand ibe operating well, but the recovery is slow. 
 If you do not remove ev^ery particle of tubercular roatter, the dis- 
 ease will return before the wound heals. You can't count on a 
 cure until three months has elapsed. The operation has to be fre- 
 quently performed over. When the disease has attacked the lungs 
 or liver, you must give the case serious consideration before 
 operating, for in the case of the lungs, the anfesthetic adds to the 
 trouble, and pneumonia may follow the operation. In the case of 
 the liver or bowels, serious complications may arise, so do not 
 operate unless the life of the patient depends on it. One-fourth of 
 the phthisical patients sufPer from "fistula in ano;" they cough up 
 the sputum, it goes down the throat, through the alimentary canal 
 and produces a fistula. If a man comBs to you pale, emaciated, 
 having fever and debilitating sweats and tells you the consumption 
 is bad enough and asks you to relieve him of the pain of the fistula, 
 I believe it is your duty to operate; at the best he caa't live long, 
 and you are justifiable in making him comfortable for this short 
 while, even at the risk of his immediate death. In performing this 
 operation do it quickly, give the angesthetic to its minimum extent, 
 split open the fistula, irrigate and pack with gauze. 
 
 Syphilis. — It is commonly thought that syphilis prevents a 
 wound from healings but my experience, having operated time and 
 time again in the acate stage, teaches me that this is not so, the 
 wounds heal well. It is not a very agreeable job, for there is dan- 
 ger of the surgeon contracting the disease, but the wound made 
 heals kindly, aud as far as the patient is concerned he is not 
 worsted, but many surgeons to-day are suffering from syphilis 
 contracted while operating on S3^philitic patients. 
 
 Eheumatism a^'d Gout. — ISTeither of these diseases retard the 
 healing of wounds. A man suffering from either makes a good 
 subject, but it is best not to add the pain of an operation to the 
 pain of an acute attack of rheumatism, you should postpone the 
 operation if possible. Often when there is a tendency to these 
 diseases, an operation will precipitate an attack, so don't be sur- 
 prised when this happens. 
 
 Caxcer, — A patient suffering from a cancer makes a good sub- 
 ject; the wound heals readily. Cancer is not inoculable, so there 
 is no danger from cutting yourself while operating. 
 
134 PRI^'CIPLES OF SURGERY. 
 
 Anemia. — This coDclition. should be corrected if possible before 
 operating, by the administration of tonics, iron, etc. If the ane- 
 mia is due to hemorrhage, as from a fibroid tumor or menorrhagia, 
 don't v^ait for medicines. In the case of the tumor remove it at 
 once. 
 
 Leuoocythemia. — This disease absolutely prohibits any surgical 
 interference. Out of one hundred cases ^here Splenectomy was 
 performed for this disease, all died. 
 
 Hemophilia. -This is a constitutional disease, characterized by 
 the individual bleeding enormously from trivial injuries. Never 
 operate on these individuals if possible to avoid it. Sometimes 
 they \Yill fool you; they may have bled profusely on several occa- 
 sions, and their ancestors ha\e died from the disease; yet ^ lien 
 operated on they do well and bleed very little. 
 
 Malaria. — This disease has a curious influence upon results. 
 ]^ot only does malaria influence the wound, but the wound influ- 
 ences malaria. A patient suffering from chills and fever is made 
 much worse by an operation; or if a patient had chills and fever 
 fifteen years before, on operating upon him, the chills and fever 
 will return and in much more serious form. A man may have lived 
 in a malarial district, but never was afl'ecled ^vith the disease, or may 
 have lived elsewhere for years, but v^hen operated on it will break 
 out, the germs having been lurking in his system ever since he lived 
 in the malarial district. There is often periodical trouble from a 
 wound due to malaria; the wound will bleed every other day, rea- 
 dens every other day and suppurates every fourth, seventh or 
 t~Yenty-first day. Give quinine and these symptoms wiU disappear. 
 
 Acute Diseases. — Never operate during acute disease, such as 
 the Lagrippe. scarlet fe^er, mumps, chicken pox, etc., unless actu- 
 ally necessary to save life. 
 
 Affections of the NEEvors System. — There are certain types of 
 individuals who comes to the doctors offlce that he can size up, he 
 has a nervous tremor, timid and effiminate; he discusses the opera- 
 tion with terror add horror. Don't think he will make a bad sub- 
 ject, after the operation he makes the bravest and most hopeful 
 patient and soon recovers. The ^orst patients are the morose and 
 sullen; no matter what encouragement you give them, and bright 
 accounts of the operation, she will sigh and say, "I am ready to 
 
PRINCIPLES OF SURGERY. 135 
 
 go when the Lord calls rae." Get the coufidence of your patients, 
 never attend a case over twice without having gained some influ- 
 ence over the patient; if you can't do it by winning their affec- 
 tions, make them afraid of you. Insane people make good sub- 
 jects, unless they are dirty in their habits and uncontrollable. A 
 patient who has teen to an asylum, kept clean, had good food and 
 deprived of alcohol, makes a splendid subject for operative 
 measures. 
 
 DiAnETES.- —This is a disease characterized by sugar in the urine. 
 How or why it is there we do not know; some observers claim it 
 is caused by irritation of the medulla, others say it is due to dis- 
 ease of the liver. However this may be, we do know that a 
 wound made on a patient suffering from the disease \vill not heal, 
 but is liable to slough or become gangrenous. Examine the urine 
 every time before operating, and if sugar is found, don't operate, 
 unless the urgenc}'- is so great that the risk is justifiable. 
 
 YiscERAE Diseases. — Every patient that comes t) you will have 
 a weak heart and can't take chloroform. They all have a "Locus 
 Minoris Resistentije" in their chest. It is the people who know 
 there is nothing the matter with their heart who die from chloro- 
 form anaesthesia. I have used anesthetics in patients with almost 
 every disease of the heart without ill effect. Patients who are sup- 
 posed to be diseased to such a degree as to contraindicate chloro- 
 form stood it well and the wound heals readily. In phlebitis, 
 artheromatous or calcareous degeneration of the vessels, the result 
 is markedly influenced; there is always danger of secondary heraor- 
 rliage and the flaps may become gangrenous from improper nutri- 
 tion. In diseases of the respiratory tract, such as bronchitis or 
 pneumonia, chloroform should be carefully given if at all. Diseases 
 of the stomach and alimentary canal often complicate results, the 
 patient wiil be unable to assimulate food, and convalescence will 
 be retarded. Constipation also influences results. Some diseases 
 of the liver is a bad complication, such as torpor, cirrhosis, fatty 
 and lardaceous degeneration. Diseases of the kianey, such as 
 Bright's disease and surgical kidney, is a positive barrier against 
 surgerv, other than pressing operations to save life. Albumen in 
 the urine is a barrier, the wound will heal well, but the patient 
 will die from uremic poison. 
 
136 PRINCIPLES OF SURGERY. 
 
 LECTURE XXX, 
 
 ANTHE AX— H Y DKOPHOB [A. 
 
 Anthrax, Malignant Pustules, or Wool Sorters Disease, is an 
 acute, infectious disease, due to the inoculation of a specific mi- 
 crobe. It is characterized by local inflammation and afterwards by 
 general infection of the \^!hole body, and usually results in death. 
 This disease is particularl}'' interesting, because of its being the first 
 disease to be proven to be of microbic origin. Pollender, in 1849, 
 with the crude instruments then is use, proved it to be due to a 
 microbe and named it the Bacillus Anthracis. It is the largest 
 pathogenic germ known, being from five to ten microns in length 
 and from one to one and a quarter microns in diameter. It is a 
 rod-shaped germ, extremely hardy, grows at ordinary tempera- 
 tures, but grows test at the temperature of the body. It grows 
 in most all the medias, can be stained easily by aniline dyes, mul- 
 tiplies in the living body by direct segmentation, and when culti- 
 vated in the laboratory ic multiplies by spore formation. Anthrax 
 never occurs spontaneously in man, but occurs primarily in the 
 lower animals and from them are communicated to man. The 
 bacillus is found in low, swampy places in warm countries, and is 
 transmitted to animals by grazing the grass on these swamps. It 
 usually attacks herbivora, less so the omnivora and never attacks 
 the carnivora. The germ locates in the lips, mouth or stomach, 
 produces the disease and usually kills. The disease is transmitted 
 to man by handling the hides or meat of these animals. It is 
 usually seen in tanners, butchers and wool sorters. Anthrax may 
 be internal or external. Internal anthrax is contracted through 
 the respiratory or alimentary tract and belongs to the physician to 
 treat. External anthrax is contracted through the skin and be- 
 longs to the surgeon, this form we will now discuss. External 
 anthrax is due to infection through the skin, and as the unbroken 
 skin acts as a barrier against infection, there must be an "'mfection 
 atrium,^'' as in wool sorters a hang nail is sufficient to allow the 
 entrance of the germ. After penetrating the skin and reaching Ihe 
 
PRINCIPLES OF SURGERY. 137 
 
 deeper tissues, the germ may produce either an anthrax carbuncle 
 or anthrax o3dema, which depends on the character of the tissue 
 reached. If the tissues are firm, dense and vascular a carbuncle 
 ■^ill result. If the tissues are loose and poorly supplied with blood, 
 anthrax oedema Avill result. The pathology of both carbuncle and 
 oedema are the same, if it attacks the face anthrax carbuncle a\ ill 
 lesult; if it attacks the forearm or back, anthrax oedema will re- 
 sult. 
 
 Symptoms. —The symptoms of anthrax carbuncle usually comes 
 on in from six to twenty-four hours after inoculation. There is 
 local tingling, burning, itching and redness, with the formation of 
 a blister, which is filled with serum, it soon becomes black and 
 bursts, exposing a small spot of devitilized tissue, which continues 
 to grow, and in a few hours is as large as a dollar. This is sur- 
 rounded by a hard, inflammatory base. The disease gradually ex- 
 tends into the neighboring tissue, and septic phlebitis or lymphan- 
 gitis may result. The pulse is rapid, skin cold and clammy and 
 there are general symptoms of septic intoxication. The symp- 
 toms in anthrax oedema are not so well marked or so easily 
 differentiated from other troubles. There is localized tino^lino;, 
 smarting and redness, the swelling and oedema then rapidly spreads 
 in all directions. The tissues are infiltrated with bloody serum 
 and death usualh results. 
 
 Diagnosis. — The diagnosis is based on the history, the fact of 
 working in a tannery or as a butcher or a wool sorter. The rr icro- 
 scope gives a positive diagnosis. The disease can be differentiated 
 'from the ordinary carbuncle, by the fact that an ordi-nary suppu- 
 rating carbuncle is nothing but a mass of furuncles and each dis- 
 charges from a separate opening, ^'^hereas in anthrax carbuncle 
 there is a single opening, and it has a characteristic gangrenous 
 scar beneath. 
 
 Pkogxosis. — The prognosis is very grave. It is based on the 
 location, character of the trouble and on the constitution of the 
 patient. The carbiincular variety gives a better prognosis than 
 the oedematous variety. 
 
 Treatment. — The local treatment is the most important. Pa- 
 renchymatous injections of carbolic acid is recommended, thoroughly 
 saturate the tissues, using a o or 10 per cent, solution. Introduce 
 
138 PRINCIPLES OF SURGERY. 
 
 the needle about a quarter of an inch from the diseased tissue and 
 make numerous punctures all around the wound. If there is no 
 improvement in six hours, repeat (he operation. Guard against 
 poisonino- the patient with the acid. If this treatment does no 
 good, apply a tourniquet, render the part clean aud excise the dis- 
 eased tissue, irrigate with a bi-chloride solutioa, cauterize the 
 wouad and pack with iodoform; dress the wound daily. Remem- 
 ber that death threatens from depression, and give stimulants and 
 good nutritious food. 
 
 HYDROPHOBIA, Rabies, Canine Madness or Lyssa are terms 
 used to designate an infectious disease caused Ly the bite of a 
 rabid animal. The essential cause is not known, several germs 
 have been found associated with the disease, but none of them 
 have been proven to cause the disease. We do know, however, 
 that the poison comes from the salivary glands of animals belong- 
 ing to the canine tribe, dogs, cats, wolves and foxes. 
 
 Hydeophobia in Dogs. — The term hydrophobia, when applied to 
 the disease in dogs, is a misnomer. The word means a dread of 
 water, and a dog suffering from the disease is not afraid of water, 
 but drinks hardily in the first stage and even in the last stages at- 
 tempts to swallow water when given tohinc. The old test of plac- 
 ing a bucket of water before the dog and if he refuses to drink, to 
 pronounce him mad, is no good. The proper name is rabies. 
 
 Symptoms.- The symptoms are in three stagei: First, premoni- 
 tor}'; second, irritability; third, paralj^sis. I do not believe rabies 
 can originate in a dog spontaneously , he must be bitten by a dog 
 or other animal suffering from the disease. After having been 
 bitten, a variable period of incubation elapses, which may be froro 
 ten days to six months; the usual period is about four weeks. A 
 dog having been bitten about four weeks before, the woand having 
 perfectly healed, the dog becomes morose and sullen. His v\hole 
 nature is changed, the former like for his master is changed to 
 dislike, when called' to his meals, he refuses to come, sulks behind 
 the house and v\ hen caught snaps at you ; again , the dog may become 
 more extravagant in his affections, and if you have a sore on your 
 hand you are liable to be inoculatea by his licking you; these are 
 the prodromal symptoms. After three or four days the irritative 
 stage comes on. The dog is taken with a desire to roam about, an 
 
PRINCIPLES OF SURGERY. 139 
 
 irresistible impulse makes him travel. His bead and tail is 
 drooped, eyes extremely red. and if another dog crosses his path 
 there will be a fight. He makes no attempt to bite a man when 
 he meets him unless the man trys to stop him. If he is put in a 
 cage he will bite the iron rods in his frenzy. Soon this stage 
 passes off and the stage of paralysis comes on. His hmd legs be- 
 come paralyzed, he is worn out from ^a ant of food and from long 
 travel, and curls up in a fence corner and dies. This generally 
 takes place in from four days to two v\eeks. 
 
 Hydrophobia in Man. — Its frequency varies, some sensible and 
 competent observers claim there is no such disease and have offered 
 large rewards for the exhibition of a case; others equally as com- 
 petent claim there is such a disease, but deny its frequency. Thirty 
 cases have been in the last year reported from the United States 
 and France. 
 
 Cause.- — The cause is the bite of a rabid animal. 
 
 Symptoms. — A man having been bitten by a dog, is in a state of 
 terror for a week or more, but as time defaces the accident he 
 thinks no more about it. In about six weeks, which is the usual 
 period of incubation, although it has been known to be as long as 
 eleven months, the prodromal symptoms appear. There is pain 
 about the old wound, which has healed, but now becomes red and 
 throbbing. He is irritable, cross, depressed, has forebodings of 
 evil and says he is going to die. After a few days more active 
 symptoms develop, there is a constricted feeling about the throat, 
 he is unable to swallow and although suffering from intense thirst 
 he dreads water; if a glass of \^ater is handed him he will attempt 
 to drink it and will be almost thrown into convulsion and will re- 
 fuse it thereafter. There is oppression about the chest, the respira- 
 tion is interfered with, not as in tetanus by rigidity of the pectoral 
 muscles, but by spasms, and constriction of the glottis. The most 
 horrible symptom is the terror of the patient, the despair and hope- 
 lessness is appalling to the doctor. Nothing yo'u can say gives hina 
 any comfort or removes the depression. The temperature runs up 
 to lUl-103-lOG degrees F. , pulse rapid and feeble. Kature is not 
 as merciful in this disease as in others, his brain remains clear to 
 the last and he suffers horribly. Death invariabl3^ occurs m from 
 four to seven days from the pain, starvation and depression of the 
 
140 PRINCIPLES OF SURGERY. 
 
 heart. You ba've no doubt heard that a man with hydrophobia 
 simulates a dog, it is unfounded, the i^-enom which produces the 
 trouble has no power of changing a n^an into a dog. The patient 
 does make a noise like the bark of a dog, but it is caused by his 
 efforts to expel mucous from his throat. And the intense pain 
 causes him to throw himself from the bed and roll on the floor. 
 
 Diagnosis, — The diagnosis is based on the history. The fact of 
 having been bitten by a dog, and the chracteristic throat symptoms 
 makes the diagnosis clear. It can be differentiated from tetanus 
 by the fact that the jaws are not locked, and from the respirations 
 being interfered with, not as in tetanus by spasms of the pectoral 
 muscles and diaphragm, but by spasms of the glottis. 
 
 Prognosis. — The prognosis depends on the stage you see the 
 patient in. If he has just been bitten by heroic treatment there is 
 a chance of recovery, but if the disease has already made its ap- 
 pearance, he wall die regardless of treatment. 
 
 Teeatment. — The prophylactic treatment is the only treatment 
 wbich gives any hope. Some individuals escape hydrophobia when 
 bitten by rabid animals, this is explained by their being bitten 
 through their clothes, and the virus is wij)ed off by them, but it is 
 your duty to treat the v\ound heroically under all circumstances 
 and risk nothing to chance. Apph^ a tourniquet as quickly as 
 possible, split the wound wide open, either remove the virus by 
 •sucking it or with the cupping glass, cauterize the wound, using 
 the actual cautery (never use nitrate of silver, as it does net pene- 
 trate deep enough), use the therm o-cautery, a red hot iron or pure 
 nitric acid. After devoting your first attention to the patient, 
 look for the dog. When you find him don't kill him, put him in 
 a cage and v/ait for developn ents, he may have worms aod will 
 simulate rabies, but will recover in a few days; but if the dog dies 
 w^lth all the symptoms of rabies, send your patient to Pasteur's 
 Institute for treatment by his serum at once. The mode of pre- 
 paration of this serum has been explained. Tbe success of this 
 treatment is without doubt. If you do not see the patient until 
 the disease has fully developed, don"t teli him he has hydrophobia, 
 he has troubles enough of his own, put him in bed and adrcinister 
 morphine and chloroform until death relieves him of his sufferings. 
 
PRINCIPLES OF SURGERY. 141 
 
 LECTURE XXXI, 
 
 GLANDERS— ACTINOMYCOSIS. 
 
 Glanders, Farcy or Eqtjinia is a constitutionai disease due to 
 the infection of the bacillus mallei. The disease never primarily 
 affects man, but is transmitted to him secondarily from animals. 
 
 Cause. — The essential cause is a germ known as the Bacillus 
 Mallei. It is a rod-shaped bacillus, m length about two-thirds the 
 diameter of a red corpuscle and about one-third its diameter in 
 breadth. It is about the size of the bacillus tuberculosis, it is im- 
 mobile, multiplies by spore formation, grows in most of the com- 
 mon culture medias, develops best at about the temperature of the 
 body, stains readily with aniline dyes and is very resisting to 
 germicides and heat. 
 
 Pathology. — A horse, when he acquires glanders, has the ap- 
 pearance of having a bad cold. His temperature per rectum will 
 be from a 108-109 degrees F., he is restless, irritable, coughs, dis- 
 charges flow from the nose, nostrils are swollen and their mucous 
 membranes are purplish in color. In a sh^rt while the mucous 
 membrane becomes spotted with red punctiform points, which 
 increase in size aad finally ruptures and pours out a nasty, fetid dis- 
 charge. If this discharge comes in contact Vvitli the broken skin 
 of man, the disease is acquired and usually results fatally. It is 
 more common among grooms, hostlers and jockeys. The disease 
 cannot occur without an ^Htifection atrittm.'''' 
 
 Symptoms,. — When inoculation occurs, say in a hostler, there is 
 a period of incubation varying from two days to six weeks. After 
 this time elapses the ])rodroraal symptoms appear. There is ano- 
 rexia, nausea, headache and fever, the wound, which has not 
 healed from being contaminated by dirty bandages, is swollen, con- 
 gested and gangrenous. The bacillus produces a chronic inflam- 
 mation, which is attended by increased formation of embryonal 
 cells, these become massed together causing pressure, and an ulcer 
 is formed, which progresses rapidly; if it is on the face, its whole 
 surface becomes involved; if on the hand, the bones may even be 
 
142 PRINCIPLES OF SURGERY. 
 
 attacked. The ccnstitutional symptoms now become worse, there 
 is a severe chill, high fever, prostration, collapse and death. 
 Glanders is sometimes said to be acute or chronic. The acute 
 variety is due to a germ of great virulenc}'" acting on tissues of 
 low resisting power and is always fatal. Chronic glanders is 
 due to an attenuated germ or virus acting on tissues of high re- 
 sisting power, and there is a chance of recovery. The symptoms 
 of both varieties are the same, only differing in intensit3^ 
 
 DiAONosis. ■ — The diagnosis is based on the occupation of the 
 patient, on the symptoms and by examining the secretions under 
 the microscope and finding the bacillus mallei, makes the diagnosis 
 positive. If you are in the country where there is no microscopist, 
 you can make your diagnosis by inoculating an animal with the 
 secretions, when if the disease is glanders, the animal w ill die in 
 four days with all the symptoms of the disease. 
 
 Prognosis. — The prognosis depends on the health, vigor and 
 robustness of the patient, on the character of the attack, whether 
 acute or chronic, on your early diagnosis, your knowledge of the 
 pathology of the disease and on your treatment. 
 
 Teeatment, — ^The prophylactic treatment consist in the destruc- 
 tion of the animal infected by burning the bodv the moment the 
 disease is detected, this is to prevent the disease from attacking 
 other animals. If 3''ou bury the dead animal, when the soil is up- 
 turned the disease will break out again. Thoroughly disirfeot the 
 stable and burn all sponges, bags and buckets used about the dis- 
 eased horse. When the disease does occur in man, the local treat- 
 ment of the ulcer is the most important. Treat it as a malignant 
 grow^th. If the ulcer be small, give an anaesthetic, render the part 
 clean, make your incision an inch from the ulcer and remove it 
 bodily, disinfect the wound with a bi chloride solution or chloride 
 of Zinc, and if ycu think advisable, use the thermo-cautery ; if 
 you haven't the improved instrument, a red hot iron answers just 
 as w ell, dust with iodoform gauze and let the ^ ound heal by granu- 
 lation. Dress daily, and if other ulcers form, treat them in the 
 same manner. If the ulcer is too large for this treatment, 
 thoroughly curette it, cauterize it and dress daily. Combat the 
 constitutional symptoms by administering strychnine, whiskey and 
 plenty of nutritious, easily digested food. 
 
PRINCIPLES OF SURGERY. 143 
 
 ACriNOMYCOSIS. — Aofcinoinycosis is a contagious clisnase, 
 due to the iufectiou of the Ray futigus or Actinomyces. The ray 
 fundus is not, strictly speaking, a bacteria, it does not belong to 
 the group of Schizomycetes, but is a fission fungi or Hyphomy- 
 cetes. It is not microscopic in size, but is large enough to be seen 
 with the naked eye. The fungus or mould resembles a chestnut 
 burr, having a depression in the center, from which radiate fibres 
 which are tipped at the ends with a bulb. It is found vtherever 
 rank vegetation grows, along margins of streams where the soil is 
 alkaline, rich and moist, and from here they are transmitted to 
 animals while grazing and from them secondarily to man. The 
 disease is seen in herbivora and omnivora, but never in carnivora. 
 The germs locate in the mouth, throat and stomach of animals, 
 and when located in the mouth constitutes a disease known as 
 "Lumpy jaw." The germ is hard to cultivate, it onl}^ grows in 
 sterilized blood serum and doesn't stain with ordinary aniline dyes. 
 Any small portion of it causes the disease. It is transmitted to 
 nan by eating the meat of infected animals. 
 
 Symptoms. — When the fungus is implanted in the tissues of man, 
 w^hich usually takes place in the mouth, throat, stomach or intes- 
 tines, it produces a chronic type of inflammation. It is so chronic 
 in type that there is no fever, redness or pain. Swelling is seen, 
 which is due to the proliferation of the fixed tissue cells of the 
 part, and a tumor is formed. This tumor is usually diagnosed as 
 a sarcoma, but the microscope gives the difference. If the tumor 
 becomes infected with the pus germs (which usually happens) it 
 becomes congested, red and painful, the pus will wort its way to the 
 surface, point and discharge. After discharging its contents, the 
 condition is not improved, suppuration continues and there is a 
 constant oozing of pus. The patient becomes emaciated, depressed, 
 there is fever, night sweats, diarrhoea, etc. Amyloid degenera- 
 tion of the internal organs frequently occurs. 
 
 Diagnosis. — The diagnosis is based almost entirely on the micro- 
 scope. It is much harder to diagnose after infection by the pus 
 germ, it being taken for either a tubercular or a syphilitic abscess, 
 but the pus from actinomycosis contains yellow bodies, which can 
 be mashed between the finger, and when examined under the mic- 
 roscope shows the ray fungus. 
 
l-i-l PRINCIPLES OF SURGERY. 
 
 Prognosis. — The prognosis is about the sarrie as that for a malig- 
 nant tumor as Carcinoma or Sarcoma. If the tumor is accessible 
 to surgery, the prognosis is good, if not the patient will die. 
 
 Treatment. — The local treatment depends on the stage of the 
 disease. If you can remov^e it before the infection by the pus 
 germ, it will not return; but if suppuration has taken place, and 
 the surrounding tissues are involved, the operation is much less 
 certain to give relief. Split open the part with a long, free inci- 
 sion, gouge out the infected tissue with your finger or curette, 
 cauterize the surface with a 10 per ceut. solution of chloride of 
 Zinz, or the actual cautery, pack with gauze and dress daily. 
 Usually there will be a small piece of infected tissue left, and the 
 disease will return, operate as before, and repeat the operation 
 every time the disease reappears. Combat constitutional symptoms 
 with whiskey, strychnia nitrate, and good nutritious, easily di- 
 gested food. 
 
 LKCTURE XXXII. 
 
 TUBERCULOSIS. 
 
 TuBEECuLosis is a chronic inflammation, caused by a specific germ 
 and characterized by the formation of nodules or tubercles. This 
 disease has long occupied the attention of the scientific world. As 
 far back as 1826 Laennec advocated that it was due to a virus and 
 was contagious. Up to this time the disease was thought to be 
 hereditar^T- or miasmatic. In 1865 Vellemin took up the work of 
 Laennec and tried to demonstrate it from personal interest, but 
 during his investigations he was inoculated accidentally and finally 
 died of Phthisis; but during his life he demonstrated conclusively 
 that tuberculosis could be transmitted by inoculation. He took a 
 lung from a patient dead of tuberculosis and injected one of the 
 cheesy masses into a rabbit, in six weeks the rabbit died of tubercu- 
 lar peritonitis, he made a solution from this rabbit and injected it 
 
PRINCIPLES OF SURGERY. 145 
 
 into another, causing a tubercular abscess. The next investigator 
 was Cohnhein, in 1877. He said it was pretty theory to inoculate 
 a rabbit and find the tubercles after death; he wanted to watch 
 the process during life, and he did it in this way. He made a 
 small slit in the iris of a rabbit, implanted a siiall piece of tuber- 
 cular tissue, and watched its elfect. In one or two days the in- 
 cision had healed, and the foreign mass could be seen through the 
 transparent cornea. Soon chronic inflammation followed and in 
 two weeks, he could see numberiess miliary tubercles in the iris. 
 In spite of these researches nothing further ^ as done until 1882, 
 when Kobert Koch, the father of modern bacteriology, published 
 a papei which revolutionized the field of surgery. lie had dis- 
 covered the essential cause of the disease, which is a bacillus which 
 bears his name, '"Bacillus of Koch." He did mor^ than discover 
 the germ of the disease, as up to this time the disease was thought 
 to be confined to the lungs, but he proved that it was tuberculosis 
 and not scrofula which attacked bones, skin, glands and various 
 other tissues of the body. This paper brought conviction to the 
 most skeptical. In it he laid now his four laws in regard to a 
 germ being the cause of a disease, which ha^e already been enu- 
 merated in a pre^'ious lecture. He proved by these laws that this 
 bacillus was the cause of tuberculosis; the bacilli was invariably 
 found in tte tubercles, they could be bred from the tubercles, 
 and would cause the disease in a healthy animal when inoculated 
 into him, and when this animal died the same germ was found in 
 his tissues. 
 
 The term scrofula is a misnomer, it is a relic of ignorance, a bar- 
 barious cloak to cover ignorance of the pathology of the lesion. 
 c was formerly used to designate diseases of glands, bone, 
 ptSltoneum, etc., bat the term has been erased from all modern 
 literature. All scrofulous troubles are tubercular troubles, no mat- 
 ter where the disease is situated, in glands, bones, bell}'^ or joints. 
 Out of a hundred cases of so-called scrofula examined by Koch, he 
 found the tubercle bacillus, which he bred and with them produced 
 tuberculosis in other animals. When speaking of tuberculosis, nat- 
 urally from contact with the laity, you mean tuberculosis of lung 
 tissue, this you should avoid. It is true the lungs are more fre- 
 quently the seat of the disease, but it also attacks the brain, skin, 
 10 
 
146 PRINCIPLES OF SURGERY. 
 
 rectum, liver, bladder, etc. The importance of this dread disease 
 can't be overestimated. Fifty per cent, of all human ailments are 
 of tubercular origin, and it is said that one-seventh of the world's 
 population die of the disease. 
 
 Inoculating Experiments. — You can take anj animal and inoc- 
 ulate him with the bacillus of Koch and produce the disease. Some 
 animals are more susceptible to the disease than others, the rabbit, 
 hedge hog, mouse, etc. , are more liable to the disease than the 
 horse or goat. The dog and cat, although so common, are not 
 employed, as the disease in theni is not so well marked. You can 
 use foi inoculating experiments the sputum, lung tissue or an emul- 
 sion from tubercular glands. You can either triturate the material 
 in a mortar aod inject it irto the animal or make an aseptic incision 
 in the animal and plant a piece of diseased tissue, afterwards sutur- 
 ing the wound. In about ten days after the inoculation, the 
 symptoms develop, fever, anorexia, weakness, exhaustion and rapid 
 death. The fever is a hectic variety, which is characteristic of 
 tuberculosis, it comes on in the evening and abates in the morn- 
 ing. After death, on dissecting the animal, you will find tubercles 
 all over the organs and can from this aninsal's tissues reproduce the 
 disease in other animals. 
 
 Inoculating experiments on man, owing to the laws, can't be 
 done, though sometimes in the future, laws will be passed allowing 
 the use of criminals for this purpose. Accidental inoculations have 
 ODcured, and upon these we must base our observations. A robust, 
 healthy house girl, while cleaning the room of a phthisical patient, 
 accidentally fell while carrying out the spittoon, and a cut was in- 
 flicted on her hand. In three weeks tubercles formed, in six weeks 
 the glands became involved, and in them the characteristic bacilli 
 were found. Another case is on record where a man, while m liv- 
 ing, cut his knee, he went to the branch and was washing it, when 
 a friend passed by and loaned him his handkerchief to bind up the 
 wound. The friend was tubercular, the man w as inoculated and 
 died of tuberculosis in less than a year. The disease has been 
 transmitted by wearing earrings of tubercular patients. Lastly, it 
 is of historic record that an old Jewish Rabbi inoculated twelve 
 children in following the old Mosaic laws of circumcision. The 
 custom was to stop the bleeding by the Rabbi spitting wine on the 
 
PRINCIPLES OF SURGERY. 147 
 
 bleeding prepuce, which acted as a styptic. The old Eabbi had 
 tuberculosis, the children were inoculated, several died from the 
 disease, a fate no less desirable than the loss of the organ as the 
 rest did. 
 
 Causes. — Predisposing. — It is "well known that consumption 
 runs in families. This is not onl}^ the idea with the laity, but life 
 insurance companies refuse all risks in consumptive families. How 
 can this be accounted for? That the grandfather, the greatuncle, 
 the father, ihe father's brother, the aunt and the sister all died 
 from tuberculosis. One set of observers claim that it is the direct 
 transplantation of the germ from the mother or father to the off- 
 spring duiing conception. That a man with tuberculosis has the 
 germ in his semen; that a woman with tuberculosis has it in her 
 ovum. That the germ may lay dormant during the growth of the 
 child and develop years afterwards. They claim that the bacillus 
 from a tubercular woman can penetrate the placenta, nature's filter, 
 and inoculate the child. They have reasons for this conviction, 
 for they have taken a tubercular mother and after scrupulously 
 observing the laws of asepticity, delivered her of a dead baby, 
 immediately it was cut open and it was found to be tubercular. 
 On the other hand, their opponents have taken a pregnant guinea 
 pig and inoculated her with tuberculosis and her offsprings showed 
 no signs of the disease. It does not seem probable that the germ 
 can lay dormant for so long a time and then suddenly produce the 
 disease. Other observers claim that the germs cannot be trans- 
 mitted from mother or father to offspring, but a child from tuber- 
 cular parents has a certain w^eakness or a hereditary predisposition 
 to the disease, and if he comes in contact with the germ in after 
 years he 'contracts the disease. 
 
 Still there are a third set of scientists who claim that the above 
 theories are all bosh. That a man has either got tuberculosis or 
 he hasn't got it. The reason why consumption runs in farailiss is 
 because the children have the predisposition to the disease from 
 being born of consumptive parents, they are then raised up with 
 the germs surrounding them, having consumptive people to live 
 with, eat with, sleep with, play with, they crawl on the floor, spat 
 on by consumptives and often nurse consumptive mothers. If these 
 children were not put in such surroundings, or were isolated from 
 
148 PRINCIPLES OF SURGERY. 
 
 consumptives from the time of birth, they would not have tuber- 
 culosis. A case is on record of an old lady whose son went West 
 and located in a town where there T\'as a Sanitarium for tubercular 
 patients. He contracted the disease, came home and was nursed 
 by his mother. Three weeks after his death the mother died of 
 tuberculosis, transmitDed to her predisposed tissues by her son. 
 
 Essential. — ^The disease cannot develop without infection by the 
 bacillus of Koch. This is, with the exception of the germ of septi- 
 cemia in mice, the smallest pathogenic germ known, in length it 
 is only one-half the diameter of a red blood corpuscle, it has round 
 ends, slightly curved and may be found singly or in bunches. It 
 multiplies by spore formation, is very hardy, resisting heat and- 
 germicides markedly, it is difficult to cultivate, not growing in any 
 of the common media, but grows in sterilized blood serum and agar 
 asrar after the addition of o;lvcerine. It is characterized bv not 
 staining with the ordinary dyes; it has to be stained vvith a com- 
 bination of dyes, which must be alkaline in reaction. When 
 stained, unlike other germs, it cannot be bleached by either sul- 
 phuric or nitric acid. This makes them easily recognized. The 
 germ may enter through the respiratory, disgestive, gen i to -urinary 
 tract or skin. A phthisical patient will spit on the floor, the 
 sputum becomes dry and is scattered over the room and is taken 
 into the lungs; if the lungs are healthy there is no danger, but if 
 there is bronchitis or the lung tissue is in a lowered state of vi'ality 
 the disease will be contracted. Milk from a tubercular cow or 
 meat from a tubercular animal may cause the disease, and it is only 
 because of the acidity of the stomach that we are protected, but 
 people with a bad digestion or those who have been taking bicar- 
 bonate of soda, thus rendering the secretions of the stomach at the 
 time alkaline, are extrenaely liable to contract the disease frcm 
 tubercular meat or milk. The disease may be contracted b\^ hav- 
 ins: connection with a tubercualr woman. The unbroken skin acts 
 as a barrier against infection, but surgeons and butchers in their 
 daily work are often inoculated by cuttino; themselves. 
 
PRINCIPLES OF SURGERY. 149 
 
 TUBERCULOSIS— Continued. 
 
 Tubercle. — A. tubercle is as much the specific lesion of tubercu- 
 losis as a chancre is of syphilis. It is the result of chroiiic iaflam- 
 mation. It is a small grayish nodule, due to an aggregation of 
 cells and characterized by the fact that it contains no blood vessels. 
 
 PI iSTO LOGICAL Structure. — A tubercle is composed of epithelioid 
 cells, giant cells, leucocytes, bacilli and a reticulum. The epithe- 
 lioid cells are round or oval, twice as large as a \^hite blood cor- 
 puscle, composed of fine granular protoplasm, with two or three 
 nuclei. They are in large numbers, making up ths major portion 
 of the tubercle, Theii^ origin is a disputed question. They are 
 the result of the proliferation of the fixed cells of the part, the 
 chronic inflammation stimulates them to proliferating and these 
 cells are formed. The giant cells are a hundred times as large as 
 a white corpuscle, made up of fine granular protoplasm, with from 
 fifteen to twenty nuclei, which are jiot arranged in the center, but 
 around the periphery of the cell in the shape of a crescent or half 
 moon. Their origin is also a disputed question, but they are 
 nothing but overgrown epithelioid or eixbryonal cells, which have 
 sprung from the fixed tissue cells, but instead of multiplying and 
 dividing it apropriates its nutriment towards its own growth. The 
 leucocytes are the ordinary white blood corpuscles; their origin is 
 from the neighboring blood vessels, the chronic inflammation hav- 
 ing caused increased porosity of the blood vessels, rheir escape is 
 made easy. The bacilli of Koch is also found in the tubercle, a 
 description of which is given in the preceding lecture. The 
 tubercle is held together by a delicate framework of connective 
 tissue. This is not a newly formed tissue, but is the old connective 
 tissue of the part, simply pushed apart by the growth of the cells. 
 The arrangement of the above elements in a tubercle is into three 
 strata. When examined under the microscope the following ar- 
 rangement will be noticed from the center outw ard. We first have 
 
150 PRINCIPLES OF SURGERY. 
 
 in the center the giant cells, two or three in number, around these 
 are the epithelioia cells and next comes the layer of leucocytes; bind- 
 ing this mass together is seen the reticulum and scattered through- 
 out the tubercle will be seen the bacilli, which are usually more 
 numerous in the middle layer or epithelioid cells and some may be 
 seen perforating the giant cells. The tubercle contains no blood 
 vessels and therefore has to obtain its nutrition by absorption and 
 percolation. 
 
 Development. — ^Essential for the development of a tubercle is 
 the implantation of thd bacilli of Koch in the tissues. "When im- 
 planted they multiply and produce their characteristic toxins, w^hich 
 acting on the tissues, sets up a chronic low grade of inflammation. 
 This inflammation causes the vessels in the neighborhood to be- 
 come more porons and leucocytes escape and wander to the infected 
 point. The fixed cells are now stimulated to proliferate, and 
 epithelioid cells are formed containing one or two nuclei, they 
 form slowly at first, but soon the process rapidly increases and a 
 considerable bulb of them are formed. Some of these cells will 
 not divide and multiply like the rest, but grows very large and 
 forms giant cells with from fifteen to twenty nuclei. The connec- 
 tive tissue is being pushed asunder as the cells are formed, and thus 
 the reticulum is formea. 'Now we have a tubercle with bacilli 
 studded all through it. It is at first microscopic in size, but soon 
 becomes as large as a , millet seed, when it can be seen with the 
 naked eye, and appears grayish. Other tubercles now form, in- 
 crease in size and two or three may coalesce. Gradually the whole 
 of the surrounding tissue is attacked and becomes a solid tubercu- 
 lar mass. 
 
 Caseous Degenekation. — The tubercle, being poorly nourished, 
 dies, the centre first, this point being the longest deprived of nu- 
 trition, also the longest exposed to the action of the bacilli and 
 their toxins. We have coagulating necrosis, the mass becomes a 
 yellow, cheesy looking substance and hence the name caseous de- 
 generation. Owang to the fact that some of the tubercles are yel- 
 low and others grayish, we speak of gray or miliary tubercles and 
 yellow or caseous tubercles. 
 
 Symptoms. — When you remember that tuberculosis may attack 
 almost any portion of the body, you can readily see that, although 
 
PRINCIPLES OF SURGERY. 151 
 
 the local syraptoins in each locality resemble each other, still there 
 is a difference, and for this reason the local symptoms will be given 
 under each respective head. The general syraptoins due lo the 
 absorption into the system, the toxins of the specific germ are as 
 folloMs: Hectic fever, which is pathognomonic of tuberculosis, is 
 always present. There is exhiliration when it is at its height and 
 profound depression when absent. It is highest in the evening and 
 falls by morning. There is a gradual failing of strength, emacia- 
 tion, anorexia, night sweats, prostration, diarrhoea, collapse and 
 dearh. 
 
 Diagnosis. — The diagnosis is based on the history. If you be- 
 lieve in heredity, search his family history, see if he tvas born of 
 tubercular parents and raised in tubercular society. Secondly, the 
 diagnosis is based on the symptoms, not so much on the local as 
 the general symptoms, such as hectic fever, emaciation, etc. When 
 the diagnosis is doubtful an infalliole test is the microscope or in- 
 oculation. Send some of the sputum if the disease is situated in 
 the lungs, clip off a piece of the skin, if it is situated on the skin, 
 or if it is in a bone send some of the exuded tubercular material to 
 a microscopist for examination. Send it in a well corked bottle of 
 either alcohol or chloral hydrate. Inoculation is a still more re- 
 liable test, and can be done where you haven't the facilities for 
 microscopic examination. Introduce some of the suspected mate- 
 rial into a guinea pig or rabbit, kill it in ten days, and if the patient 
 is suffering from tuberculosis, the animal will show the character- 
 istic tubercles. This is really a more reliable test than the micro- 
 scope, and the only differential test to tell a tubercular-nodule from 
 a syphilitic nodule. 
 
 Prognosis. — The prognosis is based on the age, general health, 
 extent to which the disease has progresstd and to its accessibility 
 to surgical interferences; thus the prognosis is better in a young, 
 robust man than in an old man, without vitality and with a poor 
 digestion: it is also better if it occupies only a small area and is 
 situated on the skin, where it can be radically removed than if 
 located in the liver or lung. 
 
 Treatment, — The local treatment consist in the radical and com- 
 plete removal of the infected tissue. If this is possible do so 
 promptly, but if you can't completely remove it, never adopt half 
 
152 PRIXCIPLES OF SURGERY, 
 
 v.ay measures, let it alone. If you can radically remove it, you 
 only have to wait for recoYery, but if you only partially remoYe 
 it, you do harm ly deYitilizing the tissues whicli nature is using as 
 a defence. In the general treatment, diet is of the first impor- 
 tance. Give good, nutritious food, as beef, mutton, chicken, pota- 
 toes, milk and eggs. Give as a stimulant good old rye whiskey, 
 administered in ccld water before meals; beer and sherry is also 
 good. They should be clad in good, warm llannels, in order to be 
 able to take exercise, no matter ^hat the state of the weather be. 
 Climate markedly influences the progress of the disease, a high 
 country, with dry atmosphere, such as at Thomasville, Ga,, is the 
 best. Cold baths should be taken regularly, they tone up the sys- 
 tem and assist him in standing cold weather. Tonics of various 
 kinds should be given, as gentain. iron and nrx Yomica. Altera- 
 tives should be given, of which Guaiacol and Cod Liver oil rank 
 first. Cod Liver is not only a good alterative, but is also a 
 splendid food. Xever use emulsions, they are a delusion and a 
 snare, only containing about 10 per cent, of Cod Liver oil. Give 
 pure Norwegian oil. half an hour after meals; in this time the food 
 will haYe been digested and passed into the small intestines. Com- 
 mence with a teaspoooful and steadily increase the dose to a cable- 
 spoonful. If the stomach refuses it, ^ait a week or so and com- 
 mence it acrain. I do not believe the good effect of Cod Liver oil 
 is so much from the alterative effect of the Iodine it contains, but 
 it acts well on account of the fat it contains; pure cream is almost 
 as good, administered in quantities from a half to a C]uart daily. 
 Koch's tuberculin has almost lost its interest to the profession, but 
 about five years ago it caused c^uite a stir among as. It is a yel- 
 low fluid, of alkaline reaction, made from the bacilli gro^vn in 
 gh^cerine and the germ is afterwards killed by heat. One drop of 
 it produces marked effect, causing fever and inflammation, but its 
 curative powers are "mZ." Its discovery has led to investigation, 
 which will no doubt soon pan out a cure. 
 
PRINCIPLES OF vSt:kgep>y. 153 
 
 LKCTURE XXXI^^. 
 
 CLINICAL FORMS OF SUEGICAL TUBERCULOSIS. 
 
 Tuberculous, Cold, Chronic, Wandering and Migratory Ab- 
 scess are synonymous terms used to designate a collection of tuber- 
 cular matter in tissues. The term abscess, as tiere used, does not 
 accord vvith the definition Ol the term previously given, as they 
 do not contain pus, but it is retained because it was used before the 
 distinction and cause was discovered. It is a misnomer. 
 
 Cause. — Tubercular abscesses are always secondary manifesta- 
 tions of some tubercular lesion of long standing. They never occur 
 primarily. They are frequen<-ly seen following tuberculosis of the 
 spine (Pott's disease), hip joint disease (coxalgia) and glands. 
 Therefore to cure them, your treatment must be directed to the 
 primary focus. 
 
 Pathology.— We first have infection by the bacillus of Koch, it 
 lodges in some portion of the ecomomy, grows and multiplies and 
 sets up a chronic inflammation, with the formation of small miliary 
 tubercles. These tubercles increase in size and number, and the 
 infected area is transfered into a granular tubercular mass. As 
 these tubercles contain no blood vessels and are therefore im- 
 properly nourished, they undergo coagulating necrosis, followed by 
 caseation and liquifaction, and you have a fluid closely resembling 
 pus, but it is not pus, because it does not contain pus cocci or pus 
 cells. It is a white fluid, containing small lumps of dead tissue and 
 sometimes bone crumbs. This material is held in positioQ and 
 prevented from, being diffused into the adjacent tissue by a wall, 
 which ig nothing but the consolidaticn of granulation tissue which 
 forms beyond the infected area. When incised, it will be found to 
 be a thick, soft, bluish membrane, very vascular and thoroughly 
 infected and should therefore be removed. As the abscess gets 
 larger, the membrane stretches and grows; soon it begins to mi- 
 grate, begins to w^ander through the tissues, which is accomplished 
 by the physical law of gravity. If it commences on the neck, it 
 
154 PRINCIPLES OF SURGERY. 
 
 will travel down and point somewiiere near the clavicie; if it com- 
 mences in the back, it may travel and point in the groin. They 
 point ana break far distant from the primary focus. 
 
 Symptoms. — The cold abscess has some of the synptoms of a hot 
 abscess, but lacks others. In an ordinary or hot abscess there is 
 pain, heat, redness, swelling and fluctuation. The tubercular ab- 
 scess gives no pain, redness or heat; the only symptoms it has of 
 an ordinary abscess is swelling and fluctuation. The first symp- 
 tom which attracts j^our attention is swelling, on palpation you 
 get fluctuation, the swelling wanders, it was first high up in the 
 back, and now threatens to burst in the groin. If the swelling is 
 not attended to, it will become a dusky color, from pressure the 
 skin becomes thin and finally ruptures and the tubercular material 
 escapes. If the abscess points in the lumbar region, it is called a 
 Lumbar abscess; if it points along the course of the psoas muscle 
 it is called a Psoas abscess, and if it points in the iliac region it is 
 called a Iliac abscess; but remember that the name of the region 
 in which the abscess is located gives no indication where the prim- 
 ary focus is. 
 
 Diagnosis, — The diagnosis is based on the history, as if a man 
 with Pott's disease, who has a fluctuating swelling on his back, or 
 with hip disease, showing a swelling near the knee, upon the en- 
 largement and fluctuation coming on slowly, accompanied by 
 neither pain, heat nor redness. If the history and symptoms are 
 not confirmatory, aspirate, dra\s out the fluid and examine it for 
 the bacillus of Koch. 
 
 Prognosis. — A young, healthy adult has a greater chance of re- 
 covery than and old, enfeebled person. A small abscess gives bet- 
 ter hopes than a large one. And it is more favorable if located 
 where it is amenable to the surgeon's knife. 
 
 Treatment. — The treatment depends on the fact whether or not 
 the primary focus can be radically removed. If it is in the glands 
 of the neck, it can be removed, but if it is a vertebrtS that is dis- 
 eased, other means will have to be adopted which are more pallia- 
 tive. 
 
 The radical treatment consist of making a free incision, curetting 
 the walls, following the various ramifications and removing all the 
 infected tissue. If you can do this the wound will heal by primary 
 
PRINCIPLES OF SURGERY. 155 
 
 inteation. "Where this cannot be done, as when a vertebriB is in- 
 volved, you must practice aspiration, irrigation and iodoformiza- 
 tion. If you simply incise one of these abscesses, you condemn 
 your patient to death, for no matter how carefully it is dressed, 
 sooner or later it will become infected from without by the pus 
 germ. Practice this method, which was devised about ten years 
 ago and has saved many lives. Render the skin clean, take an 
 aseptic trocar and with clean hands plunge it into the abscess, draw 
 the skin to one side and plunge it in obliquely, thus forming a 
 valve to prevent the escape of fluid when the trocar is withdra^^ n; 
 withdraw the blade of the trocar and let the material escape through 
 the canula. Tf the canula becomes plugged by the cheesy masses, 
 pull them out with an aseptic wire prepared for the purpose. 
 After the fluid has escaped, irrigate the cavity through the canula 
 with a Tincture Iodine solution, throw it into the abscess repeatedly 
 until it comes back untainted by the tubercular material; now dis- 
 solve in glycerine, olive oil or Ether enough iodoform to make a 
 10 per cent, solution (10 parts to 100 parts glycerine); as iodoform 
 is poisonous, only inject the first tirce one drachm of the solution, 
 and if this is well borne increase the amount. "Withdraw the 
 canula and the valve formed by the skin prevents the iodoform 
 from escaping. Manipulate the part and so difl'use the iodoform 
 into all parts of the cavity. Repeat the operation every ten days, 
 increasing the amount of iodoform solution each time until the 
 abcess disappears. While treating the abscess, build up the 
 patient's general health with good diet, tonics, stimulants and 
 plenty of outdoor exercise. 
 
 TrBERcuLosis OF THE Iris. — TMs trouble is not uncommon, but 
 is rarely seen in general practice, bsing of such a nature as to be- 
 long to the opthalmologist. 
 
 Cause.-— When the disease occurs, it is caused hj direct inocu- 
 lation, as a piece of infected filing penetrating the iris, by an 
 operation performed by a dirty surgeon, or the germ may be float- 
 ing in the blood and lodges in the iris. 
 
 Symptoms. — The symptoms are easily discernable. The nodules 
 can be seen growing through the transparent cornea. 
 
 Diagnosis is made by the character and symptoms of the disease. 
 
 Teeatmen^t. — To do an iredectomy would be absurd; the whole 
 
156 PRINCIPLES OF SURGERY. 
 
 eye must be removed. Before performing the operatioD, examine 
 the other eye and if it is diseased or he has tuberculosis in other 
 portions of the body let him alone. 
 
 TuBEKcuLosis OF THE IxTEENAL Eae. — This trouble is rare, though 
 it sometimes occurs. The germ finds a lesion in the tympanum or 
 semi-circular canals, locates and produces their baneful effect. 
 
 Symptoms. — Sometimes there is a discharge of tubercular ma- 
 terial, but this is not constant; there is pain and deafness 
 
 Diagnosis. — The diagnosis can only be made by the microscopic 
 examination of the <lischarge 
 
 Treatment. — Clean the ear thoroughly, split it open from be- 
 hind, scoop out the diseased tissue and disinfect. In performing 
 this operation thereisdanger of puncturing the mastoid cells, caus- 
 ing tuberculosis of the meninges and death. 
 
 Tuberculosis ot the Nose and Throat. — This disease is common. 
 It can be seen in any patient \vith phthisis pulmonalis if they have 
 had the disease any length of time. The mucous membrane of the 
 nose and throat becomes studded with tubercles. 
 
 Treatment. — The treatment is paliative, no radical cure being 
 possible. Cauterize the nodules and dnst with some antiseptic 
 pc w der. 
 
 Tuberculosis of the Mouth and Tongue. — This disease is fairly 
 common, and may occur by primary infection from eating infected 
 food. After localizing, the germs rapidly multiplies, forming ulcers 
 upon the tongue, tonsils, hard or soft palate. They are usually 
 flat and oval, coverod with a soft white membrane, which, when 
 brushed off, bleeds freely. It may be mistaken for syphilis or 
 cancer. 
 
 Diagnosis. — The differential diagnosis from syphilis and cancer 
 is difficult, but can be made by the use of the microscope by find- 
 ing the bacillus of Koch. They can be told from epithelioma by 
 the fact that epithelioma commences superficially and penetrates 
 deeply; tuberculosis commences deep and comes to the surface; 
 and in in epithelioma the neighboring glands soon becomes in- 
 volved, while in tuberculosis it takes a long time. It can be told 
 from syphilis by administering Iodide Potasb, and if it is syphilis 
 there will be marked incproveraent, but will have no effect if it is 
 tubercular. 
 
PRINCIPLES OF SURGERY. 157 
 
 Treatment. — The treatment coasist in as radical removernent as 
 the part allows. It is situated on the tongue, remove the organ 
 with a clean cut far from the ulcer. If the ulcer is on the hard 
 or soft palate, cauterize it with the blunt knife of the thermo-cau- 
 tery. Give detergents, mouth \^; ashes and stimulants. 
 
 LECTURE XXXV. 
 
 CLINICAL FORMS OF SURGICAL TUBERCULOSIS.— 
 
 CoNTmUED. 
 
 TuBEEcuLosis OF THE Intestines. — This is a fairly common 
 trouble, and may occur eithsr by primary or secondary infection. 
 It is due to the implantation of the germ of Koch upon the mucous 
 membrane of the intestines. If occurring primarily, the germ is 
 introduced by the food or drink, milk being a common source of 
 infection, especially in children; and if occurring secondarilv, it is 
 by extension of the disease from some other tubercular foci. 
 
 Symptoms. — The symptoms are vague and illy defined. There 
 is a feeling ol: weigbt in the abdomen, vague pains, general feeling 
 of malaise, loss of appetite, strength and flesh. There is alterna- 
 ting diarrhoea and constipation, hectic flush, rapid pulse, sweating 
 and prostration. 
 
 Treatment.— This disease properly belongs to the domains of 
 medicine, and this accounts for the number of deaths from the 
 disease. When the surgeon is called in, the bowels have generally 
 become occluded and a laparotomy has to be performed. After 
 opening the belly find the tubercular area, which is usually near 
 the ileo-caecal valve, and resect it. Many patients have been 
 treated in this manner and recovered. In performing this opera- 
 tion observe the usual aseptic precautions, make your incision, draw 
 out the gut, remove the diseased part and then either suture the 
 ends together with catgut or use a Murphy button. Intestinal 
 surgery has made rapid strides in late years. I have resected as 
 much as sixteen inches of the gut with recovery, using the Mur- 
 
158 PRINCIPLES OF SURGERY. 
 
 phy button in the operation. Theorists claim that the Murphy 
 button has seen its day and recommend the old method of suturing, 
 but not so; it is true that the Murphy "button is not without dis- 
 advantages, but scientists will soon give us a perfect device and it 
 will be on the order of the Murphy button. It is certainly the 
 best device yet invented. 
 
 TiBEEcuLosis OF THE Rectum. — This troublc is very common. 
 Three per cent, of people suffering from tuberculosis of the lungs 
 have a tubercular fistula. It is always secondary, and due to ex- 
 tension from some pre-existing focus. In a previous lecture, you 
 were advised to operate on these cases, simply to give relief. A 
 tubercular woman came to me some time siEce suffering severe 
 pain on defecation, was run dotvn in health and very much emaci- 
 ated. On examination I found the rectum studded with tubercles 
 and also a tubercular stricture. I dilated the rectum with bougies 
 and my thumbs, removed the tubercles with a spoon, irrigated the 
 rectum with an Iodine solution and removed her from the operating 
 table. I then washed out the rectum the next day with water, and 
 then an iodine solution and inserted a suppository containing 30 
 grains of iodoform, this was repeated for a while, and when I last 
 saw her, the improvement 'was renaarkable. 
 
 TuBEKcuLosis OF Tendon Sheaths, — Tuberculosis sometimes at- 
 tacks tendon sheaths, especially of the tendons at the wrist joint, 
 constituting a disease known as Tubercular tendo-synovitis. It 
 vpas long thought to be only of secondary infection, due to exten- 
 sion from some tubercular joint, but lately it has been proven to be 
 also of primary infection (brought by the blood), and extending to 
 joints or other parts unless checked. 
 
 Symptoms. — The symptoms are plam. There is a slow forming- 
 swelling along the tendons line, which is painlesiii and fluctuates. 
 It ususally commences in the flexor tendons in the palm of the 
 hand, extending beneath the annular ligament to the middle of the 
 forearm. There is a specific formation of granular tissue within 
 the tendon sheath, the sheath is separated from the tendon by a 
 yellow fluid, which contains the characteristic rice Dodies. Tbese 
 bodies are coagulated fibrin and are very infective. 
 
 Tkp:atment. — If the disease is left alone, death invariably occurs 
 from involvment of other tissues. Operative measures should be 
 
PRINCIPLES OF SURGERY. 159 
 
 prompt and thorough. Render the part bloodless with Esraarch's 
 bandage and apply a tourniquet, make the skin clean, as the wound 
 must heal by primary intention. Make a long sweeping incision, 
 exposing the whole of the tendon, allow the fluid to escape, irrigate 
 (vith a Tinct. Iodine solution, and then with a sharp spoon, curette 
 out all the infected tissue, clipping all resisting tissue with scissors, 
 scrape the tendon until you come to healthy tissue and if necessary 
 resect it. If the tendon is situated deeply, don't hesitate to sever 
 the tendons in your way, and the same must be done if the annu- 
 lar ligament keeps you from doing thorough work. After com- 
 pleting your work, suture the tendons and annular ligament, unite 
 the wound with catgut, put the arm on a splint to prevent con- 
 traction and dress with plenty of cotton. Don't remove the dress- 
 ing for two weeks, when, if your work was thorough, the wound 
 will be healed. If the joint be stiff after removing the splint, use 
 massage. 
 
 Tuberculosis of the Pekitoneum. — This disease is of frequent 
 occurrence. It is more common in women than in men. It is 
 amenable to surgery and brilliant results follow. It may be pri- 
 mary or secondary; if the former, the gem is brought by the blood; 
 if the latter (which is more usual), by extension from some other 
 tubercular foci, as from the intestines, liver or fallopian tubes. 
 The disease may be followed by two results, either ascites or watery 
 accumulation in the cavity or by plastic or solid accumulation. 
 When ascites results one or two things occur, the fluid either re- 
 mains free in the cavity, or it may become connned by adhesions 
 or an artificial wall fop it is formed. When it is free, it resembles 
 cirrhosis of the liver. When the patient la^'s on his back you get 
 a dull sound on percussion, this is because all the fluid has by 
 gravity gone backtvard and the guts protrude. When the fluid is 
 circumscribed by adhesions, the viscera and omentum become stuck 
 together and the symptoms resemble those of an ovarian tumor. 
 When the disease results in a plastic or solid accumulation, you will 
 find on cutting into the abdomen that the viscera are all glued to- 
 gether by a plastic gelatinous mass. The ascitif^. variety is curable, 
 the plastic variety is not. We will therefore only discuss the cu- 
 rable variety. 
 
 Diagnosis. — It can only be told from dropsy when the fluid is 
 free by a careful examination of each organ, by the history and by 
 
160 PRINCIPLES OF SURGERY. 
 
 introducing the trocar, obtaining some of the fluid and examining 
 it under the microscope. It is impossible to tell the circumscribed 
 Tariety from an ovarian tumor, as it usually occurs in 'v^omen, 
 grows slowly aud fluctuates od deep pressure; however, both con- 
 ditions demand operative methods, and you can tell the difference 
 after entering the belh^. The amount of fluid varies from one or 
 two pints to eight or ten gallons, it is amber colored and contains 
 rice bodies. 
 
 Tkeatment. — Open the bell}^ and let the fluid escape, when it is 
 localized by adhesions break them down. Examine the ovaries, 
 fallopian tubes, appendix, glands and omentum, and if any of them 
 are diseased, remove them. Irrigate the cavity with gallons of hot 
 water, dust with iodoform in unmeasured quantities, put in a large 
 glass drainage tube, which should extend to the bottom of the 
 cavity or "cul de sac" in front of the rectum, suture the wound 
 and instruct the nurse to empty the cavity daily; the first day there 
 may be as much as a pint of fluid, but it gradually disappears, 
 when you can remove the drainage tube. 
 
 TUBEECULOSIS OF THE SkIIn', LuPUS, LuPUS-YuLGAKIS OK ScROFULO- 
 
 DEEMA are s3"nonymous terms used to designate a disease of the 
 skin caused by the tubercle of Koch. The disease is not so com- 
 mon as might be expected from the large area exposed. 
 
 Pathological Anatomy. — The disease is most often seen on the 
 face and hands, the germ being inoculated through a crack or 
 ahrasioQ. The bacilli locates, produces their toxins which causes 
 a chronic inflammation, tubercles form and approach the surface, 
 finally from pressure the skin dinintegrates and leaves a ravs sur- 
 face exposed. Soon the wound becomes infected hy the pus germ 
 and a large ulcer forms as a result of double infection. If it is on 
 the face, other tissues become involved, and the ctieeks and nose 
 may be eaten away. 
 
 Diagnosis. — The disease is often difficult to differentiate from 
 cancer and syphilis. First try and obtain the history of the case. 
 If the family is tubercular, make a microscopic examination of 
 some product of the disease for the bacillus of Koch or inoculate a 
 guinea pig and watch the results. It can be told from syphilis by 
 the use of Iodide Potash, which markedly influences syphilis, but 
 has no effect on tuberculosis. The microscope will differentiate it 
 from cancer. 
 
PRINCIPLES OF SURGERY. 161 
 
 Peognosis. — The prognosis is unfavorable. The patient usually 
 dies of Phthisis puhnonalis. 
 
 Treatment. — Arsenic in three minim doses seems to do good, 
 administer tonics, stimulants and good food. The local treatment 
 consist in the radical removal of the diseased tissue. If it is 
 possible use the knife, cut through healthy tissue and remove the 
 diseased tissue bodily, then assist healing by skin grafting. If 
 this is not advisable, curette out all the infected tissue, dust with 
 iodoform and dress antiseptically. As fast as the nodules reappear 
 attack them with the curette or thermo-cautery. Koch's tuber- 
 culin is said to do good in this form of the disease. 
 
 LECTURK XXXVI. 
 
 CLINICAL FOPMS OF SUECICAL TUBERCULOSIS - 
 
 Continued. 
 
 Tuberculosis of the Female Genital Organs. — This disease is 
 of rare occurrence. It has only been recognized in the last fe\^ 
 years, before then it was confused with cancer and syphilis, but 
 under modern researches it \\as found to be tubercular in nature. 
 It may attack any portion vulva, vagina, uterus or fallopian tubes. 
 "When the vulva is attacked, it resembles lupus, it is nodular, un- 
 cerative and caseous and the bacillus of Koch is found in the 
 nodules on examinations. It sometimes involves the mucous mem- 
 brane of the vagina, tubercular ulcers are formed, which show the 
 characteristic bacillus on examination. TJae mucous lining of the 
 uterus may be attacked, causing tubercular endometritis, the lining 
 becomes thickened, readily bleeds and there escapes a nasty, fetid 
 discharge, ulcers form, followed by caseation. When the fallopian 
 tubes become involved, the fimbriated end becomes agglutinated 
 and hermetically sealed, the opening ioto the uterus also is closed 
 and a saucer shaped swelling is formed. 
 
 11 
 
162 PRINCIPLES OF SURGERY. 
 
 Cause. — The disease is always the result of primary inoculation, 
 it is never secondary by extension from other foci. One investi- 
 gator has taken bitches and injected the bacilli into their vagina 
 and tuberculosis resulted. ' Infection in women is also due to direct 
 contact with the germs. It is brought about by their having con- 
 nection with men having tuberculosis of the penis, or even having 
 the disease situated elsewhere, the germ being carried in the semen. 
 The disease may occur less directly, as by an operation performed 
 on these parts by a dirty surgeon using contaminated instruments 
 and sj'ringes. 
 
 Symptoms. — The symptoms depend on the anatomical seat at- 
 tacked. 
 
 Diagnosis. — The diagnosis is based on the appearance and can 
 be made positive by the microscope or by inoculation. 
 
 Prognosis.— The prognosis is good provided the disease be taken 
 in its incipiency and properh'' treated, but it is bad if the disease 
 has existed for any length of time. 
 
 Treatment. — The general treatment consist in building up the 
 patient's general health by administering tonics, strychnia. Cod 
 liver oil, guaiacol and good nutritious food. The local treatment 
 consist in the radical extirpation of the diseased tissue if possible. 
 If it is on the labia, excise it; if on the vaginal mucous membrane, 
 taKe out a section of its wall; if on the cervix, amputate it; if in- 
 volving the raucous lining of the uterus, curette it, irrigate and 
 pack with iodoform gauze or else perform a hysterectomy; if the 
 fallopian tubes are attacked, perform a laporotomy and remove 
 them. When the disease attacks the fallopian tubes, it is impos- 
 sible to diagnose it from Pyosalpiux, but both demand a laporo- 
 tomy. If in doing an operation for this disease or pyosalpinx, and 
 the tube is found so adherent as to be impossible to remove it, 
 split it open, curette it and put in drainage. 
 
 Tl'berculosis of the Male Genital Organs. — Tuberculosis of 
 the male genitals is more frequent than of the female genitals, and 
 is due to the same causes. The disease may attack the glans penis, 
 urethrae, epididymis or seminal vesicles. It is usually a variety 
 of lupus \vhen attacking the glans, it become? ulcerative and 
 caseous, and on examination the bacillus of Koch is found. AVhen 
 it involves the urethrae, it produces Tubercular urethritis; the 
 
PRINCIPLES OF SURGERY. 163 
 
 whole mucous lining becomes studded \^ith nodules. When at- 
 tacldng the epidid^^mis, it is characterized b}'- the formation of 
 hard swellings in the scrotum. The nodules are usually on one 
 side only, they increase in size, but cause no pain. If not prop- 
 erly treated, the disease will be rapidly disseminated, resulting in 
 death. When the disease attacks the seminal vesicles, it can be 
 diagnosed by the pain at the base of the bladder, sexual neurosis, 
 by the condition of the mind, and the finger placed in the rectum 
 finds them enlarged. 
 
 Pkogxosis. — The prognosis is based on the anatomical location, 
 extent and pi ogress of the disease and on the treatment applied. 
 
 Treatment. — The general treatment consist of the means heie- 
 tofore given to build up the general health. The local treatment 
 depends on the location and extent of the disease. If the disease 
 is on the glans penis, ainputate it; if the epididymis is involved, 
 resort to castration if only one testicle is involved, if both are in- 
 volved don't operate, not on account of producing impotency, but 
 because the disease has made such progress that the operation 
 would be useless. When castrating for this disease, take out all 
 the vas possible-, split open the whole inguinal canal up to the in- 
 ternal abdoininal ring, and take out all the cord possible ; don't 
 ligate the cord as a mass, for if you do you will ligate one of the 
 most sensitive nerves in the body, and the ligature will slip also, 
 causing death from hemorrhage. Ligate it in numerous sections, 
 and if it bleeds after removing the forceps, ligate again. When 
 the seminal vesciles are involved, you have a dilficult and hazard- 
 ous operation to perform. Make an incision through the perineum, 
 push the prostrate forward, the rectum backward, dissect with 
 your finger until you tincl the vescile, peel them off and ligate the 
 arteries. In performing the operation yoii are liible to produce a 
 vescial fistula. 
 
 TuBERCFLosis OF THE Bladder. — Thls is a fairly frequert trouble 
 and occurs either primarily or secondarily. It occurs primarily 
 when the germ is directly implanted in the bladder and first at- 
 tacks its surface, and is secondary when the disease extends tc the 
 bladder from a pre-existing foci, as the peritoneum or vas, and 
 this form is more hopeless. The disease occurs more frequently in 
 women than in men. 
 
164 PRINCIPLES OF SURGERY. 
 
 Symptoms. — ^The symptoms come on slowly and insidiously, and 
 at first it cannot be told from Cystitis. There is a feeling of weight 
 or heaviness in the pelvis. He complains of a burning sensation 
 and cannot long retain his urine; he can't go at first a half an hour 
 without micturating, then he has to go every ten minutes, this is 
 because of the inflamed and irritative condition of the bladder. 
 Micturition soon causes great pain and spasm of the bladder. The 
 urine at first clear, in twenty -four hours becomes cloudy from 
 mucous, which normally is just sufficient to lubricate the surface, 
 but now makes up half the urine and is stained slightly with blood. 
 
 Diagnosis. — The diagnosis is based on the family history, and 
 can only be told from cystitis by the microscope and by inoculation. 
 
 Pkognosis.— The prognosis is very grave, only a few cases being 
 curable. 
 
 Teeatment. — The general treatment should be as heretofore 
 given. The paliative treatment consist in irrigating the viscus two 
 or three times dail}^. Take an orrlinary rubber catheter, boil it 
 for three or four minutes, l^ow as to the lubricant to use, some 
 recciumend castor oil, carbolized vaseline (but it has been proven 
 that carbolic acid in grease is not antiseptic), and neither do I like 
 castor oil, use pure glycerine as a lubricant. Pass the catheter 
 gently into the bladder and allow the viscus to empty itself, now 
 fasten a fountain syringe to the catheter and irrigate with any of 
 the following, having them at a temperature of 100 degrees F. : 
 Pnre water, normal saline solution, 2 percent, solution boracicacid, 
 Thiersch's solution (which is salicylic acid tv\o parts, boracic acid 
 twelve parts and water to make a thousand), 1 per cent, solution 
 of acetate of aluminum or a 2 per cent, solution of chloral hydrate. 
 Repeat the irrigation until the solution returns clear. With the 
 progress of the disease, more radical measures must be taken ; make 
 him an artificial urethrae; to do this make a suprapubic incision 
 and allov*' it to heal, except at one point, by this meatis he can 
 urinate without pain. One experimenter is removing the bladder 
 from dogs, and he says they do well. He extirpates the bladder 
 and implants the ends of the ureters in the rectum, and he claims 
 with the exception of a slight dribbling of water in some and diar- 
 rhoea in others the dogs do well. This may in the near future be 
 applied to man. • 
 
PRINCIPLES OP SURGERY. 165 
 
 Tuberculosis of the Lymphatic Glands. — This is a very cora- 
 moa disease, so common is it that j''ou can't walk down the street 
 over ten blocks without seeing two or three cases. It is spoken of 
 by ihe laity and ignorant physicians as Scrofula and treated with 
 Iodine. They occur most frequently in the cervical glands, but 
 are sometimes seen in the glamls of the axilla. The}? give no 
 pain, but gradually enlarge and involves neighboring glands. 
 
 Causes.— The essential cause is the bacillus of Koch, directly 
 implanted in the tissues, or inherited if you believe that theory. 
 
 Patholo&y.- -A. person having eczema, a slight wound inflicted 
 while shaping or a decayed tooth, has an ' ^infection atrium.'''' The 
 germ ente'^s through one of the atriums and is carried by the blood 
 to the gland. They attack the gland, producing a chronic irflam- 
 mation, tubercles form and undergo caseation and finally the gland 
 is one solid tubercular mass, and soon other glands are involved. 
 If left to nature unchecked, one of the glands will burst and the 
 liquified tubercular material escapes into the para-glandular tissue, 
 which the germs attack and a cold abscess forms, which may irri- 
 gate and point under the clavicle. It soon ruptures and becomes 
 infected by the pus germ, which sometimes causes death in a short 
 while; again, from the virulency of the infecting pus germ , the 
 whcle mass is changed into pus and the patient is cured. 
 
 Symptoms. — The onh^ symptoms is a slow, painless enlargement 
 of a gland in the cervical region. Other glands soon become in- 
 volved and there is a chain of enlarged glands from the back of the 
 ear to the sternum. 
 
 Diagnosis. — The diagnosis is based on the history and confirmed 
 by the microscope and by inoculation. 
 
 Prognosis. — The prognosis depends oc the extent and progress 
 of the disease and on the ability of the surgeon consulted. 
 
 Treatment. — The logical thing to ao is to radically remove the 
 diseased gland. The operation is frequently performed with 
 brilliant results, but it takes a daring surgeon, one of ability, and 
 the anatomy of the neck with its large blood vessels must be 
 known. Shave the neck, render everything aseptic about the 
 operation, make an incision parallel either with the anterior or 
 posterior border of the Sterno-cleido-mastoid muscle, or make an 
 S -shaped incision, commencing at the chin. Go through the 
 
166 PRINCIPLES OF SURGERY. 
 
 Platysma Myokles muscle, and if only the superficial glands are 
 involved, you can easilj^ remove them \\it.h the handle of your 
 scalpel. If the deep glands are diseased, cut the sterno cleido- 
 mastoid muscle, reflect it, push aside the arteries, veins and nerves 
 and let an assistant hold them out of the ;vay. Ligate any artery 
 that is necessary and cut the spinal accessory nerve if you find it 
 necessary, remove the glands thoroughly or else let them alone, 
 suture the sierno-mastoid muscle, unite the skin, leaving in a 
 drainage tube, dust w ith iodoform gauze, immobilize the neck and 
 don't remove the dressings for three vveeks, unless there is fever, 
 pain or the dressings become saturated. 
 
 LECTURE XXXVII, 
 
 CLINICAL FOE MS OF SURGICAL TUBERCULOSIS— 
 
 Continued. 
 
 Tuberculosis of Bone. — This is a chronic inflammation of bones, 
 due to the specific bacillus of Koch. It is fairly common, occur- 
 ring next in frequency to tuberculosis of the lungs and lymph 
 glands. It attacks all classes of bones, but chiefly the extremity 
 of long bones, though sometimes attacking the vertebra3, carpus, 
 tarsus and bones of the skull. "When the disease attacks long 
 bones, it usually begins at the junction of the epiphysis with the 
 diathesis, this is explained by the fact that the bone is least mature 
 at this point, new cells are being formed and the blood vessels are 
 only rudimentary. 
 
 Cause, — The essential cause is the bacillus of Koch. The pre- 
 disposing cause is anything which lowers the vitality of the bone as 
 a traumatism or injury, making a point of least resistance, where 
 the germ finds suitable soil in which to localize and propagate. 
 
 Pathology. — The germ enters the blood through some 'Hnfeo- 
 tion atrium,'''' or from some pre-existing focus, and is carried to 
 some point of least resistance, which, if in bone, is usually at the 
 
PRINCIPLES OF SURGERY. 167 
 
 junction of the diathesis and epiphysis. There is chronic inflam- 
 mation set up, which stimulates the fixed cells to proliferate and 
 epithelioid and giant cells are formed, leucocytes are poured out 
 from the now porous vessels and tubercles are formed, they soon 
 undergo coagulating necrosis, caseation and liquifaclion. Slowly 
 and insidiously the focus enlarges until the periosteum is reached, 
 this is broken down and the paraperiosteal tissues become involved. 
 The process now becomes rapid, attacking fascia, muscle and con- 
 nective tissue and a tubercular abscess is formed, this, after bur- 
 rowing beneath the different structures, at last opens and dis- 
 charges through the skin 
 
 Symptoms. — The general symptoms are illy defined, and it is often 
 taken for typhoid fever. They come on insidiously and do not 
 reach a high intensity, there is a slight fever, characterized by con- 
 tinuing from day to day with slight intermission, it is of a hectic 
 type. There is emaciation, loss of strength and vigor, anorexia 
 and a peculiar progressive atiemia. The local symptoms are more 
 marked, there is pain about the part which is not acute and can 
 only be found out by questioning the patient. The pain is vari- 
 able, it is a boring, gnawing pain, and not a darting neuralgic 
 pain as in suppurative osteomyelitis; it is pathognomonic in this 
 disease for it to have nocturnal exacerbations, it is not severe enough 
 to awaken the child, but it starts with a sharp cry, grits his teeth 
 and contracts the muscles, and before the mother reaches the bed- 
 side is asleep again. The pain is not always referred to the seat 
 of the disease, as if it is seated in the upper third of the femur, 
 the pain will be referred to the kn-^e; if in a vertebree, it will 
 be referred to the stomach. Tenderness is an important feature, it 
 not only helps in locating the disease, but also tells you the extent 
 to which the disease has progressed. Swelling is a late symptom, 
 not occurring until the periosteum has beeri perforated. Eedness 
 is not present until the cold abscess approaches the skin, which 
 becomes first red then livid. Atrophy of the limb is an invariable 
 occurrence, due to non-use of the limb and to the action of toxins 
 on the trophic nerves. 
 
 Diagnosis, — The diagnosis is based on the history and symp- 
 toms. To approximate the size of the diseased area, probe with 
 an aseptic needle, when loss of resistance is felt, mark the needle, 
 
168 PRINCIPLES OF SURGERY. 
 
 push it then to the other side and mark it again, the distance be- 
 tween the marks gives the extent of the abscess. New use an 
 aspirator, remove some of the fluid and submit it to a microscopic 
 examination. 
 
 Prognosis. — The prognosis is good, provided the diseased bone is 
 accessile to surgery. Bone has great resisting power and may get 
 well spontaneously, if not radical surgery will usually eradicate the 
 disease. 
 
 Treatment. — The constitutioQal treatment is that for tuberculosis 
 in general. The local treatment consist in giving the part absolute 
 rest, putting the diseased part in a cast if necessary to accomplish 
 it. If this does no good, practice Igni puncture, take a red hot 
 iron or a thermo- cautery, have it at a white heat and plunge it 
 through the tissues into the diseased bone, itake two or three 
 punctures if necessary. This does good by giving drainage, the 
 heat kills all the germs it comes in contact with and it also stimu- 
 lates the bone to plastic regeneration. If this fails, use parenchy- 
 matous injections of Iodoform. The iodoform does not act so 
 much as an antiseptic, but it inhibits the growth of the germs. If 
 all these methods fail, you must resort to the knife, and when 
 once you commence operating never stop until you have radically 
 removed all the diseased tissue. Eender the part bloodless and 
 aseptic, cut through the soft tissues and expose the bone, chisel 
 through the bone and remove the diseased tissue with a curette, 
 first removing the sequestrium with forceps, sterilize and pack with 
 gauze or bonetchips. If after cutting down en the bone, you find 
 the disease too far progressed for the above operation, resect a por- 
 tion of the bone. Never amputate if it is possible to avoid it. 
 
 TUBEECULOSIS OF JoiNTS, AVhITE SWELLING OR ScROFULOUS JoiNTS 
 
 are terms used to designate an exceeding common tubercular^ 
 trouble involving articulationo. It is most frequently seen in the 
 knee, hip, elbow and shoulder joint, but may occur in any joint. 
 
 Cause. — The essential cause is the bacillus of Koch. The predis- 
 posing cause is some injury which lowers the vitality of the part. 
 
 Pathology. — The pathology is about the same as in tuberculosis 
 of bone. The disease is either primary synovial or primary 
 osteal; this means the germ must be implanted primarily on the 
 synovial membrane when the disease is called Primary Synovitis, 
 
PRINCIPLES OF SURGERY. 169 
 
 or be implanted primarily on the bony surfaces of the joint and 
 extend to the synovial membrane, when it is called Primary Osteal 
 Synovitis. After localization, there are the characteristic 
 changes, a chronic infiaramation, formation of ne\^ cells, formation 
 of tubercles, caseation and liquifaction. The part becomes dis- 
 tended, the capsule ruptures and a cold abscess surrounds the joint. 
 
 Symptoms. — There is hectic fe\er, loss of flesh, anorexia and pro- 
 gressive anemia. Locally there is swelling. The term white 
 swelling, although unscientific, accurately expresses the condition. 
 There is no heat or redness. Owing to the swollen condition of 
 the joint and by the muscles above and below it becoming atro- 
 phied, the joint is larger than any other portion of the limb, and 
 the limb appears spindle-shaped. The pain is variable, but has 
 the pathognomonic nocturnal exacerbations. Nature flexes the 
 joint to make room for the tubercular matter and to lessen the 
 pain, and consequently there is deformity. 
 
 Diagnosis. — The diagnosis for each joint mmst be studied, as 
 they differ, but the diagnosis for each is based on the history and 
 symptoms and by obtaining some of the fluid by aspirating and 
 subjecting it to the bacteriological and microscopic examination. 
 
 Prognosis. — The prognosis depends on the age, children giving 
 a better prognosis than adults; on the general health and on 
 whether or not the disease is con^ned to the joint. 
 
 Treatment. — Give tonics, stimulants, alteratives and good food. 
 Physiological rest is usually all that is necessary in the first stage 
 to effect a cure. Coxitis, diagnosed early and treated in this man- 
 ner, is usually cured; put the patient io bed and rest the part by 
 pulling the head of the femur out the acetabular cavity by weights, 
 aiUowing them to swing over a pulley. If this does not effect a 
 cure, aspirate and withdraw the fluid and nature usually effects a 
 cure. After the above fails, try tapping, irrigation and iodoformi- 
 zation. Eender the part clean, cocainize it, pass the trocar through 
 a flame so as to sterilize it and plunge it obliquely into the swell- 
 ing. Allow the fluid to escape through the canula, irrigate the 
 cavity with a Tinct. Iodine solution, inject about four drachms of 
 iodoform solution and seal the opening with colloidion. Eepeat 
 the operation about every three weeks, and when the swelling has 
 about subsided, place the limb in a plaster cast, so as to give the 
 
170 PRINCIPLES OF SURGERY. 
 
 joint physiological rest. If all the above methods fail to effect a 
 cure, you must resort to more radical methods. Do a resection, 
 don't hesitate to open the joint. Tlender the limb bloodless, and 
 make an incision down to the patella if it is the knee joint dis- 
 eased, sa\^ this in two, cut the lateral ligaments, and with a rat 
 tooth forceps au<l a pair of scissors remove the s3''novial mem- 
 brane. If the bone is involved, curette it; follow out all the rami- 
 fications of the disease and remove the infected tissue. When the 
 joint is opened and the disease found to have progressed too far to 
 expect to get a fairly good joint from the above operation, resect 
 the end of the bones, pin them together with bone pins and give 
 the patient a stiff joint. As a last resort to save life, amputate. 
 
 LECTURE XXXVIII. 
 
 RICKETS— HEMOPHILIA— HYSTERIA, 
 
 Rickets or Rhachitis.— This disease was discovered by the 
 English in 1850 and was called English disease. It is a constitu- 
 tional disease, characterized by distortion of the skeleton. The 
 disease is very common in Europe among the lower classes, but in 
 America where sunshine and fresh air is plentiful, where better 
 hygenic environments exipt, the disease is rarely seen, and then 
 onl}^ in negroes and poor white people. 
 
 Causes. — Heredity, improper food and bad hygenic surround- 
 ings cause the disease. Some observers claim the disease is hered- 
 itary; that it is transmitted from parent to offspring. This is not 
 so; it is true it is often seen running through a whole family, the 
 first children will be healthy, but the younger ones have rickets. 
 This is because the first children receive better food, more fresh air 
 and more clothing than the younger ones, simply because, as the 
 family grows larger, from proverty, the food and clothing gro\^ 
 worse and the house becomes more crowded, and consequently the 
 h3^gienic surroundings are not as good. The most essential cause 
 
PRINCIPLES OF SURGERY. 171 
 
 is improper food, especially when it is deficit of lime salts. This 
 has been proven by experiments on young lions, ^i hen they were 
 fed exclusively on lean meat, rickets developed; and monkeys fed 
 on skimmed milk, without lime salts, also developed the disease, 
 and were cured by feeding them on good food containing lime 
 salts. You will never see rickets in a nursing baby, because the 
 mother's milk contains the proper salts; it is seen in children fed 
 on cow's milk and artificial food. 
 
 Pathology. — The pathology merely consist of defective deposits 
 of lime salts in bones. When a child is born, its bones are soft 
 and elastic, as it grows nature deposits lime salts in them which 
 causes them to become hard and strono;. In rickets nature can't 
 do this on account of the deficiency of the salts in the blood. 
 Curves are normally found in bones, caused by muscular 
 contraction, but in rickets they are exaggerated and sometimes 
 approaches deformit}^, caused b}^ the ^\'eight of the body on the 
 soft pliable bones. 
 
 Symptoms. — The shape of the head is peculiar. It is long and 
 narrow at the forehead, sharp chin and the sternum is usually de- 
 formed, with a row of bumps running along each side of it. The 
 pelvis is deformed from the iliac bones being pushed out by the 
 mechanical weight of the body. The limbs are distorted; if the 
 child crawled at an earl}^ age, the elbows will be bent; the knees 
 are averted, due to relaxation of the joint and to pressure; the 
 digestion is poor, the stomach not having had proper food, when 
 it is given to the patient it is not digested and flatulence and diar- 
 rhoea follow. 
 
 DiAGxosis. — The diagnosis is based on the symptoms, the shape 
 of the head, bumps on the side of the sternum, arms and legs 
 bowed, diarrhoea and indigestion. 
 
 Feognosis. — The prognosis is based upon your ability to place 
 the child in better surroundings. 
 
 Tkeatmext. --Put your patient in the best possible surrounding, 
 send him to the seashore, Dse massage, hot bath, clothe in flannels 
 and give him plenty of good food and fresh air. If it is a baby 
 employ a wet nurse; if too old for this feed it on cream and milk 
 sugar, and if it is old enough feed on beef steak and vegetables. 
 Medicines do not accomplish much. Some recommend the admin- 
 
172 PRINCIPLES OF SURGERY. 
 
 istration of lime salts, but on account of their not being digested or as- 
 similated they do little good. Give tonics to build up the general 
 health, such as iron, etc., but the most Important treatment is the 
 proper hy genie surroundings and good food. This treatment does 
 not cure the existing deformity, but prevents it from becoming 
 worse, and the growth of the child may correct the primary de- 
 formity. Sometimes the deformity is so great as to demand sur- 
 gical interferences. If the child is young you can reduce the de- 
 formity by manipulating the limb with the hands until the limb is 
 straight and then applying a splint for some time. If the child 
 is too old for this and the deformity is great enough to justify it, 
 make an incision through the skin, lay bare the bone, and with 
 a chisel and mallet strike the bone a sharp blow, set it as a frac- 
 ture, put on a plaster cast and let it remain six weeks. 
 
 Hemophilia ok Bleeders Disease. — This is a constitutional dis- 
 ease, characterized by a tendency to excessive bleeding from trivial 
 causes. The disease is fairly frequent, being met with by a busy 
 surgeon about once a year. It is exceedingly dangerous to operate 
 on such patients. It is found nine times oftener in men than in 
 fvomen. 
 
 Cause.— The cause is absolutely unknown. There is no morbid 
 anatomy or characteristic symptoms, you can only tell them by 
 cutting them. The condition seems to be hereditary, some claim 
 that it is the most hereditary of all hereditary diseases. It is 
 transmitted from mother to son, this is peculiar; if a woman has 
 six children, three girls and three boys, the boys will be bleeders 
 and the girls will not, but the girls sons will be bleeders, and the 
 sons of the boys will not. 
 
 Symptoms. — There are no symptoms except bleeding on all occa- 
 sions from trivial injuries. The bleeding is not so profuse, but is 
 continuous. It is neither arterial or venous in character, but sim- 
 ply welds up from the capillaries. The inflicted individuals can't 
 be recognized, as they may be pale or ruddy. 
 
 Treatment. —Take the time and ask every patient before 
 operating on them, if he is a bleeder or if any of his family are 
 bleeders, if he answers in the afiiriiiative, don't operate. When a 
 bleeder is injured or cut, all you can do is to use styptics and 
 pressure. You can't ligate the artery, for the wound you make 
 
PRINCIPLES OF SURGERY. 173 
 
 will bleed as much as the first \^ound, neither can you use acu- 
 pressure. 
 
 HYSTERiA.--Hysteria inay be defined as an instability of the 
 nervous system, due to lack of control. It is the inability of an 
 individual to regulate the manifestations of nervous phenomena, 
 influenced by \arious stimuli. Sometimes a maximum stimulus 
 will produce little effect, again a minimum stimulus will produce a 
 Kaximum result. It is frequently met with, there will not be a 
 da}^ in your practice that your diagnosis, prognosis and treatment 
 will not be confused by it. Hysteria is really a disease, and people 
 who suSer from it deserve your sympathy and support. 
 
 Causes.- — There is no condition, race, age or sex that is free from 
 the disease, it is seen in the young and in the aged, in the intelli- 
 gent and in the fool. It is more frequent from fifteen to twenty 
 years of age, but may occur any time in life. In w^omen about 
 the time of the full development of their sexual organs, their desires 
 are not gratified and consequent neurosis, it is frequent. It is 
 more com m. on in the women than in the men, the word Hysteria 
 tells jou this. Hj'^steria was the name used by the ancients because 
 they thought it was due to some defect in the wom b. Heredity 
 can't generally be traced directly, but sometimes whole families are 
 neurotic. Diseases of the generative organs is a common cause, 
 as an inflamed ovary, endometritis, displaced uterus, hydrocele and 
 varicocele. Anemia or lack of red blood corpuscles will cause it, 
 but is readily cured by restoring the corpuscles. Dyspepsia is a 
 frequent cause. Work, worry and whiskey combined will cause 
 it, if these three conditions don't cause it, add the fourth, a wife, 
 and you have all the essentials. Work without worry will not 
 cause it. 
 
 Sy^^iptoms. — You can't classify the symptoms; sometimes they 
 appear in one way, sometimes in another; they are truly like the 
 Irishman's flea, you can't tell how they are coming. Tne psychical 
 condition is horrible. They carry everj'' action of the body through 
 an analysis, they critically examine everything they eat and can 
 describe in minutest detail its pans and constituents. They know 
 more about the alimentary canal than the doctor, having read 
 every quack pamphlet the}^ can find; they dissect with repulsive 
 boldness everj? evacuation from the bowels and describe them to 
 
174 PRINCIPLES OF SURGERY. 
 
 vou with disgusting forwardness. Their sensory organs may be 
 rendered peculiarly keen and sensative. They ca^n't stand odors, 
 a stra IV berry v/iil make then faint. Light blinds them. There 
 may be hyperasthesia or anesthesia, motor paralysis, hemiplegia, 
 paraplegia and aphonia (until you make them mad). There may 
 be unconsciousness, globus hystericus or ball in the throat, diarrhoea 
 or constipation, bladder palsy, can't hold their vsater and may pass 
 as much as a half a gallon of urine in an hour, their face may be 
 pale or flushed and the menstruation increased or diminished. 
 They sometimes simulate surgical diseases, as a hysterical knee, 
 hysterical spine or phantom tun] or. They will have some sexual 
 trouble and here your ingenuity is taxed, they imagine they have 
 some venecal disease, and will discuss it and prove to you that they 
 are right. They suffer from spermatorrhea and have been reading 
 some quack book about it and you can't tell them anything, they 
 are versed in all that pertains to the trouble. 
 
 Tkeatment. — The treatment requires tact, common sense and a 
 strong personality. Inspire the patient w ith a moral tone that may 
 overcome the uncontrollable nervous condition. Gain the confi- 
 dence and trust of your patient and use it to his cure. Drugs do 
 no good unless they smell and taste oadly, and the drugs recom- 
 mended are good only on this account. lajudicious sympathy is 
 tvhat does harm. Don't be needlessly rough, but keep on hand a 
 supply of both sympathy and roughness, and if you can't gain 
 their confidence in three days by sympathy, then make them fear 
 you. The surgical treatment consist of an operation which makes 
 a mental impression on the patient, as in a phantom tumor, give 
 them chloroform, make an incision through the skin, sew it up, 
 put them in bed and have a nurse to take their temperature every 
 twenty minutes and starve them for three days. 
 
PRINCIPLES OF SURGERY. 175 
 
 LECTURE XXXIX. 
 
 SYPHILIS. 
 
 Syphilis, Pox or Lues, is a ooDstitutioaal disease, due to a specific 
 virus and is characterized by the formation of a local ulcer, which 
 is followed by definite constitutional symptoms. The history of 
 the disease is of great interest. The first classical treatise on the 
 subject appeared in the fifteenth century. A bout this time there 
 1^ as an epidemic of the disease in Europe. By the compilers of 
 this work, the origin of syphilis in Europe was credited to America; 
 they maintained that its home was among the Indians of America, 
 and that its occurrence in the old country was brought about by 
 the return of sailors, who became inoculated on American shores, 
 but the disease has a more lengthy pedigiee. Many of the old 
 records of Leprosy ha\e been proven to have been syphilis, and a 
 more perfect and accurate reading of the ancient scrolls and manu- 
 scripts have developed the undoubted truth that the disease existed 
 in its most malignant form among the Egyptians and Chinese 3,000 
 years B. C. There are three conditions which can arise from im- 
 pure coitus, Gonorrhea, Chancroid and Chancre. Gonorrhea is a 
 suppurative infl.ammation attacking the urethrea, due to a specie 
 germ. It is entirely a local disease and yields readily to treatment. 
 Chancroid is a phagedenic ulcer, an eating sore, due to the inocu- 
 lation of a specie virus. It is entirely a local disease, and v^^hen 
 the sore is cured the patient is well. Chancre is entirely different 
 from the above. It commences as a local ulcer at the point of 
 inoculation, but the poison is soon diffused throughout the entire 
 system a ad is difficult to eradicate. In the days of John Hunter, 
 these three diseases were looked upon as one and the same, v^ere 
 treated alike and consequently many victims died from inproper 
 treatment. But John Hunter, the great surgical philosopher, 
 thought he saw a difference in the diseases. He finally, from 
 observations and experiments, stated before a society his views. 
 He was hooted at, but he said he would prove his assertions by 
 inoculating sonae of the pus of gonorrhea into his own arm. He 
 
176 PRINCIPLES OF SURGERY. 
 
 proceeded to the stage and against the protest of his friends inocu- 
 lated some of the pus into his arm, Unforluoately for John Hun- 
 ter and science, the individual from whom the pus was tal^en was 
 infected with both gonorrhea and syphilis, a chancre developed on 
 his arm and he ultimately died of sj^philis. He turned apostate 
 by this seemingly convincing evidence and said he was wrong. For 
 fifty years no one had the audacity to qnestion the matter, but 
 after that time one of John Hunter's followers, named Ricord, 
 announced that there was a difference and by careful experiments 
 proved that there was one kind of chancre which was followed by 
 constitutional symptoms andariother kind which was entirely local. 
 The first kind he called hard chancre and and the latter was called 
 soft chancre. Bassereau, the nej^t investigator, proved by experi- 
 ments that the soft chancre was not syphilis at all, but a chancroid. 
 "When syphilis was first written about in the fifteenth century, it 
 was very malignant. Charles VIII. was carrying on a campaign 
 at tne time and one-half of his soldiers died from syphilis, forcing 
 him to abandon his project. The disease was so virulent that those 
 afflicted with it only lived a year, and then their nose, cheeks and 
 ears were eaten away. But syphilis has become more and more 
 attenuated, until to-day it is comparatively harmless. Although 
 the diseasts is much less dangerous, when you inform a patient that 
 he has syphilis, he is horribly frightened from the records he has 
 read of its past malignancy. The question is frequently asked 
 wh}'^ the disease has become mild. It is because in these modern 
 times we have better hygienic surroundings, better food, clothes 
 and houses. We have better doctors, we do not salivate and not 
 only is the above true, but the disease is milder ^from being so 
 thoroughly disseminated among the people, giving us somewhat of 
 an immunity against it by an attenuated portion of the virus being 
 in our blood by inheritance. This has been demonstrated to be 
 true. In Africa the disease was unknown until the white man 
 appeared on its shores. The white man implanted it there, and 
 it worked a most deadly and malignant progress on the negroes, 
 while the white man, having it at the same time, had only a mild 
 form. The principle was also established in other diseases. Measles 
 was unknown in the Sandwich Islands until brought by mission- 
 aries, when it attacked the natives and killed nearly two-thirds of 
 
PRINCIPLES OP SURGERY. 177 
 
 them, while in this country, where the disease has raged for years, 
 death seldom occurs. All these facts go to show that an immunity 
 maybe established by inheritance. The frequency of this disease is 
 a subject I loath to discuss. As students you do not know how 
 common it is, as practitioners you will be fully impressed with its 
 prevalence. The frequency as given in text-books vary, some state 
 that in the United States one person out of every twenty has the 
 disease, while others ■ state that it is one out of every five. The 
 importance of a disease so prevalent can't be over-estimated. 
 Usually when called to a patient, your responsibility only rests 
 with the patient, but in this disease you have to look out for the 
 wives and children, and also have to decide the advisability of 
 marriage. 
 
 Cause. — Syphilis is due to a specific virus, this means it is due 
 to some vague poison which has not been discovered. The reason 
 the germ has net been isolated is because man is the only animal 
 that can be inoculated, he is- sole heir to the disease, and therefore 
 no direct investigations can be made. One observer claims he hiLS 
 produced the disease in monkeys; this is probably not so, as he 
 was working trying to prove his theory of evolution and not try- 
 ing to isolate the germ of the disease. If syphilis hasn't been 
 proven to be of microbic origin, why do I feel justifiable in saying 
 it is due to a specific germ? Because sj^philis so closely resembles 
 those diseases which have been proven to b^ due to a germ; it re- 
 sembles them in being contagious, can be transmitted from a dis- 
 eased to a h3althy person, in having a period of incubation; it is 
 accom pained by an eruption, in having a peculiar set of sequelae, 
 and lastly by one attack immunizing the individual from subse- 
 quent attacks. From this consistent chain of analogy, we say 
 syphilis is due to a germ, and the day is not far distant when it 
 will be discovered, provided our Legislature will deem ii of suffi- 
 cient importance to contribute the condemned criminals to science. 
 
 Tathology. —No two observers follow the same lines in regard 
 to the pathology, and I will take the bull by the horns and say 
 the pathology is unknown and will not be known until the germ is 
 discovered, when it can be accurately written. 
 
 Methods of Transmission. — Syphilis may be either hereditary or 
 acquired. Hereditary syphilis is due to one or both parents hav- 
 
 12 
 
178 PRINCIPLES OF SURGEP.Y. 
 
 ing the disease and from them is transmitted to their offspring. 
 This subject will be discussed in a future lecture. Acquired 
 syphilis is due to inoculation after birth. There are certain pro- 
 ducts which contain the virus. It was fornierlj thought that 
 everything about an infected person could transmit the disease, 
 tears, semen, saliva, etc. This is not true, the only products which 
 can produce the disease are the secretions from the chancre or 
 original lesion, this is the nost important and severe; the secre- 
 tions from mucous patches or small ulcers on the skin or mucous 
 membrane and lastly the blood. If any of the normal secretions 
 produce the disease, it is because the secretions from a chancre, 
 mucous patch or blood is mixed with it. As by kissing an infected 
 individual, the disease is transmitted from the secretions of the 
 ulcers in the mouth being mixed with the saliva; or if transmitted 
 from the milk of the mother to the child, it is because there is an 
 ulcer on the nipple, and if contracted from coitus, it is not due to 
 the semen containing the germ, but there is an ulcer in the urethrae 
 and its secretion becomes mixed with the semen. The use of vac- 
 cine virus obtained from the scab on a person vaccinated was 
 ttought to cause the disease, and a great uproar was raised some 
 years ago and societies were formed to prevent the use of the virus 
 obtained in this manner; further investigation proved that the dis- 
 ease was not produced from the virus, but because the scab was 
 carelessly removf^d and blood from the individual was contained in 
 it, thus causing the disease. The invention of vaccine points have 
 done away with the cranks who opposed the Qriginal method. The 
 fact that the blood of syphilitics contains the virus and is inoculable 
 is important to surgeons, for thousands cf them have contracted the 
 disease while op*^iating through a slight abrasion or by accidentally 
 cutting themselves. The virus or germ cannot enter the unbroken 
 skin or mucous membrane, there must be an ^Hnfeotion atrium^'''' 
 and wherever the lesion or abrasion occurs, and the germ enters, a 
 chancre is formed at that point; as a person having a crack on the 
 lip, hair cut on the penis, or hang nail, and the part comes in con- 
 tact with the virus, a chancre will be formed at the site of tne lesion. 
 There are two ways of inoculation by syphilis. Immediate or 
 direct infection and Mediate or indirect infection. Direct infection 
 is the most common, and is caused by an abraded surface coming 
 
PRINCIPLES OF SURGERY. 179 
 
 in contact with the blood ol: a syphilitic person or the secretions 
 froiE a chancre or mucous patch. The most frequent site of inocu- 
 lation is the penis, caused by having an abrasion on the organ, 
 which becomes infected by having connection with a sj^philitic 
 woman. Indirect infection is the innocent way and the way which 
 all claim to ha"^e acquired the disease. The virus is not conveyed 
 directly, but there is some in between media, as a drinking glass, 
 seat of a water closet, a pipe smoked by a number of persons, and 
 by catheters, towels and sponges which were not properly steril- 
 ized. However vague these stories are, there is a probability of 
 this beiao: true. There is on record an instance where an old raid- 
 wife contracted syphilis in her occupation and a chancre developed 
 on her finger. Although the disease was diagnosed, she did not 
 stop her work until arrested, when it was found out that she had 
 inoculated forty-seven women. She was imprisoned for life. 
 Another case is reported where a man who had a long prepuce, 
 met his old mistress and had connection with her. He carried the 
 hidden virus to his wife, she contracted the disease and he escaped 
 his just punishment. A similar case is reported where a married 
 woman had connection with an old lo\er, and soon afterwards she 
 had connection with her husband, she escaped, but the husband 
 bore on his body the souvenir of the lovers' meeting. 
 
 Immujv^ity.^ — Immunity to syphilis may be acquired, first, by hav- 
 ing a genuine case. This gives absolute immunity. There is on 
 record, "where individuals have had the disease twice, but doubts 
 ^ ere raised if the first attack was really a genuine case of syphilis. 
 Second, Colle's immunity. This is the immunity the mother has 
 after giving birth to a syphilitic child, fathered by a syphilitic man. 
 For instance, a syphilitic man marries a healthy woman; their 
 children will be syphilitic, but the wife will not be infected, and 
 father will be immune against the disease. Third, Profeta's im- 
 munity. This is the freedom or immunity which a person has, 
 due to their father, mother or some of their forefathers or mothers 
 having the disease. As, a man having syphilis, his child will have 
 the disease in a milder form, and his child's children will be im- 
 mune or have a stili milder form of the disease, and so on down for 
 generations, until perhaps his grandchildren v\/ill be absolutely im- 
 mune. 
 
180 PRINCIPLES OF SURGERY. 
 
 (Ilinical History of a Typical Unteeated Case of Syphilis. — 
 There are three stages of syphilis, primary, secondary and tertiary. 
 Each of the stages are preceded by a period of iocubation, so vir- 
 tual] v" there are six stages. A man has connection with a syphilitic 
 woman, and during the process abrades the head of his penis and 
 is inoculated. He goes home and sees the bleeding point, washes 
 it and in two or three days it heals and he thinks no more about 
 it. In three weeks a chancre develops at the point of the abrasion. 
 It is a hard, indurated lump, which grows and gets as large as a 
 filbert. Lines are seen running up the penis and the glands in the 
 groin are tender and sore. The period from the time of inocula- 
 tion to the formation of the primary lesion or chancre, is the 
 primary period of incubation, and from that time to the subsi- 
 dence of the above symptoms, is the primary stage of syphilis, 
 which usually last about one or two months. After the subsidence 
 of the above symptoms, the chancre and bubo disappearing, the 
 second period of incubation comes on and lasts about sis weeks. 
 After the elapse of the above time, the secondary stage appears. 
 He has little fever, is restless, disturbed, head ache, backache and 
 he thinks perhaps he has caught cold. On arising one or two 
 morrings after the above symptoms appear, he finds an eruption 
 on his chest, which looks like the eruption of measles, his throat 
 is soie, he is hoarse, and with a looi^ing glass he discovers ulcers in 
 his throat. Mucous patches form on th^ gums, in the axilla and 
 groin and from them comes a foul discharge. His eyes are red 
 and sensitive to light, his hair falls out from his head, eye lashes 
 and pubis. These symptoms now get better and the third period 
 of incubation comes on, which lasts a vfxiable length of time, when 
 the tertiary stage appears. There are deposits of gummata or 
 nodules in all the tissues of the body, upon bone tissue, in the brain 
 or spinal cord, in the heart, liver and kidneys and on the skin. 
 These deposits ulcerate and if situated on the face, they eat away 
 the cheek and nose, even exposing the teeth, nervous symptoms 
 developed, suppuration sets in, he is a disgusting object and dies 
 a slow and painful death. 
 
PRINCIPLES OF SURGERY. 181 
 
 LKCTURE XL. 
 
 SYPHILIS— CONTIND ED. 
 
 SYMPTOMS OF ACQinRED SYPHILIS.— Acquired syphilis 
 is divided into three stages, priiiiar}', secondary and tertiary. 
 Each staofe is preceded by its corresponding period of incubation. 
 
 PPJMARY SYPHILIS.— This is the stage of the chancre and 
 bubo. It has a period of incubation, that is, after inoculation or 
 after a suspicious intercourse, no symptoms develop in from two 
 to six weeks (average time three weeks). At the expiration of this 
 time there comes on definite symptoms, ^\hich result in the for- 
 mation of a chancre and bubo. A chaxcre is the primary lesion 
 of syphilis. It consist of a nodule which forms at the site of inocu- 
 lation. It is usually seen on the penis in the male and on the 
 labia in the female, but may appear anywhere, as in surgeons it 
 appears usually on the finger, that being the most frequent site of 
 inoculation. There are three varieties of chancre, superficial, deep 
 and phagedenic. Do not think this means there is a difference in 
 kind, all are due to the same specific virus, and are followed by 
 constitutional symptoms, but they differ in type and degree, due 
 to the different resisting power of the different tissues to the action 
 of the virus. The same woman may give different men any of the 
 varieties. The SuPEfiFiciAL Chancre is the most common type. 
 Out of 170 cases it occured l-IO times. It deserves its name from 
 the depth it penetrates. It appears first as a macule and then be- 
 comes a papule. Before going any further, it is better to define 
 four terrcs we shall use: A macule is a discoloration of the skin 
 which is not elevated; a papule is a discoloration of the skin which 
 is elevated; a vesicle is an elevation of the skin filled with water; 
 a pustule is an elevation on the skin filled \^ith pus. The papule 
 of a superficial chancre is solid, of a peculiar red copper color, and 
 the r.kin over it often desquamates or becomes scaly. The papule 
 develops at the point of inoculation, increases in size until it reaches 
 the size of an ammond; the skin then becomes broken, a watejy 
 discharge comes from it and an ulcer is formed. The papule has 
 
182 PRINCIPLES OF SURGERY. 
 
 a parchment like, indurated feeling when taken between the 
 fingers. The Deep or Hunterian Chancre is different from the 
 above. Tt extetids deep into the tissues, and is of rare occurrence. 
 It forms as a macule, becomes a papule, which undergoes ulcera- 
 tion, and a deep ulcer forms, with sloping margins, protrudes above 
 the surface of the skin and is bathed in a nasty pus. It is indu- 
 rated like the superficirJ chancre, but instead of feeling like parch- 
 ment, it feels like a «plit pea. The Phagedenic Chancre is noth- 
 ing but one of the preceding, which has become infected with a 
 poison which causes an eating sore. It is sometimes spoken of as 
 a migrating chancre, as it eats into the neighboring tissues, as if 
 it is situated on the penis, it w^ill extend entirely around the organ. 
 All of the above varieties of chancre are due to the same cause, 
 their difference depends on the resisting power of the tissue at- 
 tacked. The induration of a chancre is characteristic. In all in- 
 flammations there is some induration, but it gradually shades off 
 into the adjacent tissue and it is hard to tell where it stops; but 
 the induration of a chancre is different, its boundary line is well 
 denned, it stops abruptly and if once felf', you will never forget it. 
 It resembles the feel of a piece of parchment in the superficial 
 yariety and that of a split pea in the deep variety. A chancre is 
 charaterizcd by being usually single, this is because you can't have 
 syphilis but once, and the chancre is formed at the point of inocu- 
 lation; it is not auto-inoculable; that is, if you have a chancre on 
 the penis, you can't inoculate yourself from it on other portions 
 of the body, but it is hetero-inocuable; that is, it can inoculate 
 other people and a chancre tends to get well itself without treat- 
 ment, in from six weeks to two months if it is kept clean. Chan- 
 croid is not a form of pox, for it is entirely a local disease. It 
 sometimes complicates the chancre and causes it to be obscure. 
 A chancroid is auto-inoculable and areuerally plural in number. 
 There is such a thing as a mixed chancre. This is an unfortunate 
 term, as it implies a cross between the diseases, but it means the 
 individual has both diseases in the same manner as a child may 
 have whooping cough and measles at the same time, each being 
 separate diseases. In the primary stage we also have the develop- 
 ment of the Syphilitic Bubo, which is an enlargement of the 
 nearest lymphatic gland to the chancre. It may form in any 
 
PRINCIPLES OF SURGERY. 183 • 
 
 gland: if the chancre is on the penis, it forms in the groin; if the 
 chancre is on the lip, it forms in the glands below the jaw, etc. 
 The gland commences to enlarge as the chancre develops, remains 
 as long as the chancre remains and disappears with its disappear- 
 ance. The sj^philitic bubo is generally oilateral, polyglandular, 
 hard, movable and painless. 
 
 SECONDARE SYPHILIS.— The chancre of the priirary stage 
 has healed, the buboes have become smaller or disappeared, and 
 there is a rescind stage or the second period of incubation is on 
 which last about six weeks. The patient legins to think the doc- 
 tor has made a mistake, his future gets brighter and he is no l3nger 
 troubled. At the expiration of the sixth week other nanifesta- 
 tions appear, headache, backache, slight fever, anorexia and rest- 
 lessness. These symptoms last from one to two weeks and on 
 arising one morning he finds an eruption on his chest, but the 
 above symptoms have disappeared. The eruption which appears 
 is characterized by four features. I'irst, Protean type; that is, it 
 has no peculiar type, it is all mixed up, macules, papules and 
 \esicles. Second, The eruption is symmetrical, if it occurs on one 
 arm it occurs also on the other. Third, When it begins to fade it 
 leaves a peculiar dusky red copper discoloration of the skin. 
 Fourth, It does not itch. The eruption comes on suddenly and 
 fortunatelv it never appears on the face or hands and can there- 
 fore bt; hidden b} the clothing. From two days to a v^eek sore 
 throat comes on; the throat is congested and inllamed, there is 
 difficulty in swallowing and there is hoarseness. On examination 
 you will find the throat ulcerated on the upper part of the pharynx 
 and on the fauces. Mucous patches now develop. This is a most 
 disgusting symptom. They form on any portion of the body ivhere 
 the skin or mucous membrane is thin and subject to friction; in the 
 mouth, under the penis, between the fingers, in the folds of the 
 neck, rectum, etc. At first there is a little exudation beneath the 
 skin or raucous membrane, which looks like a bursa; this enlarges, 
 and the skin becomes a dusky red or copper color, it then disinte- 
 grates, leaving a raw surface from which comes a nasty discharge, 
 which coagulates on its surface, giving the patch a greenish black 
 appearance and emits a horrible odor. The lymphatic glands soon 
 become enlarged all over the body. Don't confound this enlarge- 
 
184 PRINCIPLES OF SURGERY. 
 
 ment of the glands wiih buboes, as in this stage all the glands are 
 enlarged and remain so throughout life. They enlarge slowly and 
 painlessly, and are freely movable. Alopecia or loss of hair is a 
 frequent s3"mptom, the patient becoming bald and also loses his 
 eyelashes. The eyes and ears also become affected, there may be 
 iritis, conjunctivitis, etc., or inflammation of the tympanum or 
 middle ear, causing great pain, and the disease is hard to manage. 
 TERTIARY SYPJIILIS.— The above symptoms may have ex- 
 tended over a period of twelvemonths, but with "R. S. S." and other 
 quack remedies, he thinks he has eradicated the disease. A rest 
 comes on, but after this the third period of incubation, which lasts 
 a variable length of time, the tertiary symptoms appear. This 
 stage of the disease is rarely ever reached, but if it does, the patient 
 is doomed, there is no cure for it. It is not syphilis, but the effects 
 of syphilis. It is not contagious and can't be transmitted. There 
 are depositions of gumraata or nodules in the various tissues, com- 
 posed of granulation tissue. The skin is seriously affected. There 
 is one form called Tubercular gummata, which forms on the face, 
 grows to about two inches in diameter, undergoes ulceration, the 
 cells disintegrate, the nodule breaks down and a large ulcer is 
 formed, eating away the cheek or nose. There is developed some- 
 times a sqamous trouble of the arms and hands, and scales fall 
 from the parts as from a fish. The nails become twisted and dis- 
 torted, constituting Syphilitic Onychia. The mucous membranes 
 are also affected. Gummata forms on the tongue and destroys the 
 organ; in the throat, oesophagus, colon, rectum, etc. They are 
 painless, ulcerate and are har'd to heal, and if you do heal them, 
 the contraction of the cicatrix produces stenosis, and the patient 
 "v^ill be unable to swallow if the ulcer is seated in the throat or 
 oesophagu^'. If it is in the rectum or colon, the patient may die 
 before the surgeon recognizes the trouble. The disease may in- 
 volve the solid viscera, as the heart, lungs, kidne3^s, etc. The 
 ulceration, of these organs causing death, or the contraction of the 
 cicatrix so impairing the organ that it will not be able to perform 
 its function. Xervous symptoms supervene. There are deposi- 
 tions of gummata on the brain and spinal cord, these by contrac- 
 tion impair the function of the part, causing idiocy, paralysis, loco- 
 motor ataxia, epilepsy, etc. The arterial system suffers, and the 
 
PRINCIPLES OF SURGERY. 185 
 
 trouble may be coEfounded with senile degeneration of the arteries, 
 the difference being that the latter only attacks the large arteries, 
 whilst in syphilis the small arteries are affected. In the senile 
 trouble the arterial "walls become calcareous in nature, while in 
 syphilis there is a deposit of fibrous tissue and the contraction 
 occludes the lumen of the vessel. Areolar tissue may also be the 
 seat of these deposits, which ulcerates and burst upon 
 the surface, leaving a deep ulcer. Bones and periosteum may be 
 attacked, causing periostitis, osteitis and syphilitic nodes form on 
 the subcutaneous surfaces of the tibia, ulna, radius and the cra- 
 nial bones. 
 
 LECTURE XLI, 
 
 SYPHILIS— COXTIXUED. 
 
 Hereditakt Syphilis, or syphilis due to disease of one or both 
 parents, is characterized by there being eo primary stage of the 
 chancre and bubo. The symptoms commence \^ith the secondary 
 stage. This is due to the embryo not being iroculated locally, the 
 virus being carried directly into the blood. Infantile syphilis is 
 also a term applied to hereditary syphilis. This is unfortunate, as 
 they are entirely di^erent, for infantile syphilis may be hereditary 
 or acquired. 
 
 Causes. — Hereditary syphilis may be caused by one of four 
 conditions. First. By the mother being syphilitic, the father being 
 health3% their offspring may be born in the full bloom of syphilis, 
 but it is usually of a mild type uhich is readily amenable to treat- 
 ment. A syphilitic woman will give birth to a s\^phiiitic child long 
 after she is capable of infecting her husband. Second. The mother 
 and father both being syphilitic. This is a much more frequent 
 cause and in this case the disease in the offspring is very virulent 
 and quickly terminates disastrously unless properly treated. 
 Third. The mother acquiring syphilis after impregnation. Sup- 
 
186 PRINCIPLES OF SURGERY. 
 
 pose a healthy maa and woman marry, the woman, becomes im- 
 pregnated and six months afterwards the husband acquires syphilis 
 and inoculates his wife; the child was begotten ty healthy parents, 
 but the effect of the woman acquiring syphilis is thus stated. If 
 the mother acquires the disease before the seventh month of preg- 
 nancy, the child will becoine infected, but if she acquires the dis- 
 ease after the seventh month the child will be born healthy. 
 Fourth. The father inoculating the child, without infecting the 
 mother. This seems improbable, but it is claimed by good 
 authority to be true, while others equally as eminent dispute it. 
 
 Results to the Child of Having a Stphilitic Mother may bo 
 as follows: 1. Abortion or premature birth. The products of the 
 cohabitation of syphilis is usually thrown out the wound before the 
 third month. If you have a woman who aborts time and time 
 again at or near the third month of pregnancy, treat her for syph- 
 ilis, no matter what she says, it can't do any harm, and as a gen- 
 eral thing does good. 2, Full term children born with syphilitic 
 lesions. Suppose an abortion does not occur at the end of the 
 third month and the woman goes to full term. The child in this 
 case will be born in the full bloom of syphilis, or else be born 
 healthy and develop the disease soon afterwards and in the se- 
 condary stage. In the latter event the symptoms usually develop 
 in two or three weeks, but it may be as long as a month or even a 
 year. But when the disease doesn't develop in a year's time, you 
 can safely say that the child is out of danger. If the disease de- 
 velops after a year's time, the child either had the symptoms of 
 the disease during the first year and was overlooked or else it has 
 acquired the disease from a wet nurse or by kissing a syphilitic 
 person. 
 
 Symptoms. — The general appearance of the child is striking. It 
 is shrunken and shriveled, eyes glassy, predernaturaliy bright and 
 old looking. The skin is usually covered with an eruption, which 
 is protean in charactei, distributed syrametricaliy, fades away and 
 leaves a dusky red copper discoloration and it does not itch. There 
 are mucous patches on the skin and mucous membrane, as in the 
 mouth, between the fingers and in the rectum. The throat is sore 
 and is manifested by what the old granny calls sniffles. The mu- 
 cous membrane of thfi nose is thickened, and he is unable to breathe 
 
PRINCIPLES OF SURGERY. 187 
 
 through, it, consequently he can't occlude his mouth with tbe nip- 
 ple to nurse. The hair falls out and the glands all over the body 
 become enlarged. If the child lives and the period of priiiary 
 dentition comes on, the teeth will be diseased. They will be soft 
 and crumbly-, and as soon as they come through the gums, they 
 are broken off and the child becomes snaggled toothed. With 
 these symptoms the child generally dies of marasmus despite your 
 treatment, but it may live and fight along and appear apparently 
 cured. Bui; when the second dentition comes on, characteristic 
 appearances develop. Linear lines radiate from the mouth to the 
 cheek, eye troubles develop, such as inflammation of the cornea, 
 opacity of the cornea, etc. The second teeth are called Hutchin- 
 son's teeth. The incisor teeth, espucially those of the upper jaw, 
 being wedge-shaped, broad -dl the gums and tapering down. They 
 project forward and are notched; that is, their cutting edge in- 
 stead of being straight are curved. 
 
 SYPHILIS IN G-ENERAL -Diagnosis.— As I have said be- 
 fore, this disease reposes a great responsibility on the doctor, and 
 an early and careful diagnosis should be made, as it influences the 
 w^hole life of the patient. Never deal with the disease lightly. 
 If you find out that your patient has syphilis, tell him so at once. 
 The diagnosis is largely based on the general history. If the dis- 
 ease comes under your observation in the secondary stage, it is 
 easily diagnosed, but if the disease was acquired ten years before 
 and was treated at the time, your diagnosis will not be made with 
 such ease. They seem to have forgotten all about having the dis- 
 ease and it is hard to obtain their correct history. You can't be- 
 lieve a word the}'' tell you, even though otherwise honest and reli- 
 able. You will have to use all kinds of strategy on them to get 
 the truth. If a man comes to you, and although he may be a low, 
 degraded, vile fellow and is abused and shunned by his neighbors, 
 and you find a Bot-e on his penis or some other suspicious place, 
 dou't treat him for syphilis until you make a positive diagnosis; 
 but if a man comes to you who is looked upon as a saint or a pillar 
 of a church and can pray lou<ler than any other member of the 
 congregation and shows a sore in a suspicious place, don't w^ait for 
 a positive diagnosis, put him on anti-syphilitic remedies at once, 
 as these remedies will cure one out of ten such cases. Confron- 
 
188 PRINCIPLES OF SURGERY. 
 
 tation is important in the diagnosis if it is possible to do so, as if 
 the women has a chancre she has given the man a chancre and if 
 she has a chancroid she has given him a chancroid. Inoculation 
 may be tried, but never inoculate any one else, but the man who 
 has the suspected chancre, and if it be a syphilitic sore, the inocu- 
 lation will give negative results, but if the sore be a chancroid, a 
 sore will develop at the site of the inoculation. None of these 
 tests are conclusive, as the man may have both diseases. It is im- 
 possible to make a positive diagnosis until the secondary stage. 
 Some microscopists claim they can diagnose the disease with the 
 microscope, this is exceedingly doubtful. The differential diagno- 
 sis between a chancre, a chancroid, herpes, cancer and tuberculosis 
 belongs to another department, but in regard to the difference be- 
 tween a chancre and a chancroid, I will simply give you a few 
 points I have picked up in practice. A chancre has a definite 
 period of incubation, a chancroid has not. A chancre never de- 
 velops under one or two weeks, a chancroid develops in one or two 
 days. A chancre is always single, a chancroid is always multiple. 
 A chancre is not auto-inoculabie, a chancroid is. A chancre is 
 either a superficial or a deep Huriterian sore; if superficial there is 
 no breach in the continuity of the skin and it feels like a piece of 
 parchment beneath the skin; if it is a deep Hunterian chancre it 
 has sloping margins and feels like a split pea; a chancroid has 
 sharply punched out margins and is migratory, A chancre is in- 
 durated and th3 hardness is sharply defined from the adjacent 
 tissue, stopping ver;^ abruptly, a chancroid is also slightly indu- 
 rated, but the hardness gradually slopes off into the adjacent tissues. 
 A chancre tends to heal spontaneously, a chancroid undergoes pha- 
 gedenic ulceration and spreads. A chancre is always accompanied 
 b}^ buboes, which are bilateral, polyglandular, hard, freely mov- 
 able and do not tend to suppurate, a chancroid is not usually ac- 
 companied by buboes, and if it is, the bubo is unilateral, involves 
 only one gland, it is immovable, very painful and tends to suppu- 
 rate. A chancre is always accompanied by constitutional symp- 
 toms, a chancroid is purely local and is never accompanied by con- 
 stitutional synr, ptcms. One attack of syphilis gives immunity to 
 subsequent attacks, one attack of chancroid does not give immu- 
 nity to subsequent attacks. 
 
PRINCIPLES OF SURGERY. 189 
 
 Pkognosis. — The prognosis of syphilis is good. I have already 
 stated that in forraer years the disease svas very malignant, but in 
 recent years it has become very much attenuated, and if properly 
 treated it doesn't give much trouble. If a man comes to you and 
 you suspect syphilis, give him a bottle of colored w ater, and if he has 
 syphilis he will return in six weeks with the diagnostic symptoms, 
 then if you treat him properly the symptoms will disappear in three 
 weeks, and if he continues the treatment he will be entirely cured 
 and will live to an old age and die from some other trouble. A 
 great many observers claim that Gonorrhoea killo more people than 
 syphilis. The prognosis is based on the type of the chancre, a sa- 
 perticial chancre is milder than a Hunterian chancre; on the char- 
 acter of the eruption, a macular, papular eruption gives a milder 
 case than a pustular or vesicular eruption; on the general health, 
 vigor and robustness modifies the disease and on the length of the 
 patient's purse, a man who scuffles for a living, has meals irregular 
 and badly cooked, has a harder time than a man who can afford a 
 French cook. 
 
 Syphilis and Maeeiage. — This is an important question and one 
 that will be propounded to you frequently. When a man comes 
 to you cvith syphilis, or one that you know has had syphilis a year 
 or two before and asks you the advisability of his getting married, 
 tell him he will have to postpone it. Some authors claim that a 
 man once having syphilis is never free from it and should not 
 marry, but the majority of authorities and observers dispute this 
 and claim that if a man goes Lhree years without any of the symp- 
 toms of the disease being manifested, he can marry without any 
 fears in regard to the future. So it is your duty as a doctor to see 
 that a man does not marry until three years has elapsed since the 
 last symptoms of the disease disappeared. 
 
190 PRINCIPLES OF SURGERY. 
 
 LECTURE XLII. 
 
 SYPHILIS— Continued. 
 
 Tkeatment. — The treatment of syphilis is divided into local, 
 speciiic and general. They are usually carried on at the same 
 time, but will be considered separately. 
 
 Local Treatment. — This is the treatment applied to the local 
 lesions, as chancre, bubo, mucous patch, etc., and to prevent de- 
 formity and pain. It must always be re-enforced by the specific 
 and general treatment. The local treatment of a chancre depends 
 on the variety, the superficial and Hunter ian variety requiring 
 different treatment to the phagedenic type. If a man comes to 
 you ivith a siiperficial or deep chancre, the first question that 
 arises is the advisability of cutting it out. On this question 
 authorities differ. Some claim that if it is cut out, the disease will 
 be aborted, or if symptoms do develop they v^ill be mild, while 
 other equally competent observers claim that to excise a chancre 
 does no good, constitutional symptoms always follow. My ex- 
 perience makes me belive that it is unwise to excise the sore. The 
 disease is never local, it is constitutional from the very moment 
 the lesion occurs and therefore excision can do no good. There is 
 on record a case of a man that came to the doctor six hours after 
 having connection with a s3'^philitio woman, and showed an abra- 
 sion on his penis. The wound was immediately cauterized, but in 
 three weeks a chancre developed. So, as a general rule, let the 
 chancre alone, but if the patient says he must continue sexual in- 
 tercourse or the sore is on some portion of the body where it gives 
 trouble, excise it for convenience sake and not for the abortive 
 treatment. If you want to note the difference between an untreated 
 and a treated chancre, get two patients and on one cauterize the 
 chancre with nitrate of silver and paint it with a dirty salve; leave 
 the other one alone, and the untreated chancre will get well first. 
 A patient coming to you will demand some treatment, so prescribe 
 the yellow or black wash, tell him to bathe in hot water night and 
 morning and apply the wash. When he comes again ^y°q him a 
 
PRINCIPLES OF SURGERY, 191 
 
 mild antiseptic powder to use, such as iodoform or aristoL The 
 phagedenic chancre demands prompt and heroic measures or there 
 will be disastrous results. Immediately cauterize the chancre. In 
 using a cautery in genito-urinary surgery it does not matter what 
 kind vou use, but your ability to use it. I^ever use nitrate of sil- 
 ver, it is a delusion and a snare, it is no good. Use Bromine, red 
 hot iron or fuming nitric acid. The operation can be rendered 
 painless v^ith cocaine. After cauterizing, treat the burn with an 
 antiseptic solution and dust it with some antiseptic powder. Syphi- 
 litic buboes should be let alone, as they do no harm, are painless 
 and tend to spontaneously disappear. If, however, the mental 
 condition of your patient demands it, paint them with Iodine. 
 Never order a bottle of Iodine and a camel's hair brush and let 
 the patient apply the drug, but appl}^ it yourself. Paint round 
 each gland very carefully, as if you thought too much of the drug 
 would effect disastrous results. If he comes back complaining give 
 a prescription for mercurial ointment and let him use that for a 
 while. You have to feed them on bland medicines, which really 
 do no good, but to give nature a chance. I do not teach you this 
 to make you fakirs, but it is necessary to enable you to hold your 
 patients and to keep them out of the hands of quacks. Sore throat 
 should be treated locally with gargles or sprays. Chlorate of 
 potassium, chloral, thymol, tincture of benzoin, etc., may be used 
 in solutions. If the throat is congested and contains mucous 
 patches, give him a spray containing a small amount of cocaine in 
 a boracic acid solution. Mucous patches should be wipea off with 
 some antiseptic solution, dried with a blotter and cauterized with 
 Acid Nitrate of Mercury, after this apply soixe antiseptic powder. 
 Alopecia deserves treatment. If it is insignificant, prescribe the 
 ''''Seven Sutherland Sisters' Hair ToiiiG,^"' but if it is rapidly falling 
 out, leaving patches of hair here and there, order his head shaved, 
 and then wash it night and morning with hot water and green soap 
 and apply some hair tonic. All hair tonics contain about the same 
 ingredients mixed differently. Quinine, Pilocarpine, Cantharides, 
 Glycerine, Castor Oil and Bay Rum. Iritis or inflammation of the 
 iris, if not treated, will result in either total blindness or serious im- 
 pairment of sight. The iris may even become glued to the lens. The 
 treatment consist of the unsparing use of atropia. Make a solution, 
 
192 PRINCIPLES OF SURGERY. 
 
 2 grains to the onrce of \vater, and drop two or three minims into 
 the eye three times daily. This will keep the pupil dilated, aad if 
 adhesions fcrm, the pupil being in this dilated condition, the sight 
 can be restored with the proper glasses. Use antiseptic solutions 
 freely, and use cocaine for the pain. A good mixture to meet all 
 of the above requirements can t3e ordered, consisting cf Boracic 
 acid, Cocaine and Atropine in distilled water. Hot water applied 
 to the eye frequently relieves the swelling and reduces the inflam- 
 mation. Gummata and ulcers which form in the tertiary stage do 
 Eot yield readily to treatment. You can try a salve, but they are 
 rapidly being done away with in surgery. The best salve is a mix- 
 ture of Calomel 3i to Vaseline oi. Don't delude yourself by adding 
 carbolic acid, as carbolic acid in grease is inert. If this does no 
 good, use a collodion composed of Bi-chloride of Mercury, salicylic 
 acid and collodion; paint this over the ulcer. It not oily protects 
 the ulcer, but causes the tissue it is composed of to disintegrate. 
 As a last resort, cut out the diseased tissue, making your incision 
 through healthy tissue and treat as a recent wound. 
 
 Sj>eGiJic Treatment. — This consist in cither the administration of 
 Mercury or Iodine. Mercury is an antidote for syphilis, it neu- 
 tralizes the virus, but we do not understand its action. Some ob- 
 servers claim that it is decomposed and metallic mercury is de- 
 posited, which goes through the capillaries and pushes the syphilis 
 out the back door. I believe it is due to the antiseptic properties 
 of mercury, and this is one evidence of the disease being of micro- 
 bic nature. "When should you begin mercury and when must you 
 stop it? No man living can sa}" positively that a man has syphilis 
 until the secondary stage, other diseases have almost the same set 
 of symptoms as syphilis in the primary stage, and therefore never 
 admioister mercury until the early secondary symptoms appear. 
 If you give it before this time, it is possible your patient hasn't 
 the disease, or you may so mask the secondary stage that six 
 months afterwards he appears well and you come to the conclusion 
 that your diagnosis was wrong and the treatment is stopped ; when 
 the disease appears again it is in the full bloom of tertiar}'- syphilis 
 and your patient is doomed. So when a patient comes to you, and 
 you suspect syphilis, dou't give him mercury, prescribe some bland 
 colored drug a,nd wait until he comes to you with the secondary 
 
PRINCIPLES OF SURGERY. 193 
 
 syrnptoms of syphilis, when your diagnosis is certain. Then give 
 him mercury and continue it for a year as continuously as possible. 
 ISTovv discontinue the drug and give him an occasional course of 
 the drug during the next two or three years. The preparations 
 used are Calomel, Blue Mass, Bi-chloride, Biniodide, Protoiodide, 
 Ointment and Oleate. The drug may be administered by the 
 mouth, inunction, fumigation or hypodermically. It may seem 
 foolish to give you so many avenues of introducing the drug, but 
 when you have a patient that can't take the drug by the mouth, 
 you will be glad to know of other ways of administration. The 
 mouth is the most satisfactory avenue of introduction. The bi- 
 chloride is given dissolved in some bitter tonic as Tine. Gentian or 
 Cinchonae; the biniodide is used, but is irritating; the protoiodide 
 is the best preparation, being less irritating and put up in conve- 
 nient pill forms of a 1-5 grain each. The dose of the protoiodide 
 will have to be determined for each patient. Never give an over- 
 powering dose and salivate your patient, but go about it systemati- 
 cally. Give one pill after each meal, at the end of the third day 
 give two after breakfast and one after each other meal, wait three 
 days and give two after breakfast and dinner and one after sup- 
 per, wait three days and give two after each meal and in this way 
 gradually increase the dose every third day until the patienl comes 
 to you with colicy pains in the abdomen and his teeth feeling too 
 long, then you may know you have almost salivated him. Now 
 divide the number of the pills in half and you have the dose: that 
 is, if he is taking six pills a day, give him three or half the dose 
 which produces physiological symptoms. If the patient can't take 
 the drug by the mouth, give it to him by inunction. For this pur- 
 pose the oleate or ointment is used, the 20 per cent, oleate is the 
 bes^, but is very expensive. In using the drug by inunction, take 
 a piece the size of the end of the little finger, protect your hand 
 with a glove and rub the drug in the skin where it is thin, as on 
 the belly, inner side of thigh, in the axilla, etc. Rub it in a 
 different place every night until you have made a circuit of the 
 body, for if the same place is used two nights consecutively, it will 
 cause irritation. Some authorities recommend the drug to be 
 smeared on a band, which is worn around the belly over night; 
 others smear the drug on the socks and friction from walking 
 
 13 
 
194 PRINCIPLES OF SURGERY. 
 
 causes absorption. If a patient is suffering from an acute lesion of 
 the eye or brain and j^ou wish to get him under the influence of 
 mercury at once, adroinister the drug by fumigation. Take a cane 
 bottom chair, seat the patient in it naked and enclose him in a 
 gossamer, on!}'- leaving his head out. Place under the gossamer 
 a bucket of boiling ^ater to open the pores of the skin, then take 
 20 grains of calomel, place it in a tin over an alcohol lamp and 
 place it under the gossamer. The calomal is volatilized, rises 
 through the chair and is deposited on the body. Let him remain 
 in the fumes for twenty minutes, then remove the bucket of water 
 and lamp, and let him remain ten minutes longer, when he should 
 be wrapped in a dry blanket and but to bed. Give him a bath 
 the next aay. Three such fumigations will cause salivation, but 
 in these acute lesions never dread salivation, your object is to get 
 the patient under the influence of mercury as quick as possible. 
 Sometinies when rapid effects are desired, the hypodermic use of 
 bi-chloride is used in 1-16 to -|^ grains three times a day. Make 
 the injection deep dox^n into the muscles, or else irritation follows 
 with the formation of an abscess. JSIever use a needle over two 
 or three times, as the mercury makes them brittle and there is 
 danger of breaking them off in the tissues. Mercury is a drug 
 greatly dreaded by the public on account of its abuse in the past, 
 but if given carefully, persistently and intelligently, it is of the 
 greatest value in the treatment of syphilis. It sometimes causes 
 colicky pains and diarrhoea, for these give large doses of Sub-ni- 
 trate of Bismuth and change the preparation or mode of adminis- 
 tration. Aphthous stomatitis may occur, if so, discontinue the 
 drug for a while and use antiseptic mouth washes. Salivation may 
 occur. The patient comes to you and says his teeth are too long 
 and their edges sharp, gums tender or ulcerated and bleeds easily, 
 tongue is swollen and congested, breath fetid and saliva is constantly 
 dribbling from his mouth. In this case discontinue the mercury 
 and substitute Iodide of Fotash. Grive a mouth wash and admin- 
 ister internally, the following: 
 
 R 
 
 Potassii Chloratis ■ . ") 
 
 Pulv. Sulphur a a| 31 
 
 M. Ft. cht. No. xii. 
 
 Sig : . One powder four times a day. 
 
PRINCIPLES OF SURGERY, 195 
 
 Iodine is not an antidote for syphilis, it has no effect on syphilis, 
 but acts entirely on the products of syphilis. It is not used or 
 does no good except in the tertiary stage. It causes disintegration 
 of the gummata and restores the tissues to their normal condition. 
 Appreciating the above facts, never give Iodine until the incipiency 
 of the third stage, and then continue the drug as long as symptoms 
 crop out. The preparations used are Tinct. of Iodine (in emer- 
 gencies), Iodide potash, soda and ammonium. Iodide of Potash 
 is the most popular preparation. The drug should be commenced 
 with small doses and increased steadily to the point of tolerance. 
 Order a saturated solution, commence with 5 minims after meals 
 and gradually increase the dose until 40 or 60 minims are being 
 taken or until untoward manifestations are noticed. It is well to 
 know that in a saturated solution of Iodide of Potash, as usually 
 prescribed, that each measured minim contains 1 grain of the drug, 
 but each drop of the solution does not; that is, when the medicine 
 is dropped the ounce contains 960 drops and when measured only 
 480 minims, therefore tell your patients to either measure the dose 
 or double the number of drops ordered, when the medicine is sim- 
 ply dropped from the bottle. The evil effects of the Iodides are 
 coryza and skin eruptions. 
 
 General Treatment. —While treating the disease locally aud 
 fighting the virus with mercury, don't forget the general treat- 
 ment and therefore administer tonics, and such drugs that will 
 assist the assimulation and digestion. Stop the use of tobacco, 
 chewing causes irritation and the formation of raucous patches. 
 Smoking also favors the f9rn]ation of these patches, irritation be- 
 ing caused by the pipe stem or cigar. Whiskey must be withheld, 
 as syphilis and alcohol give bad results, but in an old man who is 
 used to his morning dram, let him have it. Care should be taken 
 vpith the diet, a liberal supply of food may be allowed, but it 
 should be easy of digestion. Plenty of outdoor exercise should be 
 advised. Care should be taken in regard to the clothing; flannel 
 or silk should be worn next to the skin, and cotton or linen pro- 
 hibited, as the skin is depended on to assist in the elimination of 
 the virus and mercury, and must therefore be kept warm. A hot 
 bath should be taken three times a week, and a Turkish bath once 
 a week. If the patient is full of malaria, give him quinine; if 
 
196 ■ •PRINCIPLES OF SURGERY. 
 
 anemic, give Mm iron; if tubercular, give him cod liver oil. If 
 possible send your patient to the Hot Springs. I have served as 
 resident physician at these springs, and am convinced that the 
 medicinal virtues of the water is "?ii^." The benefit derived is 
 not from the water, but from the change of scenery, rest and the 
 regular bathing. In town a man is worried with business and his 
 family, and when he goes to the springs he gets mental and physi- 
 cal rest. The baths are no better than can be gotten at home in 
 the bath tub, but at the springs they are taken regularly and thus 
 the benefit. 
 
 LKCTURK XLIII. 
 
 T[TMORS. 
 
 The term Tumoe is often used indiscriminately by surgeons to 
 designate all kinds of swellings, but should be limited in its appli- 
 cation to neoplasms or new growth, composed of tissue, the result 
 of proliferation of embryonal cells and existing as a more or less 
 independent structure and having no physiological function. For 
 along time absurd and erroneous ideas of the nature and origin of 
 tumors existed in the minds, both of the laity and the profession. 
 Tumors were supposed to be parasites preying on the system, they 
 were thought to be composed of material essentially different 
 from that found in the human body, and in some instances to ha^e 
 a distinct circulation of their own, Johannes Muller was the first 
 to teach that the tissues of which a tumor is composed always has 
 its prototype in the body; Yirchow dispelled the belief that a 
 tumor could develop ^'de novo^''^ by proving that it always had ori- 
 gin from pre-existing cells of a similar type, and Cohnheim ad- 
 vanced a theory to explain their occurrence, which, though incapa- 
 ble of being demonstrated, is extrencely plausible. According to 
 Cohnheirn's theory, there must have been in the embryo during 
 its development more cells produced at some point than was neces- 
 
PRINCIPLES OF SURGERY. 197 
 
 sary for the formation of that particular region. These cells, not 
 utilized by the growth of the embryo, were arrested in their 
 further development, and remained in a dormant condition. If 
 their activity is excited later they proliferate and form a tumor. 
 It is extremely important, before going farther, to draw a sharp 
 line of distinction between tumors, inflammatory swellings and 
 retention cysts. All true tumors are composed of new tissue, pro- 
 duced by proliferation of embryonal cells. All inflammatory s w ell- 
 ings result from the action of pathogenic microbes upon mature 
 tissue cells. All retention cysts are due to the retention in a pre- 
 formed space of a physiological secretion or excretion. 
 
 Classification'. — Until the publication of Yirchow's paper, in 
 1863, no attempt had been made to classify tumors, and the terms 
 used to designate the different varieties were based upon their ap- 
 pearance or chief characteristics, such as scirrhus, cauliflower, 
 polyp, fungus, haematodes, etc. The modern classification of 
 tumors is based either upon their histological structure or upon 
 their clinical behavior. Thus tumors are said to be Epiblastic, 
 Mesoblastic or Hypoblastic, as their structure indicates an origin 
 from the embryonal cells of the Epiblastic, Mesoblastic or Hypo- 
 blastic layers of the foetus. Tumors are said to be Benign or Malig- 
 nant, as their clinical behavior indicates an innoceot or a vicious 
 tendency. Benign tun, ors are usually homologous or composed of 
 tissues resembling those in which it originates, have a distinct cap- 
 sule, are freely movable beneath the skin, are poorly supplied with 
 blood vessels, grow slowly, cause little pain, do not infiltrate ad- 
 jacent tissue or involve neighboring glands, and when completely 
 removed never recur. Malignant tumars are heterologous or com- 
 posed of tissues widely differing from those in which it originates, 
 has no capsule, are not movable, are richly supplied with blood 
 vessels, grow rapidl}'', cause great pain, tend to infiltrate adjacent 
 tissue, and to involve neighboring glands, aad frequently recur 
 after radical extirpation. 
 
 Cause. — The essential cause which produces a tumor is the exist- 
 ence in the body of dormant embryonal cells. The exciting causes 
 which produce a tumor are conditions which awaken the energies 
 of the latent cells, and inaugurate their proliferation. A combina- 
 tion of the two etiological factors is necessary, for the cells of the 
 
198 PRINCIPLES OF SURGERY. 
 
 matrix "would remain permanently in a latent condition, unless 
 stimulated, while all intrinsic and external exciting causes without 
 a matrix upon which to act would be powerless to produce a tumor. 
 Among the exciting causes may be mentioned (aj heredity, a ten- 
 dency to certain forms of tumors being transmitted from parent to 
 offspring; (b) race, the negro is much more predisposed to Fibroids 
 than the white race: (c) climate, the inhabitants of tropical regions 
 being: more liable to malio-nant troubles than those who dwell in 
 more temperate climates; (d) age, puberty and senility both being 
 periods at which neoplasms develop; (e) sex, men apparently be- 
 ing more frequently the victim than women; (f) occupation, the 
 refined and cultivated are afflicted with tumors more frequently 
 than the laboring class; (g) traumatism, such as a fracture some- 
 times excites the formation of a tumor; (h) irritation, such as a 
 jagged tooth, or the hot stem of a pipe produces cancer; (i) inflam- 
 mation is often followed by tumoL" production; (j) contagion is a 
 doubtful factor. 
 
 rATHOLOGT. — (1) Structure; all tumors, whether epiblastic, me- 
 soblastic, hypoblastic, benign or malignant, are composed of a 
 parenchyma and a stroma of fibrous tissue, the same as an ordinary 
 gland. In sonje instances the parenchyma or the essential cells, are 
 in excess of the strorca and the tumor is soft, again the stroma is 
 in excess of the pareu'^hyma and the tumor is hard. (2) Shape; 
 the shape aepends entirely on accidental cicuinstances, the tumor 
 always growing in the direction of least resistance. They may be 
 o'val, smooth, round, noduJated, broad, fiat or pedunculated. A 
 sessile tumor is one which grows on a broad, flat surface; a pedun- 
 culated tumor is constricted at its base; an oval tumor is one that 
 is expanded in all directions. Their surface may be smooth, lobu- 
 lated or nodular. (3) Density; some are hard and are then com- 
 posed mostly of stroma; some are soft, and are composed mostly 
 of parenchyma. Some are compressible and are then very vascu- 
 lar, and pressure causes compression by driving the blood out; 
 others fluctuate when pressure is made unequally on it, this is due 
 to the fluid it contains. (4) Color; this depends upon the tissue 
 producing the tumor, it is red in myomata or muscle tumor and 
 white in a tumor of the connective tissue; if vascular, they are 
 bright red in arterial and blue in venom tumors; if they undergo 
 
PRINCIPLES OP SURGERY. 199 
 
 fatty degeneration their color changes to yellow. (5) Growth; 
 the rapiditf of their growth depenils upon the ceils from which 
 they are formed, connective tissue cells growiag much faster than 
 nerve cells, and upon their vascularity, the greater their blood sup- 
 ply the more rapid their growth. (6) Morbid changes; these are 
 identical with those in similar normal tissue. They may undergo 
 inflammation, suppuration, etc., due to microbic infection. Ilemor- 
 rtiage may occur from rupture of a blood vessel. (7) Degenerative 
 changes; these degenerative changes are the same which occur in 
 the liver, kidney, etc. They may uadergo fatty, mucoid, amyloid, 
 hyaline, caseous, calcareous or osseous degeneration. 
 
 Diagnosis. —The diagnosis is based on the clinical history and 
 on a careful physical examiuation by palpation, percussion and 
 auscultation, and lastly by making aa exploratory incision, obtain- 
 ing a piece of the tissue ana examining it under the microscope'-. 
 
 Prognosis. — The prognosis depends upon the type of the tumor; 
 it is good in the benign, but bad in the malignant type. Upon 
 the anatomical location, if easily removed it is better than if it is 
 not accessible to the surgeon's knife, and lastly it depends on the 
 general health of the patient. 
 
 Treatment. — Medical. — There is not « single case on record where 
 a true tumor has been benefited by either external or internal admin- 
 istration of arugs, but if the swelling be from inflammation or syph- 
 ilis, it will be benefited, therefore if arsenic or mercury lessens the 
 size of a tumor, you have made a mistake in your diagnosis. The 
 only applicatioa of medicines in tumors, are tonics to build up the 
 general health. Sargioal. — This consist of the radical extirpation 
 of the growth, cleanly and completely. Some tumors are so situ- 
 ated as to give do pain or discomfort and can be let alone; others 
 do not endanger life, but must be removed on account of the dis- 
 figurement the cause. Remove all tumors if possible with the 
 knife, always cutting through healthy tissue, but if this is impos- 
 sible use the thermo-cautery, constriction or escharotics. 
 
 Palliative. —Thi^ is the treatment applied to malignant tumors, 
 which are either not accessible to the surgeon's knife or have passed 
 the pale of surgery. The treatment consist of good food, tonics, 
 stimulants and anodynes. If you have a patient ^^it)l a carcinoma, 
 and you know at the best he can't live very long, make him an 
 
200 PRINCIPLES OF SURGERY. 
 
 habitual opium eater, and so mate him live the rest of his life in 
 peace and comfort. Commence with small doses and increase the 
 dose gradually until he can take as much as 8 grains a day. JSTever 
 start to using the hypodermic syringe, as he will \Morry you to 
 death sending for you to give bim an injection. Don't give the 
 opium in pills or camphor, as it will soon upset the stomach, but 
 write for the following : 
 
 R 
 
 Morphine Sulph. grs viii 
 
 Ess. Pepsin (Fairchild's) §iv 
 
 M. Sig : As indicated. 
 
 LECTURE XLIV. 
 
 BENIGlSr TUMORS. 
 
 Fibromata or fibrous tumors are composed of fibrous tissue. 
 On section, they are smooth, firm, glistening and of a grayish 
 white colcr. Tbey occur wherever fibrous tissue is found in any 
 of its forms, but tbe most frequent seat is the periosteum. Fibro- 
 mata are oval, hard, nodulated and of uniform consistency; they 
 grow slowly, give little pain and are freely movable. They should 
 be removed as soon as discovered, and if enucleation is complete, 
 there is no danger of recurrence. 
 
 LiPOMATA or fatty tumors are composed of adipose tissue identi- 
 cal with normal fat. They have a thin capsule, wbich is attached 
 by fibrous septa to adjacent tissue. They are found commonly on 
 the shoulders, back and buttocks. Lipomata are circumscribed, 
 painless, soft, inelastic mass. They grow slowly, but sometimes 
 attain considerable size. If the edge is pressed upon by the finger 
 it slips away. They should be treated by making a free incision, 
 and shelling the tumor out of its capsule. 
 
 Chonbkomata or cartilagenous tumors are composed of some 
 variety of cartilage. On section they are homogenous, translucent 
 
PRINCIPLES OF SURGERY. 201 
 
 and pinkish ^ray in color. They are usually composed of hyaline 
 or iibrc -cartilage. They occur commonly near the epiphysis of 
 the long bones, and are sometimes seen in the testicles and parotid 
 gland. Chondromata are hard, elastic, slowly enlarging growths, 
 often nodular or lobulated and give little pam. Their treatment 
 consist in the complete removal x^ith the knife and periosteal lifter. 
 
 OsTEOMATA or osseous tumors are composed of true bone, and 
 are generally formed entirely of either cancellous or compact tis- 
 sue. Tne cancellous tx^pe is usually found near the epiphysis of 
 long bones, and may result from ossification of a chondromata. 
 The compact type is usually found projecting from one of the cra- 
 nial bones, and often is of an ivory hardness, and exceeding diffi- 
 cult to cut away. Osteomata are always connected with bone, 
 and are hard and immovable. They are either pedunculated or 
 have irregular nodular surfaces. They should ouly be removed 
 T\hen they give rise to pain or are steadily growing. 
 
 Odontomata or tooth tumors are composed of a mixture of den- 
 tine, enamel and cementum. They occur in the deial arch, and 
 are the result of the '^misdirected energy of a tooth germ."''' Odon- 
 tomata are dense in structure, irregular in shape and rarely exceed 
 a normal tooth in size. They may project through the gum along 
 with the teeth, or they may remaia embedded in the substance of 
 the alveolus. When diagnosed, they should be removed with for- 
 ceps or chiseled out with bone instruments. 
 
 Myxomata or mucous tumors are composed of jelly resembling 
 the vitreous humor of the eye. They are soft, gelatinous, semi- 
 translucent and enveloped in a capsule. They occur commonly in 
 the nasal cavity and are sometimes seen in the mammary gland, 
 intermuscular spaces and sub-mucous and sub seroas surfaces. 
 They grow slowly and may reach a large size. They should be 
 lemoved when practicable. 
 
 Myomata or muscular tumors are composed of muscle tissue. 
 Rarely these growths are forrued of striated cells; com^monly they 
 are composed of the non-striated variety. They occur frequently 
 in the uterus and prostrate gland. Myomata are firrr , sometimes 
 smooth, but more often nodular, and on being cut presents an ap- 
 pearance closely resembling a fibromata. Tiie tumor is intrinsically 
 innoceut, but sometimes mechanically interferes with the function 
 of an organ, and then demands removal. 
 
202 PRINCIPLES OF SURaERY. 
 
 Papillomata or "s\arty tumors are composed of epithelial and 
 connective tissue, and resemble in structure hyper trophied papilla 
 of the skin or raucous membrane. They occur most frequently on 
 the hands and genital organs, owing to the exposure of these re- 
 gions to dirt and irritation. Papillomata may appear as small 
 cauliflower masses, or as flattened elevations, or as villous tumors. 
 These growths, while innocent, often degenerate into epitheliomata, 
 and hence should, be removed, by either the knife or caustics. 
 
 AxGEioMATA or blood vessel tumors are composed of newly 
 formed and old dilated blood vessels. They form swellings of 
 different shapes aud sizes, all characterized however, by being 
 bright or dark red in color, soft and compressible in consistency. 
 
 The treatment of angeiomata consists ia their extirpation \\ith 
 the knife, ecrasseur or themo-cautery. 
 
 Ltphangeiomata or lymph vessels tumors correspond to the 
 angeiomata of the blood vessels, and consist essentially of dilated 
 and hypertrophied lymph vessels. The tumors sorcetiraes reach a 
 considerable size, and are filled with a fluid which usually is clear, 
 but sometimes miity. The treatment consists of excision and 
 when this is considered hazardous, the growth may be destroyed 
 by splitting it open, and packing with iodoforn gauze. 
 
 jS'edromata or nerve tumors are composed essentially of new 
 formed nerve fibre. It is necessary to draw a distinction between 
 true and false neuromata. A false neuromata consists in a growth 
 of fibrous or muscular tissue on a nerve trunk or terminal, which 
 displaces or destroys its fibre; as an example, may be cited the 
 so-called amputation neuromata. The true neuromata consist of 
 newly formed nerve fibres. Neuromata are innocent growths, but 
 often cause great pain. The treatment consists in e;stirpation, 
 and if this necessitated the division of a nerve trunt, the subse- 
 quent restitution of continuity by a plastic operation. 
 
 Lymphomata or tumors of lym.pbatic glands arise from pre exist- 
 ing lymphatic glands, and are usually seen on the neck or in the 
 axilla. They are disfiguring, and while, innocent in nature, may 
 cause danger mechanically. They should be removed by free dis- 
 section. 
 
 Adenomata or glandular tumors are composed of acinous or 
 tubular glandular tissue mixed with connective tissue in varying 
 
PRINCIPLES OF SURGERY. 203 
 
 proportions. Adenomata are innocent growths and give little 
 pain. The acinous variety occurs in the mammary, ovary, tests 
 and other glands. The tubular in the intestines; especially the 
 rectum. The treatment consists in early excision. 
 
 CysToiMATA or C3"stic tumors are growths whose walls are pro- 
 duced from a matrix of embryonal cells, and whose contents are 
 the products of the cells lining the cyst wall. This definition re- 
 stricts the term cystomata to neoplasms or new growths, and does 
 not include the class of swellings due to the retention in a pre- 
 formed space of physiological secretions or excretions from the ob- 
 struction to the outlet of a gland. The w^all of a cystomata is 
 formed by proliferation of cells, and the contents of the cyst is a 
 substance produced by the cells of the cyst wall. A cystomata 
 grows rapidly, and ma^v cause considerable pain. Its density de- 
 pends upon the tension tc which the wall is subjected by its con- 
 tents. It may be soft and fluctuating, it may be so firm as to im- 
 part the sensation of solidity. Their most frequent seat is the 
 neck and abdominal region. Cystomata are benign growths, but 
 cause trouble from pressure. They should be early and completely 
 removed. 
 
 Teratomata are tumors composed of tissues which do not nor- 
 mally exist at the place where the tumor grows. The highest 
 type of a Teratomata is where an organ or set of organs develop. 
 
 The simpler variety is composed of heterogeneous tissue, such as 
 bone, teeth, hair and skin. Teratomata are usually located in the 
 ovary, but they may develop at almost any partoP the tody. It is 
 impossible to make a diagnosis until an exploratory incision is 
 made. They should be removed. 
 
204 PRINCIPLES OF SURGERY. 
 
 LECTURE XLV. 
 
 MALIGNANT TUMORS. 
 
 Sarcomata. A sarcomata is a malignant tumor composed of 
 embryonal connective tissue, and may exist wherever normal con- 
 nective tissue is found. Their characteristics are those of all malig- 
 nant neoplasm; it is not encapsulated, are plentifully supplied 
 "with blood, grows rapidly, causes great pain, infiltrates adjacent 
 tissue, and when removed they tend to recur. 
 
 Structure. — A sarcomata is formed of connective tissue cells em- 
 bedded in a homogeneous matrix. It has no stroma or connective 
 tissue trabeculae, but is held together by an amalgam or cement 
 substance which binds the cells together and separates one from 
 the otiher. The solidity of the tumor depends on the amount of the 
 cement substance. (A carcinomata has trabeculae and fascia to 
 hold the cells together but has no intercellular cement substance.) 
 A sarcomata contains a bountiful supply of blood vessels, which 
 run between the cells in the cement substance. Their walls are 
 thin and imperfect, sometimes only consisting of a mere channel in 
 tbe cement substance. Sarcomata contain no lymphatics. 
 
 Varieties. There are three varieties, the difference being based 
 on the variety of cells they contain. 
 
 (1) Round cell Sarcomata. — This tumor is composed of round 
 cells, the result of the proliferation of embryonal connective tissue 
 cells. The}'" are about the size of a white blood corpuscle, con- 
 tains one or two nuclei and are held together by a intercellular 
 cement substance forming a fluctuating mass. This is a rapidly 
 growing tumor and is very malignant. Their most frequent site 
 is in the periosteum of bones, buc are also found in fascia, sub- 
 mucous tissue, mammary gland, ovary, &c. 
 
 (2) Spindle cell sarcomata. — This is a little higher type, the con- 
 nective tissue cells being more mature. It is formed of spindle 
 shaped connective tissue cells, resembling very much bearded oats, 
 with sprangled ends. They are laid side by side their ends inter- 
 lacing and are bound together bv a sticky gelatinous cement sub- 
 
PRINCIPLES OF SURGERY. 205 
 
 stance which is leiss in proportion than found in the round cell 
 variety, and the tumor is therefore harder and denser than the first 
 variety. They are found in the mammary gland, ov^ary, uterus, 
 testes, and sometimes in the prostate gland. 
 
 (3) Giant cell s^rccmaz!^.-— This variety is not formed entirely of 
 giant cells, but a mixtare of round cells, spindle cells and giant 
 cells, but receives the name of the most characteristic type, which 
 is the giant cells. These cells are a hundred times as large as a 
 white blood corpuscle, contains granular protoplasm, and has about 
 fifteen to twenty nuclei which are arranged around the periphery 
 of the cells. The cells are bound together by an intercellular 
 cement substance. They are only met with in bones, the most 
 common seat being the medullary canity. They grow slowlv, 
 causes considerable pain, and can be diagnosed by the bulging of 
 the bone. 
 
 Pathology. Row do these cumors grow, start and progress? 
 They begin to grow the moment the ilet of deposit of dormant em- 
 bryonal cells are stimulated, which causes the cells to proliferate. 
 The c»^l)s rapidly divide but none of them ever reach maturity. 
 They do not push the cells in which they grow aside, as in a benign 
 tumor, but infiltrates and penetrates them. Then there is a grad- 
 ual dissemination of the growth and colonies form on different por 
 tions of the body. This is accomplished by some few of the sar- 
 comatous cells entering a vein and are carried to every portion of 
 the body and form new growths. There is no dissemination through 
 the lymphatics, as these tumors contain no lymph vessels, but are 
 bountifully supplied with bloodvessels. These tumors on account 
 of their rapid formation, poor development, are liable to degenera- 
 tive changes; such as fibrous, osseous or calcareous degeneration. 
 
 Symptoms. — These vary with the variety of the sarcomata and 
 the location. There is in all the types pain, swelling and de- 
 formity. If the tumor is seated in the liver, its function is inter- 
 fered with; if in the brain, there is imbecility, &c. 
 
 Diagnosis. — The diagnosis depends, 1st, on the age of the 
 patient; sarcomata rarely forming after the 35th or iOth year. 
 2nd, on its consistency, there are usually cystic cavities in the in- 
 terior which makes it unequally hard to the touch. 3d, They are 
 differentiated from a benign tumor by the fact that they develop 
 
206 PRINCIPLES OF SURGERY. 
 
 rapidly; and frcm the carcinomata by not involving the neighbor- 
 ino; D-lands. 
 
 Pjrognosis — The prognosis depends on the type; the round cell 
 sarcomata is more malignant than a spindle cell sarcomata, and 
 the spindle cell sarcoirata is more malignant than the giant cell 
 sarcomata. It also depends on the anatomical location of the 
 tumor; if it is in brain or stomach the prognosis is grave, but i^ it 
 is situated on the periosteum, hand or foot, where it is accessible 
 to the surgeon's knife, the prognosis is better. 
 
 Tkeatment. — The treatment consist in the immediate and abso- 
 lute removal of the growth. It a man comes to you with a sar- 
 comata on his hand, and it is yet in its incipiency, cut off the arm; 
 if on his foot, cutoff leg; if on the breast of a woman, extirpate the 
 gland, and if it is on the uterus, perform a hysterectomy. If the 
 patient does not come under your care until general dissemination 
 has occurred, don't operate, it is too late. Although eminent sur- 
 geons claim that the Toxins of the germ of Erysipelas does not affect 
 sarcomata; you can try them on the hopeless cases as a last resort. 
 
 Cargijs-omata or Cancer. — This is a malignant neoplasm or 
 tumor formed from embryonal epithelial cells, and having clam- 
 like prolongations extending from its margins into the adjacent 
 healthy tissue. It has all of the characteristics of a malignant 
 tumor; it has no capsule, has a bountiful blood supply, grows 
 rapidly, causes great pain, infiltrates adjacent tissue, involves 
 neishborino- s'lands arid tends to recur when removed. 
 
 Structdrb. — It is composed essentially of epithelial cells held 
 together by trabeculae or stroma. It contains no intercellular 
 cement substance and is held together only by the trabeculae or 
 stroma. The stroma is composed of connective tissue which in- 
 tersects and divides the growth into small apartments. Each 
 apartment is filled with epithelial cells, which are so concentrically 
 arrang:}d that they are said to have a nest-like appearance. The 
 tumor is richly supplied with blood vessels and lymphatics and as 
 they pass by each apartment oE cells, a cwig is given off to them. 
 
 Pathology. — A carcinomata or cancer begins in individuals 
 who have formed in embryonal life, more epithelial cells than 
 were necessary to build up the foetus. These superflous cells lay 
 dormant until stimulated, when they divide rapidly, each beget- 
 
PRINCIPLES OF SURGERY. 207 
 
 ting a child after its own kind and a tumor is formed. These cells 
 do not })ush aside the adjacent tissue, but permcjates and infiltrates 
 it. Cancer like a sarcomata tends to form colonies in various por- 
 tions of the bod}'-, but the disease is not disseminated through the 
 blood vessels as in sarcomata, but by the lymphatics. When the 
 disease commences to disseminate the lymphatics and also their 
 glands become hard, gland after gland is conquered until the gen- 
 eral lymph circulation is reached; the diseased cells then pass 
 through the heart and is disseminated through the body, when 
 general infection occurs. 
 
 Varieties. — There are two broad classes; Epithelial cell carci- 
 mata and Spheroidal cell carcinomata. Epithelial cells occur nor- 
 mally! either as a squamous or a columnar, and cancerous 
 growths always possess one of these types of cells. Tney are 
 squamous cells when they come from the skin, and spheroidal 
 when they come from a gland, and this being the case, the micro- 
 scope will tell you where the cells came from. (1) Epithelial cell 
 carcinomata.- — This type is composed of squamous epithelial cells, 
 held together and di\^ided o(f into apartments by a stroma of con- 
 nective tissue. It develops usually at the junction of the skin 
 and mucous membrane; as on the alae of the nose, corner of the eye, 
 lips, penis, &c., but it also occurs in other localities, but more 
 frequently in the places named above. (2) Spheroidal cell carci- 
 nomata or columnar cell carcinomata is that variety of cancer 
 which forms in glands and whose cells are spheroidal or columnar 
 shaped and divided off into apartments, and held together by a 
 stroma of connective tissue. They occur in the mammary gland, 
 ovary, uterus, liver, pancreas, kidney, spleen, testes, and some- 
 times in the prostate gland. 
 
 Symptoms- — The sjnriptoms depend on the location of the tumor. 
 There is always pain and deformity and the other symptoms depend 
 on the anatomical seat of the disease. Besides the local syrap 
 toras. there are general symptoms spoken of as Cancerous cachexia. 
 The patient has a peculiar appearance, which consist of a pale white 
 hue of the skin. It is not like the appearance of a malarial or anemic 
 person, but the skin is drawn, eyes sunken and gives the appear- 
 ance of a being drawn downward. There is also anemia and loss 
 of strength and tissue, which is not only due to pain, but also to 
 the absorption of the specific toxins. 
 
208 PRINCIPLES OF SURGERY. 
 
 Diagnosis. —The diagnosis is based oa the age, carcinomata 
 rarely occur under fort}'" years of age; on the tumor sending out 
 prolongations into the adjacent tissue, and it is diagnosed from 
 sarcomata by the lymphatic glands being involved. 
 
 Prognosis. — The prognosis depends on the variety, the epithelial 
 cell carcinomata being more easily eradicated than the spheroidal; 
 upon the seat of the tumor, if on the nose or lip, or any place of 
 easy access to the surgeon's knife, the prognosis is better than if 
 it is seated in the uterus or liver. ISTo matter how often and how 
 completely removed, this class of tumor always tends to recur. 
 Statistics show that after complete excision, 75 per cent, oi the 
 operations are not permanently successful. The important point 
 is to remove the tumor before glandular enlargement has taken 
 place, with general dissemination. 
 
 Treatment. — ^Extirpate the tumor as early as possible. Remove 
 the organ involved if possible, and if accessible, remove the dis- 
 eased lymphatic glands. You must operate in all cases of cancer, 
 not with the view of curing the patient, but it always does good 
 by stopping the pain, life is prolonged and hope restored. 
 
 LECTURE XLVI. 
 
 RETENTIOiSr CYSTS. 
 
 A Rerention Cyst is an enlargement due to the retention of a 
 normal secretion or excretion in a performed space, the retention 
 being caused by the obstruction of the duct by which the secre- 
 tions or excretions normally escape. For example: one of the 
 ureters may become obstruccted, and a retention cyst will form in 
 the pelvis of the kidney or even in the substance of the gland 
 itself. The term Retention cyst is vaguely used and is often con- 
 founded with Cystomata; but a cystomata is a tumor formed from 
 the proliferation of embryonal cells, the cyst wall and contents 
 are freshly built; whereas in a retention cyst, the walls pre-existed 
 
PRINCIPLES OF SURGERY. 209 
 
 and the only abnormality is the obstruction of the duct with con- 
 saquent retention of normal excretions or secretions. 
 
 Stkucture. — It consists of a cyst wall and cyst contents. The 
 iwall is the duct or the gland itself; for instance, if the obstruction 
 is at the hilura of the kidney, the kidney and its capsule would 
 form the C3^st wall; but if the obstruction Avas in the ureter near 
 the bladder, the wall of the ureter would form the cyst wall. 
 "When a cyst commences to grow, its walls are thick, but from 
 pressure they beccme as thin as paper or the wall may be thin, 
 and from irritation becomes thickened. The walls of a cyst are 
 gradually reduced to sin pie connective tissue, the glandular tissue 
 being absorbed. The cyst contents consists primarily of the 
 secretions or excretions of the gland in which it is formed, but 
 as the cyst grows, various changes occur which so alters its ap- 
 pearance that it will not be recognized as a normal fluid; inflamma- 
 tion and supjmration may occur, when it will be mixed with pus 
 or some tlood vessel will rupture and pour its contents into the 
 cyst and so disguise its contents. 
 
 Causes. — The causes are numerous, but the most frequent are 
 inflammation or some mechanical obstruction. For instance, 
 some large gland secreting from one to twenty pints a day through 
 a fine capillary duct which becomes obstructed; on examination 
 you \shl find the adjacent tissues inflamed, causing obstruction to 
 the duct or it is being pressed on by a tumor. 
 
 "Varieties. — Retention cysts may occur in almost any portion 
 of the body, but the following situations are the more frequent 
 sites. (1) Skin; they occur on the skin in one or two types, 
 Sebaceous or Sudoriferous cyst depending upon whether the duct 
 of a sebaceous or sweat gland is obstructed. Sebaceous cyst are 
 usually situated on the scalp, but may occur on any portion of 
 the body. When incised they shell out readily. The treatment 
 consist of rendering the part aseptic, incising the lump, grasp the 
 sack with forceps and shell it out; stop the bleeding, take one or 
 two stitches and dress the woucd. Sometimes inflammation has 
 occurred causing adhesion to form, and the sack will have to be 
 dissected out, for if it remains the cyst vfill recur. (2) Mucous 
 membrane; retention cysts sometimes form on mucous membranes. 
 There are in all mucous surfaces, mucous crypts whose functions is to 
 
 14 
 
210 PRINCIPLES OF SURGERY. 
 
 secrete mucous which lubricates the surface. If the mouth of 
 these crypts become occluded a retention cyst forms. The treat- 
 ment consist of a free incisioo and the removal of the capsule. 
 Kern ember in the treatment of all cyst, that it does no good to 
 incise the enlargement and allow the capsule to remain; and if 
 you find the capsule so adherent as to be impossible to be dis- 
 sected out, destroy it by curetting and packing with iodoform 
 gauze, which should remain until the pressure has destroyed the 
 capsule. (3) Fallopian tubes; these tubes are open at both ex- 
 tremities, and if one or both ends become occluded a retention 
 cyst forms. The usual cause is gonorrhea, but it may be pro- 
 duced by a more innocent cause. If the contents of the cyst is 
 composed mostly of water, it is called Hydrosalpinx, and if it 
 contains pus, it is called Pyosalpinx. The fallopian tube, though 
 normally very small, is distended until it looks like a saucer. 
 (4) Appendix: the openicg into the appendix, situated at its 
 junction with the caecum, sometimes becomes occluded, mucus 
 accumulates and suppuration may occur, but the trouble was 
 originally a retention cj^st. (5) Ovary: a graafian follicle reach- 
 ing maturity fails to rupture, its secretions and excretions can't 
 escape, distention occurs and the follicle is transformed into a 
 retention cyst, which may reach an enormous size. (6) Testicles: 
 there is a possibility of the duct of these giacds becoming occluded, 
 with consequent accumulation of its secretions and a retention 
 cyst is formed. (7) Gall tract: the gall duct, common duct or 
 cystic duct, from inflammation, pressure of a tumor or impaction 
 of a calculus, will cause the bile to be retained, and althougli some 
 of it will be reabsorbed, a retention cyst forms. (8) Kidney the 
 ureters may become obstructed by a calculus, inflammation, pres- 
 sure of a tumor, or by the ligature of a careless surgeon, and the 
 urine being unable to escape is retained, constituting a disease 
 known as Hydronephrosis. The cyst may contain a gallon cf 
 urine. These cysts are also sometimes seen in the Pancreas, 
 Thyroid gland. Mammary and Salivary giacds, due to obstruction 
 of their ducts. 
 
 Symptoms. — The first sj'^mptom is swelling or increase in bulk, 
 which is also common to hypertrophy and other troubles. The 
 general symptoms depend on the organ involved; if it is in the 
 
PRINCIPLES OP SURGERY. 211 
 
 salivary gland, the symptoms are practically "nil," but if it is in 
 the gall tract, there will be jaundice, profuse vomiting, &c., and 
 if in the kidney, there will be pain, tenderness, scant urine and 
 swelling. 
 
 DiAGKosis. —The diagnosis is based on the clinical history, care- 
 ful physical examination by palption, percussion and auscultation 
 and can be confirmed by the aspirator. 
 
 Peognosis. — The prognosis is based on the organ involved , and 
 on the complications. A sebaceous cyst amounts to nothing, but 
 if it is a cyst of the kidney, the prognosis is bad, especially when 
 core plicated by suppuration with a low grade of septicenia or 
 Pyaem ia . 
 
 Tkeatment. — The proper treatment, if it is possible to do so, is 
 to remove the obstruction. If there is a cyst of the gall bladder 
 due to pressure from a tumor, remove the tumor, or if in the 
 kidn^, due to the obstruction of the ureter by a calculus, remove 
 /the calculus. Jf you can't remove the obstruction, the neat best 
 treatment, is to make an artificial fistula. For instance: if there 
 is obstruction to the urethrae and you can't remove the otstruc- 
 tion, make an artificial urethrae; if he is suffering from Hydro- 
 nephrosis, make an artificial fistula, and the rest given the ducts 
 by these fistula, frequently return them to their normal condition. 
 If you find none of the above pracitcable, excise the whole busi- 
 ness; if it is a sebaceous cyst, remove the whole gland; if it is 
 Hydronephrosis, remove the kidney. 
 
212 PRINCIPLES OF SURGERY. 
 
 LECTURE XLVII. 
 
 ASEPTIC AND ANTISEPTIC SURGERY. 
 
 ITS ORGANIZATION AND DETAILS OF PREPARATION. 
 
 Reparation of the patient. — The patient should be under ob- 
 servation for some days before the operation, and, if possible, con- 
 fined to bed for the last da}' or two, thus allowing the various or- 
 gans to accustom themselves to the new conditions in \^hich they 
 will be placed. The function of the skin, kidneys and bov\ els should 
 be stimulated, if sluggish from improper habits of living, the 
 heart carefully examined to determine the safety of the anaesthetic, 
 and the urine analyzed to ascertain the condition of the oigans 
 T^hich excrete it. A warm plange bath should be given daily, and 
 also an antiseptic vaginal douche, if the patient be a woman. The 
 diet should be simple and nutritious, and of a character to leave 
 little residual matter in the intestines. The bowels should be evac- 
 uated daily, and a purgative given the night before the operation, 
 followed by a simple enema the next morning. A large dose of 
 quinine should be given, as clinical experience has shown that its 
 influence lessens surgical shock. 
 
 The morning of the operation a general bath should be given 
 with warm water and soap, and the part to be operated upon 
 cleanly shaved. The area should be well scrubbed with hot 
 water and green soap, washed with alcohol, then with a 1:1000 
 solution of bichloride of mercury, and finally a dressing of 
 bichloride gauze applied, and retained in place b}^ a bandage or 
 binder. The patient should be dressed in a fresh suit of merino 
 under clothing, woollen socks or stockings, a night-gown, and a 
 warm wrapper. 
 
 Ko food should be given some hours before taking the anaes- 
 thetic, and immediately before the operation the bladder should 
 be emptied. 
 
 Preparation of Operating Room. — Nothing need be said under 
 this head With reference to hospital work, as all connected with 
 these institutions are thoroughly familiar with the details. 
 
PRINCIPLES OF SURGKRY. 213 
 
 Nearly all large hospitals have an. operating room specially ar- 
 ranged for surgical work, and patients are taken to this room, 
 operated upon, and then carried back to their beds in the private 
 rooms or wards of the buildings. In operating in a private house, 
 however, it will be found easier to operate in the room in w hich 
 the patient is to be placed during convalescence, as it entails less 
 inconvenience in the household, and lessens the work of prepa- 
 ration. 
 
 The room selected should be moderately large, well-lighted, 
 and easily ventilated and heated. The carpet should be taken 
 up, and the curtains, pictures and unnecessary furniture removed. 
 
 The wails should be brushed down, and the floor, frames of the 
 doors aiid windows, and wood-work of the furniture washed with 
 1:1000 solution of bichloride of mercury. 
 
 The furniture should consist onlv of a bed, two chairs, an ope- 
 rating table, and four small tables. 
 
 The bed should be a single one, preferably of iron, and should 
 have a good spring and a firm hair mattress. It should be placed 
 so as to be accessible from both sides and the foot. 
 
 The chairs should be stiff ones, not rockers, and of wood, so 
 they can be washed without injury. 
 
 The operating table should be firm and of a suitable size and 
 shape. A pine table, such as is commonh^ found in the kitchen, 
 or two small tables placed end to end, will answer. The ope- 
 rating table should be placed opposite the window which admits 
 the best light, and the lower panes of the ^^indow screened by 
 tacking a piece of muslin or a towel across them. On the table 
 should be placed a folded blanket and a pillow, and over these a 
 rubber protective and a sterilized sheet. 
 
 The four small tables should be covered with sterilized sheets or 
 towels. One should be placed at some distance from the operating 
 table, and contain the basins and solution used in sterilizing the 
 hands. One to the right of the first assistant for the sponge 
 basins, one to the light of the operator for the instruments and 
 aessings. and one behind the operator for the basin of pure water 
 in which to wash his hands during the operation. 
 
 Akeangemexts of the Patient. — It is important to prevent the 
 patient being chilled during the operation, as it increases shook 
 
214 PRINCIPLES OF SURGERY. 
 
 and retards reaction. Care should be raken to keep the tempera- 
 ture of the room uniforn], to a^cid draughts, to make no unneces- 
 sary exposure of the body, and to prevent \^etting. 
 
 If the site of the operation permits, the patient's limbs should 
 be closely wrapped in a blanket, and the chest protected by a 
 folded piece of flannel. Hot water bags may be placed at the 
 patient's feet. The limbs should be secured fcy passing a band- 
 age over them just above the knees, and tying tightly under the 
 table. The arms should be confined to the sides by twisting one 
 end cf a sterilized towel around the hand and wrist and thrusting 
 the other end under the patient's hip. Rubber pads or sheets 
 should be adjusted so as to prevent the various solutions employed 
 from saturating the patient's clothing and bedding. The protec- 
 tive dressing should be then removed from the seat of operation, 
 and the surface again washed successively with alcohol, 1:1000 
 solution of bichloride of mercury and sterilized water. The 
 part should be covered with a large piece of aseptic gauze having 
 a slit cut in it large enough through which to work. 
 
 Pkepaeation of Operator atsd Assistants. — Before beginning a 
 serious operation, the operator and his assistants should take a 
 full bath, and put on an entirely fresh suit of clothiag. Their 
 heads should be protected by linen caps, and their bodies by linen 
 gowns or sheet aprons. Their arms should be bare to the elbow 
 and their hands carefull}'' sterilized. 
 
 Duties of Assistants. — As delays in an operation are not only 
 annoying to the surgeon, but dangerous to the patient, ic is impor- 
 tant for assistants to be well drilled, and to know exactly what 
 they are expected to do. 
 
 The number of assistants and their duties varies with different 
 operators, and with the same operator under different circum- 
 stances. The following is a convenient division of the work: 
 
 The Anct^sihetizer stands at the headof the table. His duty con- 
 sists solely in the administration of the antesthetic, which requires 
 his individual attention. 
 
 The Fir^t Assistant stands on the left side of the table oppo- 
 site the surgeon. He sponges the wound, catches bleeding ves- 
 sels, and assists the operator in every way possible. He should 
 endeavor to anticipate the needs of the surgeon, and direct the 
 
PRINCIPLES OF SURGERY. 215 
 
 other assistants in their work, thus saving the operator time and 
 trouble. 
 
 The Instrument Assistant stands to the right of the surgeon 
 at the side of the table which contains the instruments and dress- 
 ings. He hands instruments to the operator, supplies the first 
 assistant with ligatures, and threads needles with the required 
 material, as they are needed. As soon as an instrument has been 
 used, he washes it in sterilized water, and returns it to its place 
 in the trays. 
 
 He should keep an accurate list of the instruments in solution, 
 to be certain that none are lost. It is also his duty to cut the 
 dressings in the desired shape, and if their application devolves 
 on the firat assistant, to assist him, taking the place at the side 
 of the operating table vacated by the surgeon. 
 
 The Sponge Nurse stands behind and to the right of the first 
 assistant, at the side of the table on which are placed the basins 
 for the sponges. The basins should be two in number, one con- 
 xaining cold, and the other warm sterilized water. The first as- 
 sistant, after using a sponge, throws it into the basin of cold 
 "v^ater, the nurse frees it thoroughly from blood, and places it in 
 the basin of warm water, from which she takes it, squeezes it 
 dry, and hands it to the first assistant when needed. 
 
 Sponges should be washed first in cold water, because it does 
 not coagulate the fibrin of the blood, and' thus prevent its re- 
 moval. They should then be placed in warm water to elevate 
 theii temperature, and to prevent their chilling the tissues to 
 which they are applied, and lowering their vitality. 
 
 The nurse should make a written record of the number of sponges 
 in her charge; and if this number is increased during the opera- 
 tion, either by the addition of new sponges or by the division of 
 one already in use, the record should be corrected. At the close 
 of the operation, she should count the sponges aloud, thus as- 
 suriQg the surgeon that none have been left in the wound or 
 abdominal cavity. 
 
 Extra Assistant. —The assistants just named are not allowed to 
 touch anything which has not been sterilized — hence it is neces- 
 sary to have an extra assistant to alter the position of the patient 
 on the table, to assist the antesthetizer if the patient vomits, to 
 
216 PRINCIPLES OF SURGERY. 
 
 empty and refill basins, to open and close the windows and 
 doois, and todothe many little things which, if done by one of the 
 other assistants, would necessitate the re-sterilization of their 
 hands and thus delay the operation. 
 
 After-Caee of the Patient. — Unless complications occur, the 
 management of the patient after an operation is simple. After 
 the patient is put in bed, a nurse should remain at the bedside 
 until the effects of the anaasthetic wear off. If there is much 
 shock, it should be combatted ty appropriate remedies. ]!^ausea 
 is usually a troublesome symptom, but should be created tenta- 
 tively. Anything m the stomach aggravates the trouble, and 
 hence little or no vvater should be given. A cloth wrung out of 
 ice-cold water placed on the forehead, or a mustard plaster on 
 the abdomen, does good. The dressmgs should be frequently 
 examined to see if there is any indication of secondar}?^ hemor- 
 rhage. Food at first should be given sparingly. It should be of 
 a liquid form, concentrated, nutritious, and easily digested. The 
 bowels should be moved on the second day. Unless drainage has 
 been used, the dressings should not be disturbed for a week or 
 ten days. The three indications for changing the dressings at an 
 earlier date are: Pain, fever, and saturation of the dressings with 
 secretions from the wound. In dressing a wound, the same care 
 should be exercised to prevent its infection as was originally ob- 
 served at the time of the operation. 
 
 Pkeparation of Water. — An abundance of both hot and cold 
 water for irrigating the wound and cleansing the hands, instru- 
 ments, and sponges, is essential in an operation. Water should 
 be free from both inorganic and organic matter, as the presence 
 of inorganic matter acts as a mechanical irritant, and the exist- 
 ence of organic matter vitiates asepsis by the introduction of 
 bacteria. The inorganic, or mineral constituents, can be removed 
 by either distillation or filtration, and the organic, or bacterial 
 element, by boiling. The method of purifying water, therefore, 
 embraces two processes — 
 
 1st. The water should be filtered or distilled, 
 
 2d. It should be boiled in a clean vessel for at least ten 
 minutes. 
 
 A portion of the water sbould be allowed to cool, so that during 
 the operation the temperature of the hot water can be lowered by 
 
PRINCIPLES OF SURGERY. 217 
 
 adding cold water to it. JSTurses sometimes cool water by putting 
 in a lump of ice, under the mistaken impression that the freezing 
 process has destroyed all germ-life, and that hence the water re- 
 sulting from the melting ice is sterile. Tt is as important for the 
 cold water to have been boiled as it is for the hot, and hot steril- 
 ized water should never be cooled by the addition of cold water 
 which has not been so treated. If sufficient time is not available 
 to allow the water to cool, the process may be hastened by sur- 
 rounding the receptacle with ice, but the ice should not come in 
 actual contact with the water. 
 
 Peepaeation of Solutions. — Solutions are used as disinfectants 
 and to irrigate and clean wounds and cavities. The folio (ving are 
 the methods of preparing those most commonly in use. 
 
 Pure Water is prepared by filtering or distilling water, then 
 boiling for ten minutes, and allowing it to cool to the desired tem- 
 perature. 
 
 Normal Salt Solution is prepared by adding a drachm and a 
 half of chloride of sodium, sterilized by heat, to two pints of pure 
 water, filtering through filter paper, boiling, and allowing it to 
 cool. 
 
 TliiersoK' s Solution is prepared by dissolving two parts of sali- 
 cylic acid and twelve parts bcracic acid in one thousand parts of 
 water, filtering, boiling, and allowing to cool. 
 
 Bichloride Solution is prepared by dissolving in a given quan- 
 tity of distilled water the number of tablets of bichloride of mer- 
 cury that are specified on the bottle by the manufcturer to make 
 the requisite strength. 
 
 Carh'oliG Solution is prepared by adding carbolic acid to water. 
 The strength usually used is 3 per cent., and the solution can ap- 
 proximately be made by adding four drachms of carbolic acid 
 to one pint of sterilized water. 
 
 Hands. — The hands of the operator and assistants are the most 
 frequent source of wound infection — hence, great care should be 
 taken in their sterilization. 
 
 In sterilizing the hands, the arms should be bare to the elbow, 
 the skin free from abrasions, the finger-nails closely trimmed aod 
 well cleaned, ard rings, if worn, removed. 
 
 The following is an effective process: 
 
218 PRINCIPLES OF SURGERY. 
 
 1st. Wash the hands with warm water and green soap, to re- 
 move dirt. A nail-brush should be vigorously used, to render the 
 process thorough, and special attention devoted to the finger-nails 
 and tissues around them. 
 
 2d. Einse all trace of soap from the hands, aad immerse them 
 in absolute alcohol for one minute. 
 
 3d. Soak them for the same length of time in a warm 1:1000 
 solution of bichloride of mercury. 
 
 4:th. Final!}'', wash them in one or two sterilized waters, to re- 
 move the bichloride, and dry them on an aseptic towel. 
 
 It is as important for the hands of an assistant, who handles 
 sponges, instruments, or dressings, to be as clean as the opera- 
 tor's, and they should receive the same careful attention. If, 
 during the course of an operation, the surgeon, or an assistant, 
 touches any object which is not aseptic, his hands should be 
 scrubbed and disinfected anew. 
 
 Instruments. — Instruments should be simple in construction, 
 and readily taken apart, to facilitate cleaning. The instruments 
 selected for an operation should be cleaned by washing with green 
 soap and warm water, a nail-brush being used on the locks and 
 serrated parts, such as the jaws of artery forceps. The blades of 
 the knives should then be wrapped in cotton to prevent their 
 being dulled, and the needles stuck in a piece of gauze to keep 
 them from being lost, and the instruments wrapped in atov^el. 
 The bundle should be tied with a bandage, or fastened with safety 
 pins, and disinfected by being placed in a sterilizer and oteamed 
 for forty minutes. After the administration of the an£esi:hetic has 
 been commenced, the package should be opened, and the instru- 
 ments slid into trays containing sterilized water. 
 
 An equally effective though more troublesome plan is to place 
 the instruments in a 1 per cent, solution of carbonate of soda, and 
 boil for ten minutes. The soda is a germicide and also prevents 
 rusting. 
 
 In minor operations, it is frequently thought sufficient to place 
 the instruments in a tray containing a 5 per cent, solution of car- 
 bolic acid for fifteen minutes and then pour off the solution and 
 refill the tray with sterilized vvater. 
 
 If an instrument is dropped on the floor during an operation, it 
 should not be used until disinfected ag-ain. 
 
PRINCIPLES OF SURGERY. 219 
 
 When an operation is over, the instruments should be v^ell 
 washed, carefully dried, and returned to their cases. 
 
 Sponges. — During the lirst craze for asepsis, sponges were 
 almost abandonsd, and pledgets of cotton or wads of gauze used 
 in their place. These artificial substitutes proved unsatisfactory, 
 and it was found that with care sponges could be rendered per- 
 fectly sterile, they again returned to favor. Some surgeons even 
 now throw a sponge away after using it in one case, doubting the 
 power of germicides to destroy the microorganisms with which it 
 may have become infected, but it is illogical to suppose that if 
 the sponge, which was once filled with decomposing matter, can 
 ever be rendered aseptic, that the process cannot be repeated. 
 Sponges can be used and resterilized many times ^ith safety, the 
 only limit being the resistance of their tissue to the action of the 
 solutions used. IV hen the sponge becomes soft and friable frnm 
 the effect of an antiseptic or bleaching fluid, it shoid be destroyed. 
 
 If sponges could be boiled then sterilization would be much 
 simplified, but very hot water causes them to shrink, to lose their 
 elasticity, and to become darker in color; hence, they should never 
 be put in a solution warmer than can be comfortably borne by the 
 hand. The following is one of the best methods to sterilize new 
 sponges : 
 
 1st. Put the sponges in a bag and beat them well to remove 
 sand. 
 
 2d. Wash them several times with warm water and green soap 
 to remove dirt, and adulterants sometimes put in by dealers to 
 render them more saleable. 
 
 3d. Soak them for twenty-four hours in a "A per cent, solution 
 of hydrochloric acid to dissolve calcaeous matter. 
 
 4th. Wash them in plain w^ater until the acid is removed, which 
 can be determined by testing with blue litmus paper. 
 
 5th. Put them in a saturated solution of permanganate of po- 
 tassium, and allow them to remain until stained a mahoffanv 
 brown. Then rinse in sterilized \^ ater. It must be remembered 
 that the strength of the solution deteriorates after a number of 
 sponges have been through it, and that fresh permanganate has 
 to be added from time to time to keep it up to the standard. 
 When this is done the sponges should be taken out of the liquid. 
 
220 PRINCIPLES OF SURGERY. 
 
 the permanganate dissolved, and the spoQges put back, for if the 
 drug is put in on the sponges it discolors them in spots. 
 
 6th. After the sponges have been freed from an excess of per- 
 manganate they should be placed in a saturated solution of oxalic 
 acid until bleached. Care should be taken to remove them as 
 soon as tbey are white, as a prolonged bath in the bleaching fluid 
 softens their fibre. Additions of oxalic acid have to be made to 
 the solution at inteivals to keep it up co the standard. 
 
 7th, Put them in a 1 :10U0 solution of bichloride of mercury for 
 one hour. 
 
 8th. Finally wash them in repeated baths of sterilized water to 
 remove all trace of the chemicals previously employed. 
 
 It is almost as easy to prepare several hundred sponges as it is 
 to prepare a dozen, and in hospitals it is customary to sterilize a 
 large number at one time. When this is done, and the process 
 just described is completed, the sponges are placed in large glass- 
 covered jars which are filled with a 3 per cent, aqueous solution of 
 carbolic acid, to ',^hich a small proportion of glycerine is added 
 to prevent the spooges from becoming blackened. Before each 
 operation the required number of sponges are removed from the 
 solution by a pair of aseptic forceps, and washed in sterilized 
 water to remove the carbolic acid. 
 
 After sponges are used in an operation they should be well 
 washed in cold water to free them from blood, dried, and put into 
 a bag. When they accumulate in sufficient numbers they are 
 again sterilized. 
 
 To sterilize sponges which have been used they should be soaked 
 in a saturated solution of baking soda for twelve hours to remove 
 all animal matter, rinsed plain water to remove the alkali, and 
 then put in the solution of permanganate of potassium and after- 
 wards treated by the method just described. 
 
 Basins, etc. — Irrigators, pitchers, basins and trays used in the 
 operating room should be scrupulously clean. They should be 
 made of some material which is not affected by solutions of cor- 
 rosive sublimate, such as glass, rubber, porcelain or agateware. 
 
 Prior to the operation they should be T\'ashed with water and 
 green soap, and filled with a 1:1000 solution of bichloride of mer- 
 cury. Before using, the solution should be poured out and the 
 utensils washed in sterilized water. 
 
PRINCIPLES OF SURGERV. 221 
 
 OrERATiMG-RooM LiNEN. — The linen which requires sterilization 
 for an operation consist of sheets, pillow-cases, tow^els and ope- 
 rating gowns. The}" should be placed in the sterilizer and sub- 
 jected to high temperature for fory minutes before the operation, 
 and removed as needed by an assistant whose hands have been 
 rendered sterile. After the operation they should be soaked in 
 a cold solution of baking soda to remove the blood, immersed 
 for one hour in a 1,000 solution of bichloride of mercury, Trashed 
 in plain water, and sect to the laundry. 
 
 Ligatures axd Sutures. — Ligatures are made from a variety of 
 materials, and sterilized by many different processes. The fol- 
 lowing are methods of preparing silk, cat-gut, and silk-\^orm gut: 
 
 Silk. — In hospitals silk is usually kept in a glass ligature box, 
 which has several spools for the different sizes. The silk, when 
 it comes from the dealer, is wound on the glass spools, and the 
 spools containing the silk boiled in water for five minutes and 
 returned to their places in the box The ligature box is then filled 
 M ith equal parts of alcohol and water, to which is added enough 
 carbolic acid to make a 5 per cent, solution. Three days before 
 an operation the hands should be sterilized, and the required 
 quantity of the different sizes of silk removed frcm the ligature 
 box, and washed in several sterilized waters to remove the carbolic 
 acid. It should then be m ound on small glass spools, which are 
 rendered aseptic by washing in a solution of bichloride, and the 
 spools placed in a clean test tube, the end of which is tightly 
 plugged with absorbent cotton. The tube, or ignition tube, as it 
 is called, should be placed in the sterilizer for half an hour on 
 three successive days and subjected to high temperature. The 
 plug of cotton should not be removed until the silK is actually re- 
 quired for use- 
 
 Cat-Gut. — Cat-gut is exceedingly difficult to sterilize, as it con- 
 tains a large proportion of fat, and is infected with germs from 
 its very source, being made from the sub-mucosa of the intestines 
 of sheep. The ready-prepared article found on the market is not 
 trustworthy^ and should not be used. Raw cat-gut should be 
 soaked in ether for twenty-four hours to remove the fat. It 
 should then be sterilized by boiling in alcohol. To do this effec- 
 tually, the cat-gut should be wound on a glass reel, immersed in a 
 
222 PRINCIPLES OF SURGERY. 
 
 bottle filled with absolute alcoliol, and the mouth of the bottle 
 tightly plugged with absorbent cotton. The bottle should then 
 be placed in a water- bath, care being taken that evaporation 
 doe» not leave any part of the reel uncovered. 
 
 After the process has been completed, if it is desired to chroma- 
 cize the cat- gut, and thus render it less absorbable, it can be done 
 by placing it in a solution of one part chromic acid, 200 parts car- 
 bolic acid, and 4,000 parts distilled water, for fortj -eight hours. 
 Only a quantity of cat-gut equal in weight to the carbolic acid in 
 the solution should be immersed, as a larger quantity would not 
 be thoroughly chromacized, and a small quantity might be over- 
 prepared. After being thus sterilized,* or chromacized, cat-gut 
 should be kept in absolute alcohol. When required for use, the 
 quantity needed should be removed with surgically-clean hands, 
 again boiled in alcohol, and placed in a tray containing a mixture 
 of one part glycerine and nine parts alcohol, which gives the gut 
 greater smoothness and pliability. 
 
 Silk-Worm Gut. — -Silk-worm gut can be rendered sterile by 
 boiling, by baking, or by immersing in solutions of carbolic acid, 
 or bichloride of mercury. The following method is an excellent 
 one: The ragged ends of the strands are clipped, and the bunch 
 put in a 1 per cent, alcoholic solution of methylin blue, where 
 they should remain for twenty-four hours. This stains them a 
 dark violet, and renders them more easily seen. They are then 
 rinsed in water and soaked in a 1:1000 bichloride of mercury 
 solution for twenty- four hours. They should be kept in absolute 
 alcohol until needed. 
 
 Drainage Material. — Drainage is usually effected by rubber 
 tubing, glass tubes, strips of gauze, or strands of cat-gut. 
 
 Euhher drainage tubes should be prepared by first washing 
 them well with soap and water and rinsing in clear water, then 
 soaking for twenty-four hours in a 1:1000 solution of bichloride 
 of mercury, and finally storing them in a glass jar containing a 
 5 per cent, solution of carbolic acid. Before using, the disinfect- 
 ants should be removed by rinsing in boiled water. 
 
 Glass drainage ttibes should be washed with soap and water, 
 boiled for half an hour in a 1 per cent, solution of carbonate of 
 soda, and kept in a 5 per cent, solution of carbolic acid. Rinse 
 in pure water before using. 
 
PRINCIPLES OF SURGERY. 223 
 
 Gauze drains are strips of aseptic gauze one yard long and about 
 au inch wide. They should be cut by the draw- thread method, 
 thus preventing ravelling. The strips are made in little rolls, and 
 placed in a tube, and sterilized in the manner described for the 
 sterilizatior of silk. When required for use, the plug of cotton 
 should be removed, and the strips handed to the surgeon by meaus 
 of sterilized forceps. 
 
 Dkessings— C'ozli^o/?.. — Eeliable cotton can be purchased from 
 dealers put up in cartoons. It may be v\iell, however, to sterilize 
 it again by baking in a hot-air oven for an hour before using. 
 
 Game. — Gauze can be purchased on the market, put up in her- 
 metically-sealed jars, v^hich is perfectly reliable. Except where 
 very large quantities are used, it will be found more satisfactory, 
 as well as economical, to use the preparation of some reliable 
 manufacturer than to attempt its preparation. 
 
 The following are methods of .making the varieties of gauze 
 most commonly used : 
 
 Plain Aseptic Gauze. — Soak the cheese-cloth for one hour in a 
 sud of soft soap and water to remove the "sizing,'^ wash several 
 times in clear water to free it from soap, and then steam in the 
 sterilizer for an hour, and store in clean glass jars having well- 
 fitting covers. 
 
 Bichloride Gauze. — Free the cloth from sizing and remove all 
 traces of the soap, as in the previous process, and immerse it for 
 several hours in a 1:1000 solution of bichloride of mercury, to 
 which has been added a little glycerine. Then dry in the steri- 
 lizer and store in clean jars. 
 
 Carholized' Gauze is prepared in the same manner as bichloride 
 gauze, except that a 5 per cent, solution of carbolic acid is used 
 in place of the bichloride solution. 
 
 Iodoform Gauze is prepared by taking plain aseptic gauze and 
 cutting it in three-yard lengths. Each length is placed in an 
 emulsion composed of ten drachms of iodoform and six ounces of 
 soapsuds —the suds being formed by the addition of castile soap 
 to sterilized water. After thoroughly rubbing the emulsion into 
 the meshes of the gauze, it is gently squeezed, sprinkled lightly 
 with glycerine, and dried in a hot-air oven at a low temperature- 
 It should then be stored in colored glass jars. 
 
224 PRINCIPLES OF SURGERY. 
 
 Rubber Tissue. — In dressing wounds strips or sheets, of rub- 
 ber tissue will frequently be used. They should be sterilized by 
 soaking in a solution of 1 : 1000 of bichloride of mercury for an 
 hour, and then rinsed in boiled water. 
 
 Bandages. — Pressings are secured in place by bandages of cot- 
 ton or flannel. They should be rendered aseptic by heating in the 
 sterilizer for an hour before using. 
 
X 
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 Write to Us for Quotations. 
 
Since this material was introduced into surgery by Lister, a vast amount of labor 
 and thought has been expended in attempts to properly prepare it for use. The 
 literature of this subject is very extensive. The methods and suggestions em- 
 brace every possible device for rendering it sterile, and recommend a vast list of 
 antiseptics for its preservation. 
 
 Notwithstanding all this, reports have heretofore shown that none of the infi- 
 nite number of processes were wholly satisfactory. Those processes that produced 
 sterile ligatures made them brittle ; methods that did not make the strings tender, 
 left them infected. Finally, if by chance made aseptic, they were easily reinfected 
 so that no one was really furnishing absoluteh' aseptic ligatures. 
 
 We have given attention to this vexing problem in our laboratories almost con- 
 tinuously for ten years — trying every conceivable plan — following every suggestion, 
 working out every method. . We venture to say that our experiments and re- 
 searches have cost many times our profits upon tnis material. The difficulties to 
 be overcome can be partiallj' realized when we consider the nature of this gut (the 
 intestines of sheep, twisted into hard cords) . It is a gelatenous substance, often 
 infected with the deadly Anthrax, and sometimes with germs even more resistant 
 than those of Anthrax. It is impenetrable by most solutions, destroyed by heat, 
 rotted by chemicals ; and, worse than all, a substance that will gather germs in 
 handling. It is a jelly-like thing, that in itself receives, holds and nourishes germ 
 life ; easy to infect, hard to disinfect. 
 
 At last we produced the Red Cross Aseptic Ligatures, that are as their name in- 
 , dicates — aseptic — free from genu life, protected from infection by handling, with 
 their tensile strength and elasticity unimpaired. The processes by which this is 
 accomplished have been published in detail. Their completeness consists in the 
 fact that sterilization is accomplished by means of a series of operations by which 
 the organic structure of the infecting bacteria is removed and their life destroj'ed 
 without touching the strings by the hands. In brief, the Ligatures are sterilized 
 while inside a protecting envelope that allows the sterilizing agents to penetrate, 
 but prevents the operator from touching the gut. The Ligatures reach the surgeon 
 in this same envelope (still further protected by an outer covering), then sealed in 
 glass. These strings reach the wound (untouched save by the surgeon) direct from 
 the sterilizer. 
 
 We are safe in saying no known system approaches that under which Red Cross 
 Ligatures are sterilized and handled. Our claims for them have been verified by 
 purposely infecting strings with the most resistant germs and passing them through 
 the sterilizing processes. Thorough bacteroilogical tests have shown that the 
 germs were wholly destroyed. 
 
 Further ample proofs have been given by exhaustive tests made by our surgical 
 friends during the course of experiments, and by the fact that in the thousands of 
 packages sent out since placing them upon the market, not one report has been 
 made of the occurrence of infection from Red Cross Aseptic Ligatures. These 
 Ligatures are put up in strings 30 inches long, each string in a double germ-proof 
 envelope ; 12 envelopes are put in a glass bottle and sealed. They therefore can- 
 not become infected in their handling and sale by the dealer. One or more liga- 
 tures can be renioved without endangering the remaining strings. If the inner en. 
 velope is opened with disinfected hands or forceps all possible danger is easily 
 avoided. The important point is that they are rendered absolutely sterile in their 
 treatment, and with a moderate amount of care will reach the surgeon in perfect 
 condition. A sample of these Ligatures will be sent any surgeon on application. 
 
 JOHNSON & JOHNSON, New Brunswick, N.J, 
 
Surgical Instruments. 
 
 Fever Thermometers, Hypodermic Syringes, 
 Operating Cushions, Obstetrical Cases and 
 Forceps; Dissecting, Pocket, Buggy and 8ad- 
 dle Cases. All of first quality, latest im- 
 provements, AND AT NEW YORK PEICES. 
 We solicit examination and comparison be- 
 fore purchasing. 
 
 ROBINS, 
 
 Marsha// and Second Streets, /i/C//MOND, VA. 
 
 BLOOD GENESIS 
 
 T 
 
 HE formation of a rich nutrient circulating fluid. Blood which shall contain an abundance 
 
 of red corpuscles of the necessary structural and physico-chemical integrity. 
 How to " build " such blood is an ever-present therapeutic problem for the physician to solve. 
 
 i1\ 
 
 is a powerful blood-forming agent ; it induces the generation of haemoglobin, the oxygen carrying' 
 
 constituent of the blood ; it is a genuine haemoglobinogenetic. It feeds the red corpuscles 
 
 with organic Iron and Manganese which are quickly and completely absorbed in cases of 
 
 Anaemia from any cause. Ghlorosls, Amenorrhoea, Chorea, Bright's Disease, etc. 
 
 To assure proper filling of prescriptions, order Pepto-Mangan "Gude" in original bottles ( 3 xi). 
 
 IT'S NEVER SOLD IN BULK. 
 
 I M.J. BREITENBACH COMPANY, SoIe Agents for U. S. and Canada, 
 
 56 & 58 WARRENJST., NEW YORK. 
 
 LABORATORY. 
 
 LEIPZIG, GERMANY. 
 
Yale Surgbon's Chair. 
 
 '99 
 
 ^^HIGHEST AWARD WORLl^^'S 
 
 !, OCT. 4th, 1893. 
 
 ^1 r^ 
 
 'Fig. V. — Semi- Reclining. 
 
 w 
 
 (^.\ \ Qth. The leg^ and foot rests folded out of the operator's way 
 .^ at any time— Fig-s. XI, XV and XVIL 
 
 10th. Head Rest universal ia aujustment, with a raug-e of 
 irom 14 inches above seat io 13 inches above back of 
 chair, furnishing- a perfect nrportia Dorsal or Sim'« 
 „ position. — Fig-s. XIII and XV. 
 
 llths Affording- unlimited modifications of positions. 
 12tfa. Stability and firmness -while being- raised and rotated* 
 13th. 0;:ly successful Dorsal position ■withntU moi'ing patient. 
 14t!a- Croad turntable upon which to rotate the chair, -whicll 
 
 cannot be bent or twisted. 
 ISth. Sirtrdsupon its owa merits and not tipon the repwta- 
 tiou of others. 
 
 1st. Raised by foot and lowered by automatic device. — Fig-. I. 
 
 2d. Raising- and lowering- without revolving- the upper part 
 of the chair. — Fig- VII. 
 
 3d. Obtaining heig-ht of 39J^ inches.— Fig-. VII. 
 
 4th. As strong in the highest, as when in the lowest position. 
 —Fig. VII. 
 
 5th. Raised, lowered, tilted or rotated -withoat disturbing- pa. 
 tient. 
 
 6th. Heavy steel spring's to balance the chair. 
 
 7th. Arm Rests not dependent on the back for support.— Figi 
 VII — always ready for use; pushed back when using- stir- 
 rups — Fig. XVII — may be placed at and away from side 
 of chair, forming- a side table for Sim's position— Fig-. 
 XIIL 
 
 Sth. Quickect and easiest operated and most substantially se- 
 cured in positions. 
 
 Fig. XVIT— Dorsal Position, 
 
 Pronounced tli3 ne puis ultra by the Surgeon, Gynsecolegist, Ocnlist and Aurlst. 
 
 MANUFACTURKD SXCLUOtVEUY BY 
 
 Canton Soe^^sscAL hn^ Dental Chair Co 
 
 38 t« 64 East Eighth and 60 to 62 South Walnut Streets, CANTON. OHIO. 
 
MEDICAL BOOKS. 
 BlaoK Book^s, Note Bool<;s, 
 
 Best Made and Warranted. 
 
 Writing Papers and Tablets, 
 
 HUNTER & CO., 
 
 Books and Stationery, 
 
 629 East Broad Street, RICH3IOXD, VA. 
 
 e:©t^bil.isiie:d is36. 
 
 MAKERS OF 
 
 Surgical Instruments, Hospital Supplies, Aseptic 
 Iron and Glass Furniture, &c. 
 
 Orthopaedic Appliances, 
 
 &c. 
 
 
 ^^^T^UB^R^CO^^ W^^, 
 
 STEEL 
 
 sCf''^ 
 
 
 ECLIPTIC msouE d^^^laP 
 
 ^^^^'^^^ ^^ ~^-'-^^- "'"T hrcU'- 
 
 107 Park Row, 
 
 New York. 
 
■ 
 
 COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as : 
 provided by the library rules or by ..fecial arrangement with 
 the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 
 
 
 
 JUN 8 U 
 
 )7I 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 C28(955)100MEE 
 
 
 
 
RD47 
 
 H55 
 
 1897 
 
 Hillsman 
 
 Jptes__on_p.rinciples of surgeiy . 
 
 APR 4 
 
 mi 
 
 smo&x^ 
 
 v. mn 1 9^. ^,^jr;te:^cA^- 
 
 Ot{jjU'y^r^(i^^Jj\\>jOi^ '<^ 
 
 mi 
 
 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
 RD 47 H55 1897 C.1 
 
 Notes on priniples of surQerv from ect 
 
 2002196387